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Within this assignment I will be reflecting on an experience I endured during my time as a

student Operating Department Practitioner (ODP) with the use of Gibbs’ (1998) Reflective

Cycle. Whilst spending time on anaesthetic placement I was involved in delivering

evidence based care with the use of warming devices to a patient who was admitted to

theatre to have a mastectomy of her right breast. A mastectomy is one of two main breast

cancer surgery procedures, this is the removal of all the breast tissue, including the nipple.

(NHS choices, 2016). I certify that this is my own work and confidentiality has been

maintained by the use of pseudonyms.

Before the patient arrived within the anaesthetic room my mentor asked me to set up and

ensure we had everything prepared to start the case. Whilst doing this he asked me to set

up a Compound Sodium Lactate (Hartmann’s) drip and attach a warming device to this.

Hartmann’s is a balanced crystalloid solution that is used to replace the fluid and

electrolytes lost during the period of starvation (Bedi et al, 2013). National Institute for

Clinical Excellence (NICE )2008) guidelines state that the patient’s temperature should be

documented before surgery and every 30 minutes during surgery, monitoring the

temperature and keeping the patient warm during surgery reduces the risk of

postoperative complications. A combination of warming devices were used to maintain the

patient’s temperature such as a forced air warming device and intravenous fluid warming

device, this is due to the patient losing heat from factors such as the actions of the

anaesthetic drugs, uncovering of the skin and administration of cold fluids (Chapman,

2015). This is the reason fluid warmers are designed, they carry fluid around the body at a

temperature of 37oC to help prevent hypothermia from occurring (Anon, 2017).

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When asked to apply a fluid warmer to the intravenous (IV) fluid drip I was making up I

didn’t feel too confident in doing so, the reason for this being I was unsure how to connect

the warming device to the drip and I was worried about not doing it correctly. My concern

was that If I was to attach the extension before the fluid warmer rather than after, i would

not be able to fit the warming device in the correct position which would result in needing

to disconnect the drip which is not best practise as this would increase the risk of venous

air embolism and fluid contamination. Venous air embolism caused by intravenous air

infusion can be life threatening, several studies have suggested it would take a range of

100-300mls to cause this (Zoremba et al., 2011). When applying the warmer to the drip I

asked my mentor to watch me to ensure I was doing the procedure correctly and to make

sure there were no air bubbles within the drip. I was assured that a tiny air bubble within

the drip wouldn’t do any harm to the patient, however I feel that if it can be avoided then it

should be as I feel it is bad practice to allow air to travel through a connected drip.

Overall I feel that the situation went well, When I was unsure I asked for help straight away

to avoid any unnecessary harm coming to the patient by incorrectly attaching the warmer

to the drip. My mentor took the time to watch me and assured me that I was connecting

the warmer device to the drip correctly and in the most sterile way I could to avoid any

contamination of the fluid. Once the warmer was connected to the drip I ran the

Hartmann’s fluid through to ensure there was no air left in the drip. The fluids were all

ready before the patient even entered the anaesthetic room and there were no problems

when the anaesthetist connected them to the patient’s cannula.

On reflection I now understand more about why fluid warming devices are used and how

they work. They aim to improve comfort to the patient and avoid any postoperative

complications due to hypothermia. Unintended hypothermia is a common occurrence

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throughout patient’s perioperative experience, to reduce such occurrences NICE (2016)

guidelines state that all intravenous fluids should now be warmed to 37 oC. John et al

(2014) states that the administration of intravenous fluids at a room temperature of 21 oC

decreases the core body temperature by 0.25oC. However, a study with a total of 1250

participants concluded that warm intravenous fluids keep patients warmer during surgery

than room temperature fluids although it is unclear if the actual differences in temperature

are clinically meaningful (Campbell et al, 2015). This shows me the importance of

warming devices as this is only one of the factors that causes the patient to lose heat.

“Patients lose heat to the environment through four mechanisms: radiation, convection,

conduction and evaporation” (Continuing Education Activity, 2013). With the use of a fluid

warmer, a forced air warming device and covering the patient with a blanket this will

control and help maintain the patient’s temperature.

To conclude from this experience, I feel that by getting background knowledge whilst in

this situation from my mentor about the risks that could occur when the patient is not

warmed correctly, I learned how to prevent these risks from happening. This has helped

me in this situation and in any future situations, as I believe that you should understand

the reason behind why we use the medical equipment. Now I know the risks that can

occur with the fluid warmers I feel more confident about setting them up, as I now

understand what to look out for such as air bubbles and decontamination. I feel that I could

continue to research more about the different types of warming devices to keep up to date

with the best and most current practise.

This experience has made me more confident using devices such as fluid warmers. I feel

positive with setting the intravenous fluid drips up with the warming device attached.

Discussing my concerns with my mentor helped me understand and carry out the correct

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and safe procedure of connecting the device. It showed me that I am not afraid to ask for

help when I’m unsure of something. However, I feel by continuing to set the fluid warmers

up with guidance from my mentor will help me become competent at doing so in practice. I

still need to continue with research on the warming devices and keep up to date with the

current guidelines that the National Institute for Health and Clinical Excellence put in place.

I can do this by looking on the NICE website and searching their current guidance and

guidelines.

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References:

Anaesthesia Journal of the Association of Anaesthetist of Great Britain and Ireland, 63:10.

Available at: http://dx.doi.org/10.1111/j.1365-2044.2008.05561.x

Anon, (2017). [online] enFlow IV fluid and blood warming system. Care fusion. Available

at: www.carefusion.com/Documents/brochures/anesthesia-delivery/VS_enFlow-fluid-

warming-system_BR_EN.pdf [Accessed 25 Jun. 2017].

Bassot, B. (2016) The reflective journal. 2nd edn. London: Palgrave.

Bedi, A., McKendry, R. A., and Sweeney, R. M. (2013) Perioperative Intravenous Fluid

Therapy for Adults. Ulster Medical Society: 82(3), pp. 171-178

Campbell, G., Alderson, P., Smith, A. F., Warttig, S. (2015) Warming of intravenous and

irrigation fluids for preventing inadvertent perioperative hypothermia. Cochrane

Anaesthesia, 13(4). Available at: http://dx.doi.org/10.1002/14651858.CD009891.pub2.

Continuing Education Activity (2013) The role of irrigation fluid warming in hypothermia

prevention. Available at: www.pfiedler.com/ast/1223a/files/assets/common/downloads/The

%20Role%20of%20Irrigation%20Fluid%20Warming%20in%20Hypothermia

%20Prevention%20-%20AST.pdf [Accessed 25th June 2017].

Chapman, S. (2015) Keeping people warm during surgery: what’s the evidence? [pdf]

Evidently Cochrane. Available at: www.evidentlycochrane.net/keeping-people-warm-

during-surgery-whats-the-evidence [Accessed 25th May 2017]

John, M., Ford, J. and Harper, M. (2014) Peri-operative warming devices: performance

and clinical application. Anaesthesia. 69, pp. 623-638. Available at:

http://dx.doi.org/10.1111/anae.12626

National Institute for Clinical Excellence (2008) Hypothermia: prevention and management

in adults having surgery. Available at:

https://www.nice.org.uk/guidance/cg65/chapter/recommendations [Accessed 23rd May

2017]

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NHS Choices (2016) Breast cancer (female)- Treatment. Available at:

http://www.nhs.uk/Conditions/cancer-of-the-breast-female/Pages/treatment.aspx

[Accessed 23rd May 2017].

Zoremba, N., Gruenewald, C., Zoremba, M., Rossaint, R. and Schaelte, G. (2011). Air

elimination capability in rapid infusion systems. Anaesthesia, 66(11), pp.1031-1034.