[Fatal burn from a heated mat on the operating table]

A number of heating mats were developed for use on operating tables in order to avoid hypothermia and incidental cardiocirculatory changes in patients undergoing prolonged surgical interventions. Because of inadequate technical safety devices, they can cause burns in patients. We report the case of a patient who, undergoing surgery for an aortobifemoral bypass, died of 2nd and 3rd degree burns after having been placed on a Maquet mat. Other possibilities which may lead to such severe burns are discussed.