NURSING PATIENT CARE POLICY & PROCEDURE
November 30, 2016
Nursing Manual (Red)
Policy #: 8.26AP
Title: Use of Intravenous and Rapid
Infusor Fluid Warmers (Adult &
To establish guidelines for registered nurses on the priming and proper use of rapid
A. Blood warmers are used to warm the temperature of intravenous (IV) solutions
and blood products (packed red blood cells, whole blood and fresh frozen plasma
only) to approximate body temperature, as opposed to room temperature.
Warming is necessary when large volumes of blood or fluid are being
administered to promote maintenance of normal body temperature and avoid
B. Warming may also be indicated to provide patient comfort during apheresis
procedures, to reduce likelihood of transfusion reactions for patients with cold
agglutinin autoantibodies, and to maintain normal body temperature in the
anesthetized patient or a patient receiving multiple units of blood products.
C. Blood warmers are recommended for use with unstable infants and pediatric
patients who require a rapid transfusion of a large amount of blood or fluid (more
than 15 mL/kg/hr).
D. When rapid infusion is utilized, it requires a large bore IV or central line. Rapid
infusion needs close monitoring to prevent IV bags from becoming dry
introducing air into the system.
E. Warming is not recommended for platelets or cryoprecipitate.
CAUTION: Hemolysis can occur with excessive warming (temperature greater than
42 degrees Celsius [C]).
A. There are seven types of blood/fluid warmers used at UWHC:
Product Indication Equipment Location
Fluid Warmer Rapid infusion
Hot Line Fluid Warmer Model HL-90 Fluid warmer ED
Ranger Blood/Fluid Warming System Fluid warmer TLC, Infusion center,
Rapid Infuser Rapid infusion
TLC, ED, OR
Belmont Buddy ™ and Fluid warmer ED
Belmont Buddy lite ™ Fluid warmer (battery
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Astotherm®plus Blood warmer Infusion Center
B. Machine-specific tubing
C. Extension tubing (if desired)
A. General use and patient monitoring
1. Use of a rapid infusion device is done by a trained individual.
2. Patient monitoring and care:
a. During rapid infusion, monitor the patient’s vital signs every 5 to
15 minutes as indicated. As the patient’s condition becomes more
stable, assessment of vital signs may be done less frequently (every
30 minutes to one  hour until the blood pressure remains stable
for more than two  hours).
b. During rapid infusion, assess the integrity of the IV site every 15
c. During use of rapid infuser monitor patient’s temperature every 15
to 30 minute.
d. During use of fluid warmer without rapid infusion, monitor
patient’s temperature at least every hour, as indicated by patient
condition and according to physician orders.
B. Level 1
NOTE: Level 1
also makes a combination rapid infuser/fluid warmer (model H-
250). The fluid warming feature may be used alone on this model. If the rapid
infusion feature is used, fluids must be warmed through the fluid warming tube.
The Level 1
Rapid Infusion model is used only in the Cardiothoracic Surgery
and Cardiology Intensive Care unit.
1. If pressure is used to administer the fluids rapidly, one (1) person must
only monitor the system for air, the need to change IV bag or blood
2. General information
a. IV sets allow infusion of 10 degrees C blood at up to 700 mL/min
or crystalloid up to 1,300 mL/min. At the lower flow rates
generally used without the rapid infusion feature, fluids are
delivered near 37 degrees C.
b. Level 1
Normothermic Irrigating Sets warm room temperature
irrigating fluids to a minimum delivery temperature of 36 degrees
C at flow rates to 760 mL/min.
c. Heating occurs when warmed water is rapidly circulated counter-
flow through an anodized aluminum tube.
d. Rapid infusion rates can be achieved by changing the bar above the
infusion holders to positive. Do not exceed 300 mmHg. NOTE:
Hand pumping can generate over 1,000 mmHg.
3. Safety features include:
a. Air eliminator: Vents micro-bubbles of gas released from fluids as
they are warmed, and is capable of venting up to 400 mL/min of
air from the system. The screen filter traps micro-aggregates.
b. Temperature control: Free of "Hot Spots" and limits the circulating
water to 40 degrees C maximum.
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4. Procedural steps
a. Prime tubing (IV Fluid tubing D-100 [CS Item Number 2200452])
i. Close all clamps above the heat exchanger (straight piece).
ii. Remove all air from IV bag. Remove bag spike cap.
Spike the bag.
iii. Hang bag from IV pole and open corresponding clamp.
iv. Squeeze drip chamber so it is full.
v. Remove male luer cap at end of tubing and open clamp.
vi. Close roller clamp (near end of tubing) when patient line is
primed. The filter/air eliminator will self-prime.
vii. Tap filter/air eliminator against cabinet to release all
trapped air. Prime is complete.
viii. While priming, turn the power switch ON. It takes three (3)
minutes to reach operating temperatures of 37 to 40
b. Set up
i. Push bottom end of IV tubing into the heat exchanger fully
into the bottom socket, number 1.
ii. Pull slide lock up to unlock number 2, the top socket. Slide
the bottom part of the next section of IV tubing into this
area. Make sure the straight stiff section is into number 2
(marked on infusor). Slide top socket down over heat
exchanger until latch "clicks".
iii. Snap filter/air eliminator into number 3, the holder.
iv. When correctly installed a green "system operational" light
will illuminate on the display panel when the fluid warmer
power switch is turned ON. If the disposable set is
incorrectly installed and the unit is on, the "check
disposables" light will illuminate and an intermittent alarm
c. Filter replacement
i. Replace the filter/air eliminator every three (3) hours or
when the filter becomes clogged or air is slowly vented.
Another option would be to prime new level 1 infuser
ii. All air must be removed from the fluid lines prior to
connection to the patient.
iii. Monitor fluid lines to ensure they are air-free. Never
transfuse fluids if there are air bubbles in the line between
the filter chamber and patient connector.
iv. Set-up priming and use required aseptic technique.
d. Re-priming: If air is inadvertently introduced into the disposable
set, it may be removed as follows:
i. Close the roller clamp on the patient line.
ii. Spike a new fluid bag and allow the filter/air eliminator to
iii. Partially open the roller clamp and observe air bubbles
leaving the heat exchanger.
iv. IMPORTANT: Adjust the roller clamp so the air pocket in
the top of the filter/air eliminator does not exceed ¼ inch.
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v. When no more air bubbles are observed leaving the heat
exchanger and all air has been vented from the filter/air
eliminator, resume normal flow.
e. Replacing air filter/eliminator
i. Close all clamps on the disposable set and new filter.
ii. Remove used filter from holder while still connected to the
iii. Install new filter in holder.
iv. Disconnect upper luer-lock fitting, remove bio-barrier cap
and connect to new filter inlet.
v. Holding used filter horizontally, disconnect patient line
luer-lock. Connect used filter luer-lock fittings together and
vi. With filter outlet tube clamped, open clamp above heat
exchanger. The filter will prime itself.
vii. Slowly release the outlet tube clamp and allow outlet tube
to fill completely.
viii. Remove second bio-barrier cap and connect outlet tube
luer-lock to patient line.
ix. Remove the filter from holder and tap against pole until all
trapped air bubbles have been vented out. Replace.
x. IMPORTANT: Thoroughly check patient line for air
bubbles before opening roller clamp. If air bubbles are
present, disconnect from patient and re-prime before
f. Display panel: There are five (5) displays:
i. Water temperature – green light indicates warming taking
ii. System operational – green indicator
iii. Add water – red indicator and pulsed audible alarm indicate
additional distilled water must be added
iv. Check disposables – red indicator and pulsed audible alarm
indicating disposable set is not properly installed and no
warming is taking place
v. Over temperature – red indicator and audible alarm indicate
a malfunction of the primary temperature control system
WARNING: In the event of “over temperature” alarm,
immediately stop the fluid flow to the patient and remove
the fluid warmer from service.
g. Troubleshooting Level 1
Fluid Warmer. Many factors that are
insignificant in low flow fluid administration are restrictors of high
i. Old blood – stored blood (5-7 days) can develop particulate
ii. Bag not fully spiked
iii. Bag port filter (if used)
iv. Clamps partially engaged
v. Tube set – happens when clamps are engaged for extended
vi. Tube kinks
vii. Trapped air in filter
viii. Clogged filter
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ix. Extension lines – need to be 3.3 mm or larger
x. Stopcock or Y-adapter – need to be large bore
xi. Needle or catheter – minimum 14 gauge or 8 ½ Fr catheter
xii. Quality of infusion site
C. Hot Line Fluid Warmer Model HL-90 - 120v (90-130)
a. The active warming is achieved by surrounding the patient line
with precisely temperature-controlled circulating water. The water
flows through its own pathways that completely surround the IV
line. The Hot Line is not considered a rapid infuser. The infusion
rate is dependent on the IV pump and/or other device that is
controlling the infusion rate.
b. An onboard water supply is precisely heated to 40 degrees C by
this unit and circulated through the Hotline disposable set.
Electronic circuitry continuously monitors the water temperature,
and will shut down the system and activate visual and audible
alarms in the event of an over-temperature condition.
2. Visual alarms and circulating water temperature appear on the display
panel on the front of units.
a. A green “Operating" light illuminates on this panel when the unit
is set up and operating correctly.
b. “Disposable”: This red indicator and pulsed audible alarm indicate
the Hotline disposable set is not properly installed and no fluid
warming is taking place.
c. “Add Water": This red indicator and pulsed audible alarm indicate
additional distilled water must be added to the reservoir. No fluid
warming is taking place.
d. “Over Temp": This red indicator and pulsed audible alarm indicate
a malfunction of the primary temperature control system. No fluid
warming is taking place.
3. Tubing for the "Hotline Disposable Set"
a. Disposable single unit package with sterile fluid path.
b. A plug-in fitting on the tubing engages a socket in the Hotline unit.
This is the only connection necessary to provide the warming
4. Set up
a. Clamp the Hotline to IV pole.
i. Do not mount the Hotline more than 42 inches above the
(For convenience, 42 inches is indicated on the electrical
cord by a black marker.)
ii. This unit is cooled by convection. Be sure the air vents on
the bottom and the back of the unit are kept clear.
b. Unscrew the fillport plug on the water tank.
c. Fill the water tank with 1.4 liters of distilled water. CAUTION: Do
not fill the water tank with Hotline disposable tubing in place.
d. Replace the fillport plug.
e. Plug the Hotline into a 120 v outlet.
NOTE: An interlock switch will not allow the unit to operate
without tubing set in place.
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f. Plug the Twin-Tube connector of the tubing into the socket on the
right side of the unit. Be sure it is fully seated. Activate the power
switch on the left side of the unit. The green "Operating" light
confirms proper operation.
g. Connect IV fluid supply and fully prime warming set, then make
patient connection without entrapping air.
h. Using a clamp to adjust flow, begin administering fluids when
water temperature reaches approximately 37 degrees C
(approximately 10-15 minutes).
WARNING: Do not puncture Hotline tubing set with needles.
Patient injury or death could result.
i. Clean after every use. Completed by Clinical Engineering
following the manufacturer’s directions.
• CAUTION: Do not use abrasive cleaning agents,
alcohols or solvents, and do not immerse any part in
• For external disinfecting, a 30 percent isopropyl
0 or 10 percent bleach/distilled water
solution may be used. Distilled water should be
changed every 30 days.
• For internal disinfecting, use alcohol solution only
and rinse tank with distilled water twice before
returning to use.
ii. CAUTION: Do not fill Hotline water tank with tubing set
in place or a temperature check in place. Silicone grease
should be applied to the O-rings.
D. Ranger Blood/Fluid Warming System
The Ranger device is a blood and fluid warming unit with a disposable
administration set. The system will allow flow rates from keep vein open (KVO)
to 150mL/min. The blood/fluid temperature delivered ranges from 33 to 41
degrees C, and takes less than two (2) minutes to warm up to the 41 degrees set
a. Ranger Warming device
b. Administration set (CS Item Number 4006505)
c. Standard set: delivers up to 150mL/min
d. Replacement filter (if needed)
e. IV pole
a. Standard tubing
i. Attach device to IV pole. Tighten clamp securely.
ii. Slide the fluid warming cassette into the slot in the
warming unit. (The cassette will only fit into the unit one
iii. Connect the fluid warming tubing to the blood/solution
iv. Prime tubing to purge all air. Invert the bubble trap while
priming and fill. Turn the bubble trap right side up and
complete priming the system.
v. Place the bubble trap in the holder located on the side of the
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vi. Close all clamps.
vii. Turn the warming unit ON. The device is now ready for
b. Discontinuing use
i. Close the inlet clamp proximal to the fluid warming
cassette and open all clamps distal to the cassette (toward
ii. Allow the fluid to flow into the patient. This may take 2-3
iii. Remove the cassette from the warming unit and discard in
trash container. Refer to UWHC Hospital Administrative
Policy 8.12, Blood and Blood Component Transfusion
(Requiring Pre-Transfusion Testing).
iv. Reconnect the patient IV line to the fluid source to continue
the infusion without warming.
c. Trouble shooting: Air in line, Standard set
i. To remove air from the cassette, close the clamp between
the injection port and the patient connection.
ii. Invert the bubble trap.
iii. Insert a syringe in the injection port and aspirate the air
until trap and line are free of air.
iv. Place bubble trap right side up in holder.
v. Open clamp, continue infusion.
d. For alarms, see Appendix A (page 1) in the Related section on U-
Rapid Infuser (used for patients greater than 10 kg)
Rapid Infuser can infuse fluids from 2.5 mL/min (150 mL/hr) to
750 mL/min. Warming of fluids does not occur until the rate is greater than or
equal to 10mL/min (600 mL/hr).
• Catheter size and length influence flow rates.
• Recommended fluid is Normal Saline. Do not mix calcium
containing (Lactated Ringers) solutions with blood products.
• Do not infuse platelets, cryoprecipitate, or granulocyte suspensions
through the Belmont
• Use the Belmont
Rapid Infuser tubing, and no extra filters are
a. 3-Spike Belmont
Rapid Infuser Tubing (may use one or all
2. Steps for setting up
a. Remove the tubing from the tray and load into the infuser.
i. Load circular heat exchanger with red arrow pointing up
and the red tubing aligned with the red line on the system.
ii. Load interlock block into air detector with the arrow
pointing into the machine.
iii. Thread pump tubing over pump head.
iv. Thread tubing into second air detector. Make sure the
tubing is all the way in, this will avoid false air in line
v. Place tubing on both sides of valve. Thin tubing matches
with thin line, thick tubing with thick line.
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b. Set up the unit for infusion
i. Switch the power switch ON.
ii. Spike fluid to be infused.
iii. Press “Prime” to self-prime the main circuit. After main
circuit is primed, press PRIME PT LINE to prime patient
infusion line (press and hold this key down to prime
iv. Visually inspect patient line for air. Press STOP when all
air has been removed.
c. Set and adjust rate for infusing
i. Touch one button “500 mL/min” for rapid infusion.
ii. UP and DOWN keys infuse from 2.5 to 750 mL/min.
d. Infuse a preset rate with the BOLUS key
i. New bolus volume will appear in the VOL line as BOL.
ii. Bolus amount cycles from 100 mL to 500 mL in increments
of 50 mL.
iii. Release the key when the desired bolus volume appears and
start the infusion.
e. Tubing should be changed when clogged or every four (4) hours
when blood products are used.
f. When done using unit, clean black sensors inside the door with
alcohol wipes. Refer to UWHC Hospital Administrative Policy
13.20, Cleaning, Disinfection and Sterilization of Patient Care
Instruments and Equipment.
g. Screen will track total IV Intake infused with the Belmont. When
the Belmont is turned OFF, this number will be erased.
F. Belmont buddy™ and buddy lite™
The Belmont buddy™ and buddy lite™ warms infused IV fluid and/or blood
products at a lower flow rate than the Belmont rapid infuser. Belmont buddy™
and buddy lite™ tubing sets are interchangeable. Heater units are internally set
and do not require any adjustments.
1. The buddy™ operates on AC power and can warm and infuse blood and
IV fluid for flow rates below 100 mL/min (about 6,000 mL/hr).
2. The buddy lite™ operates on battery power and can warm and infuse IV
fluid up to 80 mL/min (4,800 mL/hr) and approximately 50 mL/min
(3,000 mL/hr) for blood. Currently the buddy lite™ is used for Critical
Care Transport (Med Flight and CHETA).
3. Platelets or cryoprecipitate should not be infused through the Belmont
buddy™ or Belmont buddy lite™. Use of pressure infusers are not
a. Buddy standard tubing
b. Standard blood filter, if infusing blood product
c. Clean heater unit and surfaces by wiping down with Cavi or bleach
wipe after every patient use.
5. Steps for setting up buddy™ and buddy lite™:
a. Open heater unit, and install disposable set with the notches
aligned in the heater unit (RED tab to RED tab)
b. Close and latch the case (heater unit will not close if the set is not
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c. Attach fluid bag to buddy™ set. Open the roller clamps of the
administration set and prime the unit assuring no air is visible in
the IV line. Tap the heater unit while priming to expel any air.
d. Turn unit ON.
i. Buddy™: Press ON/STANDBY button on the power
module that is on an IV pole.
ii. Buddy lite™: Press the ON/OFF switch on the battery
housing. Blue LED LIGHT indicates that the unit is ON.
Red LED flashes once if unit is functioning normally. If
this does not occur, unit needs to be serviced.
e. Secure the heater unit in a horizontal position on a flat surface near
f. When use of equipment is completed refer to UW Health Clinical
Policy 4.1.7, Cleaning, Disinfection and Sterilization of Patient
Care Devices and Equipment.
6. Warming temperatures
a. The blood/fluid temperature ranges 38 degrees C plus or minus
(+/-) 2 degrees C (36 degrees C to 40 degrees C) of delivered fluid.
b. The system is designed to maintain normothermic temperature at
flow rates specified (50 mL/min for undiluted RBCs at 10 degrees
C and 80 mL/min for 20 degrees C crystalloids). However, at
higher flow rates, the fluids administered may not heat to
normothermic. There are no external adjustments for the Heater
a. Belmont buddy™
i. See Appendix A (pages 2-4) in the Related section on U-
Connect for details about alarm conditions, system
response and recommended actions.
b. Belmont buddy lite ™:
i. Belmont buddy lite™ battery should be fully charged.
Green solid LED light indicates that the battery is fully
charged. Recharge time requires approximately 2.5 hours
from fully discharged to fully charged.
ii. See Appendix A (page 5) in the Related section on U-
Connect for details about alarm conditions, system
response and recommended actions.
A warmer for warming infusion, transfusion and blood transfusion.
A warmer for preventing hypothermia during longer procedures such as dialysis,
hemofiltration, or apheresis.
1. Warm fluids administered to a patient at flow rates of 0 to 6000 ml/hr (0-
2. The temperature of the heat exchanger is monitored by a temperature
control system and two independent alarm systems. It will switch off
automatically in the event of excessive high temperatures.
a. The mean temperature of the heat exchanger is what is displayed;
this is not the temperature of the medium to be warmed.
3. When the temperature of the heat exchanger is below 15°C, the display
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b. Astotube infusion extensions
5. Steps for setting up Astotherm®plus
a. Attach Astotherm®plus to an IV pole
b. Plug into electrical socket
c. Push the “Standby Button” to switch the mode to On Mode
i. Blue “Standby LED” turns off and green “On LED” turns
d. Press the “Increase Button” or “Decrease Button” to change the
e. Press the “Start Button” for at least one second to switch from On
Mode to Heating Mode. The “Start LED” illuminates green.
i. “Alarm LED” will flash until the setpoint temperature has
ii. If setpoint temperature needs to be changed, press the
“Increase Button” or “Decrease Button” to change the
• Confirm new temperature setpoint within five
seconds by pressing the “Start Button” (green LED)
flashes until “Start Button” has been pressed.
f. Clip the V end of the infusion extension (female Luer Lock) into
the rear tube holder.
g. Starting from the back, wind and insert the infusion extension in a
counter clockwise direction up and around the circumferential
groove of the heat exchanger. Gently pulling makes it easier to
insert and improves the seating of the infusion extension.
h. After leaving the last circulation, clip the infusion extension into
the front tube holder
i. Check the correct position of the infusion extensions
i. Infusions extension is fully in the groove
ii. Infusions extension “skips” no circulation
iii. Infusions extension is not kinked or twisted in itself
j. Connect the infusion extension with the infusion set of liquid
k. Prime the infusion system: allow fluid to flow until no air is
observed in the infusion line and the lines are completely filled
l. Connect the patient side end of the infusion extension to the patient
cannula and ensure a good fixation
6. Steps for discontinuing Astotherm®plus set-up
a. Discontinue infusion
b. Press the “Standby Button” for one second to switch off
i. All indicators turn off, the LED turns blue
c. Disconnect the infusion extension from the cannula
d. Wrap the infusion extension out from the circumferential grove of
the heat exchanger
e. Clean and disinfect Astotherm®plus after each use according to
hospital policy 4.1.7 Cleaning, Disinfection and sterilization of
Patient Care Devices and Equipment.
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7. Alarms and Troubleshooting
a. Except for the low temperature alarm, all alarms switch the heating
function off immediately
b. Low Temperature Alarm
i. Display shows an actual temperature 4° or more bleow the
setpoint temperature and “Alarm LED” flashes yellow and
alarm sounds every 2 minutes for 15 seconds
• Maybe caused by the inlet temperature of the liquid
is too low and the flow rate is too high
A. Reduce flow rate
• Warmer is defective
A. Contact Mechanical Engineering
c. Excessive Temperature Alarm
i. Display shows the current temperature which drops slowly
after the alarm was activated, “Alarm LED” flashes yellow,
“Start LED” flashes green, and audible alarm sounds
• External heat source (i.e. sunlight, radiator) or
ambient temperature too high
A. Eliminate the heat source and/or select a
B. Press the “Start Button” to switch the device
back to Heating Mode or the “Standby
Button” to switch device to Standby Mode
• Warmer is defective
A. Contact Mechanical Engineering
d. Cable Break Alarm
i. Display shows “---“, “Alarm LED” flashes yellow, “Start
LED” flashes green, and audible alarm sounds
• Warmer is defective
A. Contact Mechanical Engineering
e. Processor Alarm
i. Device is plugged in, “Alarm LED” flashes yellow, audible
alarm and none of the buttons can cause a device recation
• Temporary program fault
A. Press the “Increase Button” and the
“Decrease Button” at the same time until the
device switches to Standby Mode. Unplug,
wait one minute and plug back in.
f. Standby Mode Failure
i. “Standby LED” is off and the device cannot be switched to
On Mode by pressing the “Standby Button”.
• Make sure device is plugged in and electrical socket
works. When plugged into a working electrical
socket press the “Standby Button” and then the
“Start Button” to switch device to Heating Mode
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V. UWHC CROSS REFERENCES
A. Appendix A, Alarm Conditions and Recommended Actions (see Related section
B. Hospital Administrative Policy 8.12, Blood and Blood Component Transfusion
(Requiring Pre-Transfusion Testing)
C. Hospital Administrative Policy 8.94, Massive Transfusion Procedure
D. UW Health Clinical Policy 4.1.7 , Cleaning, Disinfection and Sterilization of
Patient Care Devices and Equipment
A. Astotherm®plus: warmer for blood, intravenous fluids and irrigation fluids.
Instructions for use. Germany: Stihler Electronic GmbH.
B. Belmont buddy ™ and buddy lite ™ Operator’s Manual. Billerica, MA: Belmont
Rapid Infuser Operator’s Manual. Billerica, MA: Belmont Instrument
D. Level 1
Rapid Infusor/Warmer Instructions for Use Manual 2004.
E. Lynn-McHale Wiegand, D. J. (Ed.) (2011). AACN procedure manual for critical
care (6th Ed.). St. Louis, MO: Elsevier Saunders Co.
F. Proehl, J. A. (2009). Emergency nursing procedures (4
Ed.). St Louis, MO:
Elsevier Saunders Co.
G. Ranger Blood/Fluid Warming System Operator’s Manual. (1999). Eden Prairie,
MN: Augustine Medical, Inc.
H. Teruya, J. (2010). Administration and complication of red cell transfusion in
infants and children. UpToDate. Retrieved from
VII. REVIEWED BY
Clinical Nurse Specialist, Cardiac Surgery
Clinical Nurse Specialist, Emergency Services
Clinical Nurse Specialist, Trauma Life Support Center
Clinical Nurse Specialist, Pediatric Intensive Care
Clinical Nurse Specialist, Oncology Services
Nursing Patient Care Policy and Procedure Committee, October 2016
Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer