A patient safety alert has been issued by NHS England on the risk of hypothermia for patients on continuous renal replacement therapy (CRRT).
The alert, issued in response to a series of patient incidents, has been disseminated via the Central Alerting System (CAS) to ensure that staff are aware that it is never safe to use CRRT equipment without a fluid warmer, even for short periods.
To avoid the risk of hypothermia, CRRT equipment continuously monitors the temperature of fluid being administered. If the measured temperature differs from the set target, the equipment alarms and if the heater is integrated, it stops the pump.
In the incidents reported to NHS England, it appeared that when the equipment alarmed repeatedly, staff were not always sure how to access urgent advice on repair or replacement, and mistakenly believed the priority was maintaining CRRT. They switched off the fluid warmer and restarted the pump without it, believing they would be able to detect and manage hypothermia before it harmed the patient.
However, unheated fluid for CRRT can rapidly lower patients’ core temperature and returning cool blood to the patient also has detrimental effects on coagulation, the immune system and metabolic function.
