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Human Error in Throat Pack Management: Report of Two Cases

Baranger, Violaine MD*; Bon Mardion, Nicolas MD, PhD; Dureuil, Bertrand MD, PhD*; Compère, Vincent MD, PhD*

doi: 10.1213/XAA.0000000000000348
Case Reports
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Throat packs are frequently used after tracheal intubation during ear, nose, and throat surgery. We report 2 cases of complications related to throat packs retained at the end of surgery. Miscommunication between anesthesiology and surgery teams on throat pack management led to an upper gastrointestinal endoscopy examination under general anesthesia in the first case and to severe respiratory distress requiring tracheal reintubation in the second case. Our 2 case reports highlight the importance of good communication between anesthesiology and surgery teams and of standardized procedures and checklists for the management of throat packs to ensure patient safety.

From the *Department of Anesthetics and Intensive Care, Rouen University Hospital, Rouen, France; and Department of ENT Surgery, Rouen University Hospital, Rouen, France.

Accepted for publication March 17, 2016.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Vincent Compère, MD, PhD, Department of Anesthetics and Intensive Care, Rouen University Hospital, 1 Rue de Germont, 76031 Rouen, France. Address e-mail to vincent.compere@chu-rouen.fr.

The throat pack is a posterior pharyngeal tampon. It is commonly inserted after nasotracheal or oral intubation as part of ear, nose, and throat (ENT), maxillofacial, and dental surgery. The purpose of a throat pack is to protect the airway and digestive tracts from surgical residues (liquid, dental, or bone) and to reduce postoperative nausea and vomiting.1–3 However, throat packs are associated with several complications, the most frequently observed being a sore throat during the postoperative period. In addition, rare but serious situations are reported in cases of failure to remove the throat pack.4,5 Despite 20 years of standardized procedure in our tertiary care center, we describe here 2 complications directly related to the failure of throat pack management. Both patients have given their written consent for publication of these 2 case reports.

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CASE REPORT 1

A 57-year-old man, with nasopharyngeal cancer in remission (ASA physical status II), presented for meatotomy. Induction and maintenance of general anesthesia (propofol and remifentanil) proceeded uneventfully. Immediately after orotracheal intubation (7.5-mm tracheal tube), the anesthesiologist inserted a throat pack in the patient’s posterior pharynx. Right endoscopic meatotomy was achieved without difficulty. At the end of the surgical procedure, the patient was tracheally extubated in the operating room. No information regarding throat pack removal was given to the postanesthesia recovery room team that was unable to confirm the removal of the throat pack in the operating room. Because clinical examination and chest radiography were normal, an upper gastrointestinal endoscopy was then performed under general anesthesia to check whether the throat pack was still retained. Although examination by gastrointestinal endoscopy was unable to locate the throat pack, it showed excess blood in the esophagus, the stomach, and the second duodenum. The surgical team had likely removed the pack at the end of the surgical procedure but had not updated the patient’s chart accordingly. The patient was discharged and able to go home late afternoon the same day.

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CASE REPORT 2

A 34-year-old woman, ASA physical status I, presented for meatotomy under general anesthesia. After anesthetic induction and orotracheal intubation (7-mm tracheal tube; Cormack 1), the nurse anesthetist inserted a throat pack in the patient’s posterior pharynx. The scheduled surgical procedure was achieved, the surgical resident then left the operating room, and the senior surgeon remained alone to perform a second surgical procedure, namely ablation of a nevus of the upper lip. This second procedure was not initially planned but was added at the express request of the patient just before induction of general anesthesia. At the end of the second surgical procedure, the senior surgeon informed the anesthesiology team of the removal of the throat pack, assuming that the surgical resident had removed the throat pack as is usual practice. The patient was then transferred to the postanesthesia recovery room where tracheal extubation was performed. A few minutes later, the patient developed sudden respiratory distress with laryngeal dyspnea associated with hypoxia (80% Spo2) under oxygen at 6 L/min delivered via a nasal cannula. Posterior pharyngeal obstruction was immediately suspected, but clinical examination was difficult and incomplete and could not identify the obstruction mechanism. Despite a short and partial amelioration with administration of an aerosol of corticosteroid and adrenaline, general anesthesia was performed. After a crush induction (succinylcholine/propofol), the obstruction in the glottis was identified by laryngoscopy examination as the retained throat pack, which was then removed, and the patient was intubated. Because respiratory distress had immediately disappeared, the patient’s trachea was extubated after 15 minutes of mechanical ventilation. Chest radiography performed before extubation was normal. The patient remained in the hospital for 12 hours postoperatively. She was informed of the reasons for this complication. Subsequently, she developed posttraumatic stress for which she has initiated a financial compensation procedure.

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DISCUSSION

The use of throat packs remains common; anesthesiologists and surgeons report systematic (39%) and occasional (52%) use of throat packs in ENT surgery.6 Furthermore, the anesthesiology team is most often responsible for insertion (82%) and removal (68%) of the throat pack. Throat pack management is critically important; the French authorities have issued guidelines for risk situations (2009 accreditation program).5 Indeed, several case reports in the literature have focused on the consequences of retained throat packs.7 The most important of these are respiratory complications, like in our second case. There is less clinical impact from retention of a throat pack in the esophagogastroduodenal tract, but this complication lead to additional invasive investigations such as the endoscopy reported in our first case.

Miscommunication between surgery and anesthesiology teams was clearly involved in both of these cases. Furthermore, the last minute addition of a nonscheduled surgical procedure may have interfered with the protocol for nasal throat pack management, thus increasing the risk of complications. A multidisciplinary team briefing using a safety checklist has been demonstrated to reduce the number of communication failures in the operating room, to promote team communication,8 and to decrease major complications.9

The presence of a throat pack was not included in our checklist because we used the World Health Organization Surgical Safety Checklist that is a prominent example of a surgical checklist intended to ensure safe surgery and minimize complications.10–12 Indeed, the presence of a throat pack was only reported on the anesthesiology chart but not on the surgery chart. For selected procedures such as ENT surgery, we propose including the item “throat pack” on the operating room checklist.

Moreover, with the development of standards and protocols, procedures have been described to reduce the risk of throat pack complications. For example, the same dedicated person should perform both the insertion and removal of the throat pack.13,14 Monitoring the pack (insertion and removal) must be reported in real time. It is usually possible to leave a length of the pack hanging externally. After removal, it must not be discarded but must remain in view of the entire team during the entire recovery process. The literature has described a “throat pack in situ” label on the cap of the assistant surgeon indicating the presence of a throat pack as long as it remains in place.15

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CONCLUSIONS

Our 2 case reports underline the need for a very high level of vigilance when using a throat pack. Failure to remove the throat pack is possible and can be associated with potentially dramatic complications. Miscommunication is often the leading factor involved in accidents and could be improved by (1) including the use, insertion, and removal of a throat pack in the anesthesiology and surgery checklist; (2) displaying a label on the cap of the operator indicating the presence of a throat pack as long as it remains in place; and (3) debriefing to discuss possible postoperative complications.

Finally, the risk–benefit ratio of the posterior pharyngeal tampon must be discussed, and its use should probably be restricted to procedures with the most bleeding or in cases of high risk of ingesting solid residues (bone, dental material, etc.). In the latter case, and as part of nasal surgery, positioning nasal plugs under direct or endoscopic view could be an alternative to the throat pack.

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ACKNOWLEDGMENTS

We are grateful to Nikki Sabourin-Gibbs, Rouen University Hospital, for her help in editing the manuscript.

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REFERENCES

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