|LETTER TO EDITOR
|Ahead of print publication
Throat packs: Protocols never to be violated
Sonia Bhan, Debashish Paul, Shalendra Singh, Nipun Gupta
Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
|Date of Submission||24-Jan-2020|
|Date of Decision||23-Feb-2020|
|Date of Acceptance||06-Mar-2020|
|Date of Web Publication||12-Sep-2020|
Anaesthesiology and Critical Care, Armed Forces Medical College, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
We want to share an incident of retained throat pack in a surgical case of carcinoma oral cavity. Although not much reported, it is one of the most dreaded iatrogenic causes that can increase the rate of morbidity. Hence, we want to sensitize the surgical team about the consequences and where we stand in safety precautions with a throat pack.
A throat pack is a surgical sponge constructed of woven gauze/swab that wicks up fluid and prevents surgical debris from entering the patient airway or digestive tract.
Throat packing has been performed since time immemorial during head-and-neck and maxillofacial surgeries. The indications are to provide a physical barrier to prevent leakage of bodily and external fluids into the respiratory and digestive passages, to prevent leakage of gases around the tracheal tube during the provision of general anesthesia, and to stabilize the artificial airway device to prevent displacement.,
There are several case reports that discourage the use of throat packs because of the complications, such as trauma during insertion, postoperative persistent sore throat, and retained throat packs.
A 78-year-old male, known hypertensive and tobacco chewer, a case of carcinoma oral cavity and carcinoma base of the tongue on the left side, was posted for left hemimandibulectomy with modified radical lymph node dissection and pectoralis major myocutaneous flap. The patient was accepted in ASA Physical Status Classification II. Written informed consent including consent for emergency tracheostomy was taken. General anesthesia was administered. Awake fiber optic intubation was done placing a nasal flexometallic tube. A throat pack was inserted around the endotracheal tube of our patient using Magill forceps. Once we were comfortable with all standard monitoring, including invasive blood pressure, the patient was handed over to the surgical team. Hemodynamic instability was observed in the intraoperative period and so he was placed on inotropic support. In view of prolonged surgery, intraoperative hemodynamic instability and difficult airway, the patient was not extubated and placed for elective ventilation. Plan for tracheostomy was dropped off.
The next day morning, following T piece trial and cuff leak test, the patient was extubated. The patient was comfortable but after 45 min, or so, the patient became restless, tachypneic, and started desaturating. Patient presented with rapid shallow breathing and the patient wanted to cough out something. Quick laryngoscopy under local spray (10% lignocaine) revealed that the patient retained the throat pack. Considering the gradual desaturation and anxiety, the patient was deeply sedated followed by mask ventilation. Throat pack was taken out once situation was under control.
The National Health Services, UK, have formulated a few guidelines for throat pack insertion, which are mainly:
- The indication for throat pack insertion should be discussed by an anesthesiologist and a surgeon, and it should have been documented with absolute indication
- The individual making the decision assumes responsibility for the device. Trained anesthesiologist or surgeons are responsible for the insertion of the pack
- There should be visual as well as documentary checks
- As a visual check, the end of the pack should be left protruding from the mouth
- The anesthesiologist documents insertion on the anesthetic chart
- A “throat pack in situ” sticker is applied to the catheter mount
- The anesthesiologist documents insertion on the swab board.
Ideally, throat packs should be surgically counted sponge. It should be made of radiopaque material for easy identification which was not the case in this incident [Figure 1] and [Figure 2]. Had it been a radiopaque material, it could have been detected in the immediate postoperative chest X-ray.
Any additional pack insertion needs to be communicated to and documented by the anesthesiologist and the swab count by the nurse/operating room technician. Any alteration of the pack by the surgeon should be clearly communicated to and documented by the Anaesthesiologist and/or swab count nurse. Removal of inserted packs should be documented on the anesthetic chart and the swab board. On handing over the patient, the insertion and removal of the throat pack must be communicated to the recovery room staff.,
In this case, it was realized that because of miscommunication among the members of the surgical teams, the throat pack had been left unnoticed. Although we did not land up into serious hazard, the clinical risk associated with the insertion of throat packs is high. This incident could have resulted into serious implications such as prolonged mechanical ventilation, agony of the patient and relatives, possibilities of damaging the flap, and most importantly medicolegal issues. Confirmation before shifting the patient to the intensive care unit was not done, and a check laryngoscopy at the time of or tracheal suctioning was not done.
To conclude it is a learning for all the care givers that leaving a throat pack in situ can lead to a disastrous consequences. Proper communication, displaying and recording of placement, and removal of throat pack are the steps of immense importance. Checking and documenting of inserted throat pack should always be the part of the safety check list. Radio-opaque throat pack should be used and it should be a standard type of throat pack.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his 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
Conflicts of interest
There are no conflicts of interest.
| References|| |
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Gray H, Brett C, Worthington J. Retained throat packs represent a potentially catastrophic airway hazard. Anaesth Intensive Care 2006;34:119-1203.
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Worcestershire, Acute Hospitals NHS Trust, NHS Trust Policy; January, 2014.
Recommendations from National Patient Safety Agency Alerts that Remain Relevant to the Never Events List 2018; January, 2018.
[Figure 1], [Figure 2]