Accident of blood warmer and its complication
Takehara, Y.; Uno, T.; Motomatsu, K.
Masui. Japanese Journal of Anesthesiology 30(9): 992-995
1981
ISSN/ISBN: 0021-4892 PMID: 7328747 Document Number: 181849
A 40 yr old woman was given epidural anesthesia with supplements of N2O, O2 and diazepam for radical hysterectomy. When blood loss amounted to 500 ml, 400 ml of blood was given by warming in warmed water and then a blood warmer was used for further blood transfusion. Immediately after the infusion of blood through the blood warmer, transfusion tube scorching was detected and the patient's blood pressure fell. A 2 grade burn occurred at the left forearm in contact with the transfusion tube and phlebitis progressed proximally from the point of venous cannulation. Blood transfusion was stopped and another i.v. route secured at the right forearm. Blood pressure was restored with rapid infusion of lactated Ringer's solution without vasopressor. The blood warmer consisted of a heater 50 cm in length which heated the transfusion tube directly. The cause of accident was the overheating of the heater which was led by impairment of the SCR (silicon controlled rectifier). Chest pain, chest eruption and hematuria were observed during the postoperative course. These probably resulted from the accident. Renal, pulmonary and hepatic dysfunctions were not detectable. The safety of a blood warmer designed for direct heating should be reconsidered.