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BJA Advance Access published online on August 6, 2004
British Journal of Anaesthesia, doi:10.1093/bja/aeh236
© 2004 by The Board of Management and Trustees of the British Journal of Anaesthesia
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Accepted June 14, 2004

Case Report

Thermal injuries in three children caused by an electrical warming mattress

D. J. Dewar 1, J. F. Fraser 2*, K. L. Choo 3, R. M. Kimble 4

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; University of Queensland, Department of Paediatrics and Child Health, 3rd Floor, RCH Foundation Building, Royal Children's Hospital, Queensland 4029, Australia
3 Paediatric Surgery, Royal Children's Hospital, Brisbane, Queensland, Australia
4 Burns, Royal Children's Hospital, Brisbane, Queensland, Australia

* To whom correspondence should be addressed. E-mail: j.fraser{at}uq.edu.au.


  Abstract

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.

Keywords: anaesthesia, paediatric; burns; equipment, warming mattress; measurement techniques; monitoring.
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