Correspondence Address:
Dr. Manbir Kaur
Department of Anesthesia and Critical Care, All India Institute of Medical Sciences, Jodhpur - 342 005, Rajasthan
India

Full Text



Oropharyngeal packs or throat packs are commonly used intraoperatively to prevent aspiration of blood and surgical debris into the airway. Retention of throat packs by oversight can lead to life-threatening complications.[1],[2] We wish to highlight our experience of the consequences of miscommunication and lack of documentation between surgeons, anaesthesiologists and nurses.

A 40-year-old female with limited mouth opening of 1.5 fingers and limited neck extension was posted for release of temporomandibular joint ankylosis. Awake fibreoptic-guided nasotracheal intubation was performed and a throat pack was inserted. The surgery was completed uneventfully but just after extubation, the patient became restless and started desaturating with an accompanying paradoxical respiratory pattern. We suspected incomplete recovery from neuromuscular blockade or laryngospasm. As bag mask ventilation was ineffective, it was decided to reintubate the patient using a C-MAC videolaryngoscope. A blood-soaked gauze pack was found during videolaryngoscopy which was removed immediately.

Later, we realised that handing over of clinical details was possibly incomplete during the changeover of anaesthesiologist in the evening while the surgery was still in progress. The first anaesthesiologist who inserted the throat pack forgot to communicate this to the relieving anaesthesiologist in addition to missing its documentation in the anaesthesia record.

Several methods have been suggested in literature to prevent the retention of throat packs such as attaching a suture to the throat pack, leaving a part of it outside the mouth or applying a wristband indicating the presence of a throat pack.[3]

The WHO Surgical Safety Checklist, besides mentioning that nothing is left inside the body cavity at the 'sign out' time, also highlights that the whole team is responsible for this action.[4] In our case, non-compliance with the WHO checklist, along with a lack of communication among surgical, anaesthesia and nursing personnel, became important reasons for the incident.

A debriefing involving the whole operating team followed wherein the importance of documentation of throat pack insertion and its removal was emphasised to prevent possible mishaps due to its inadvertent retention. This 'near miss' prompted us to prepare a robust protocol regarding insertion and removal of throat pack and its documentation. We also started mentioning the use of throat packs on the operating room board, just as use of surgical gauzes and pads is mentioned. In addition, we started documenting the placement and removal of a throat pack on the anaesthesia record and designating a person to ensure its proper removal after surgery.

This case once again highlights the need to follow the WHO Surgical Safety Checklist and the importance of proper communication among healthcare professionals. Eternal vigilance on the part of all concerned can save the day.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References