Item: **Smiths Medical, Fast Flow Fluid Warmer Models 250, 500 and
1000.**

Specific Incident: Hospitals in Australia report serious patient injury
from intravascular air embolisms introduced while using the Smiths
Medical fluid warmers identified in this Alert.

Action: 1. Promptly (within one week) check local inventory to identify
all units affected by this Alert and institute recommended practices to
minimize risk **(attached)** for all users of Smiths Medical Fast Flow
Fluid Warmers, models 250, 500 and 1000.

> 2\. Procure and install the Smiths Medical accessory Air
> Detector/Clamp, model H-31 that is designed to reduce the risk of air
> embolism introduction while using the Smiths Medical Fast Flow Fluid
> Warmers, models 250, 500 and 1000.

Addl. Information: All new models of Smiths Medical fluid warmers
include the air detector/clamp as a standard component. Also, while we
are unaware of other sites without this accessory, check your inventory
and contact your Smiths Medical representative to update their list and
order the H-31 detector/clamp.

Source: VA Center for Engineering & Occupational Safety and Health

> Smiths Medical and ECRI

Contact: Paul Sherman (CEOSH): 314-543-6700

[Smiths Medical recommendations to minimize]{.smallcaps}

[risk of air embolism while using their fluid warmers:]{.smallcaps}

\(1\) Remove all air from fluid bags and lines before connecting to
patients.

\(2\) Follow all instructions for priming the infusion line and set.

\(3\) Monitor fluid lines, and check to ensure that they are free of air
bubbles.

\(4\) Do not open ports in the infusion system unless precautions are
taken to prevent the entry of air.

\(5\) Do not reconnect partially emptied fluid bags. Disconnected bags
may contain a significant volume of air, which can enter the bags when
they are first disconnected.

\(6\) Do not use autotransfusion bags with warming systems unless the
warmer is clearly indicated for this use.

[List of VA sites with H1000 fluid warmers [without]{.underline} the
H-31 Air Detector/Clamp - as identified by Smiths Medical:]{.smallcaps}

  ------------------------ ------------------------- ----------------------------- -----------------------
  **[City]{.underline}**   **[State]{.underline}**   **[Street                     **[Serial
                                                     Address]{.underline}**        Number]{.underline}**

  **Chicago**              **IL**                    **2030 West Taylor St**       **J02087**

  **Clarksburg**           **WV**                    **1 Medical Center Dr**       **20020120**

  **Clarksburg**           **WV**                    **1 Medical Center Dr**       **J02062**

  **Cleveland**            **OH**                    **10701 East Boulevard**      **20030492**

  **Gainesville**          **FL**                    **1601 SW Archer Rd**         **J01886**

  **Huntington**           **WV**                    **1540 Spring Valley Dr**     **20030151**

  **Indianapolis**         **IN**                    **1481 West 10th Street**     **20010209**

  **Lexington**            **KY**                    **2250 Leestown Rd/Bldg 12**  **J01386**

  **Lexington**            **KY**                    **1101 Veterans Dr**          **20020139**

  **Lexington**            **KY**                    **1101 Veterans Dr**          **20020135**

  **Lexington**            **KY**                    **1101 Veterans Dr**          **20020136**

  **Los Angeles**          **CA**                    **1103 Wilshire Blvd**        **20000648**

  **Louisville**           **KY**                    **800 Zorn Ave**              **20010033**

  **New York**             **NY**                    **423 East 23rd St**          **19990447**

  **Philadelphia**         **PA**                    **University Ave**            **J01791**

  **Pittsburgh**           **PA**                    **University Dr**             **20000379**

  **Shreveport**           **LA**                    **510 East Stoner Ave**       **J01725**

  **Temple**               **TX**                    **1901 S 1st St**             **20030300**

  **Tucson**               **AZ**                    **3601 S 6th Ave**            **19990286**

  **Wichita**              **KS**                    **5500 East Kellogg**         **20030482**
  ------------------------ ------------------------- ----------------------------- -----------------------