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BJA Advance Access originally published online on August 6, 2004
British Journal of Anaesthesia 2004 93(4):586-589; doi:10.1093/bja/aeh236
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© The Board of Management and Trustees of the British Journal of Anaesthesia 2004

CASE REPORT

Thermal injuries in three children caused by an electrical warming mattress

D. J. Dewar1, J. F. Fraser2,*, K. L. Choo3 and R. M. Kimble4

1 University of Queensland, Brisbane, Australia. 2 Intensive Care Medicine, Prince Charles Hospital and Department of Paediatrics and Child Health, Royal Children's Hospital, Brisbane, Queensland, Australia. 3 Paediatric Surgery and 4 Burns, Royal Children's Hospital, Brisbane, Queensland, Australia

* Corresponding author: J. Fraser, University of Queensland, Department of Paediatrics and Child Health, 3rd Floor, RCH Foundation Building, Royal Children's Hospital, Queensland 4029, Australia. E-mail: j.fraser{at}uq.edu.au

Peroperative hypothermia is recognized to increase mortality and morbidity, and the paediatric anaesthetist faces specific challenges resulting from the increased body surface to volume ratio, particularly in smaller children. We describe three children who were consecutive patients on one operating list and sustained severe thermal injuries. These were due to a malfunctioning electrical heating mat, despite appropriate use and monitoring by the attending anaesthetist. It is rare for thermal warming devices to cause injury. We review the use of heating mats, and suggest modifications in their manufacture which may minimize the risks associated with heating devices.


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