Articles and Case Studies

Beware retained throat pack

31 Mar 2007

Dr Sara Bird

by Dr Sara Bird

Consider this case. The 24 year old patient was scheduled to undergo prolonged oral surgery.

At the request of the surgeon, the anaesthetist placed a throat pack at the start of the procedure. The surgery was uneventful. The patient was extubated without any complications and he was transferred to the recovery ward. The patient coughed up the throat pack some hours later on the ward. He was very distressed and later wrote to the anaesthetist complaining that he was suffering from nightmares as a result of the events surrounding the retained throat pack. The patient refused to pay the ‘gap’ fee for the anaesthetic. After discussion with MDA National, it was agreed that it would be reasonable for the anaesthetist not to pursue the ‘gap’ payment. MDA National assisted the member in preparing a response to the patient’s letter, including the offer to waive the ‘gap’ payment.

Discussion

In this case, although the pharynx was sucked out under direct vision at the end of the procedure, the blood stained pack was not seen until the patient coughed it up several hours post operatively. Sporadic reports of this complication continue to occur, sometimes with disastrous consequences for the patient. A number of strategies have been proposed in the literature to prevent retention of throat packs, including:

  • labelling the forehead of the patient;
  • attaching a label at the end of the tracheal tube;
  • fixing the pack onto the tracheal tube at a predetermined site; and
  • recording the pack as part of the count sheet.

 

Alertness to the danger to the airway and a protocol for handling surgical packs, including throat packs, by theatre staff, the surgical team and the anaesthetist are critically important for prevention of similar mishaps.

Clinical, Anaesthesia, Surgery
 

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