According to the new recommendations of opioids prescription, there is no place for the use of transdermal fentanyl in the patients with chronic non-malignant pain [1]. In practice it is occasionally still used by some pain management specialists due to the advantages of delivering a steady dose and improving patient compliance. However, intoxications with large fatal outcomes have been widely reported in the literature. Wearing a fentanyl patch under heat sources such as heating pads, electric blankets, saunas, heated waterbeds, hot baths or sun bathe may increase the amount of fentanyl that reaches the blood and can cause life-threatening breathing problems and death. Burn injuries associated with hot air sauna are rare [2] but associated with complex injury with deeper tissue destruction [3].

Case Report

Written informed consent was obtained by the patient for publication of this case. We present the case of a 48-years-old Caucasian male patient who suffered severe burns by falling unconsciousness in a hot sauna.  In past history amphetamine abuse, Attention Deficit Disorder (ADD) treated with dexamphetamine, depression, obesity, sleep apnea. About 7 years ago received initially weak opioids for treating of right hip pain related with arthrosis. The opioids doses escalated and after gastrointestinal bleeding due to duodenal ulcers in 2016 he received fentanyl patches. Unfortunately, he failed to reduce his consumption and after a duodenal switch operation in 2016 he continued to use for his hip pain relatively high doses fentanyl patches 100µg/h. One year later, the patient was found unresponsive in hot air sauna with a fentanyl patch applied on his skin. It was unclear how long time passed until the patient was found unconsent Upon arrival in the emergency department the patient displayed signs of opioid overdose (pinpoint pupils, hypoventilation, respiratory frequency 8/min, saturation 86%, hypoxia PaO2=7.4 pKa). The patient was drowsy and confused (RLS 3), but responds to strong stimulation. Laboratory test showed an impaired renal function with creatinine 174 mmol/L, GFR=40 mL/ml/1,73, rhabdomyolysis with myoglobin 3000 ug/L and metabolic acidosis (BE=-6.3, Lactate=6.2 mmol/L). Urine drug test was positive at admittance for opioids and amphetamine. RLS 3/8). His core temperature was 39.2 °C due to accidental hyperthermia.  The patient was intubated in emergency department and underwent CT which couldn`t revealed other injuries. Clinical examination revealed burns covering 4% of Total Body Surface Area (TBSA) with a mixed depth accordingly. Superficial dermal burns on the neck (0.75% TBSA) back (3,0% TBSA) and trunk (0,25% TBSA). Deep dermal burns were seen on the skull 025% TBSA.  The patient was moved to the burn unit for demarcation of the burns and was treated with dressing changes every other day. As anticipated with hot air sauna burns, his burns developed into full thickness skin burns and after six days the burns were clearly demarcated. Necrotic areas were excised down to the fascia on the neck, back, skull, and abdomen. All burns were grafted with split thickness autologous skin grafts. The skin grafts on the scalp, the neck and back became infected with staphylococcus aureus and a majority of the grafts were lost. The patient was put on antibiotics and underwent dressing changes daily. Nineteen days after the injury further revision of the burn wounds was performed on the scalp, back and neck. In addition, parts of the trapezius muscles were removed due to necrosis and covered with split thickness skin grafts. On the scalp the tabula externa was removed and covered with dermal substitute (Nevelia^Ò). The patient was discharged after 30 days and planned for a third operation to cover the dermal substitute on the scalp with split thickness skin graft. However, the dermal substitute was accidently removed and the patient received a double rotation flap to cover the defect.  In regular follow ups during 18 months the patient showed good skin quality and was not in need of any additional treatment. The patient complained during hospitalization of severe pain to the sites of injury and Acute Pain Services were contacted. He received opioids, for his nociceptive pain and antiepileptic, anti-depressive medication for his neuropathic pain. On discharge he was prescribed opioids and adjuvants and followed by Transitional Pain Services. His regimen failed to improve his persistent pain and three years after burn injury he received opioid substitution with buprenorphine 16 mg/day.