Retained throat packs represent a potentially catastrophic airway hazard.
The operation proceeded uneventfully and the pack was removed by the surgeon at the end of the procedure. A quick inspection by surgical, anaesthetic and nursing staff showed that the pack was apparently intact, with minimal blood staining.
Direct laryngoscopy of the child's upper airway was then performed by the anaesthetic team revealing a small piece (approximately 1.8 cm X 1 cm X 1 cm) of foam lying in the pharynx. This was removed with Magill forceps and extubation and recovery proceeded uneventfully.
Subsequent detailed inspection of the foam throat pack revealed that a piece, corresponding with that recovered from the child, was missing from the side of the pack (Figure 1).
The most likely cause of the tearing of this foam throat pack was the use of Magill forceps to place the pack at the start of the surgical procedure. The torn piece of foam corresponded to the distal end of the pack, furthest away from the end grasped by the surgeon at the conclusion of the operation.
This case highlights a new hazard with throat packs. Previous reports (1,2) have identified issues related to retained whole packs. In our case the pack had been removed, apparently intact, and accounted for by the operating theatre team. In our theatre we record throat pack placement on the patient, in the anaesthetic notes and with the theatre swab count as previously recommended (2-4). None of these safety checks identified that a piece of foam had torn off the pack.
[FIGURE 1 OMITTED]
Although direct laryngoscopy prior to extubation did demonstrate the torn piece of foam, it is conceivable that it could have been retained in the child's upper airway where its aspiration into the trachea would have had serious consequences.
The use of foam packs adds to this particular hazard for two reasons: firstly they are easy to tear in a way that 'older' gauze packs were not, and secondly they are not radio-opaque, making them impossible to identify radiologically should they become dislodged, inhaled or swallowed (1).
We would like to bring this 'near miss' critical incident to the attention of the anaesthesia community and recommend that in addition to previously published aide-memoirs (2-4), extreme care is exercised when using Magill forceps to place foam throat packs, and close inspection of the removed pack is performed.
(1.) To EWH, Tsang WM, Chan YM. A missing throat pack. Anaesthesia 2001; 56:383.
(2.) Burden RJ, Bliss A. Residual throat pack--a further method of prevention? Anaesthesia 1997; 52:806.
(3.) Stone JP, Collyer J. Aide-memoir to pharyngeal pack removal. Anesth Analg 2003; 96:304.
(4.) Crawford BS. Prevention of retained throat pack. BMJ 1977; 49:1029.
Department of Anaesthesia
Christchurch, New Zealand
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|Author:||Gray, H.; Brett, C.; Worthington, J.|
|Publication:||Anaesthesia and Intensive Care|
|Date:||Feb 1, 2006|
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