Failure of a water-bath design intravenous fluid warmer.

摘要

We write to highlight the failure of an intravenous fluid warming device, HOTLINE~R HL-290 Blood and Fluid Warmer (Smiths Medical International, Kent, UK), which could have resulted in harm to the patient. Fluid warmer failures are becoming more prevalent, as evidenced by the United Kingdom Medicines and Healthcare Products Regulatory Agency (MHRA) issuing a recall of all Level 1 SIMS fluid warmer sets.The fluid warmer in our case is designed differently. Warm water is pumped into a counter-current system around an inner sterile infusion lumen. The warming fluid is kept in a non-sterile water bath, emphasizing the need for extreme care with all water-bath fluid warmers.