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LETTER TO THE EDITOR
Year : 2014  |  Volume : 7  |  Issue : 3  |  Page : 251-252

The curious case of a missing throat pack: our experience and lessons learnt


Department of Anesthesia, Pain & Surgical Intensive Care, Max Superspeciality Hospital, Shalimar Bagh, Delhi, India

Date of Submission16-Oct-2013
Date of Acceptance19-Aug-2014
Date of Web Publication27-Aug-2014

Correspondence Address:
Uma Hariharan
BH 41, East Shalimar Bagh, Delhi 88
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.139527

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How to cite this article:
Hariharan U, Sharma P, Sharma D, Sharma N. The curious case of a missing throat pack: our experience and lessons learnt. Ain-Shams J Anaesthesiol 2014;7:251-2

How to cite this URL:
Hariharan U, Sharma P, Sharma D, Sharma N. The curious case of a missing throat pack: our experience and lessons learnt. Ain-Shams J Anaesthesiol [serial online] 2014 [cited 2019 Sep 19];7:251-2. Available from: http://www.asja.eg.net/text.asp?2014/7/3/251/139527

A 64-year-old female patient was posted for dorsolumbar disk surgery under general anesthesia in the prone position. She was a known hypertensive and diabetic patient, well controlled on medication. In accordance with accepted practice both worldwide and in our institution, a throat pack was inserted around the endotracheal tube of our patient using Magill forceps, after a standard general anesthesia and before prone positioning for spine surgery. In our theater, we recorded throat pack placement on the patient, in the anesthetic notes as well as with the theater swab count. After an uneventful surgery, the patient was turned supine and tube placement was confirmed. While preparing for reversal of neuromuscular block, direct laryngoscopy was performed to remove the inserted throat swab. Surprisingly, the throat pack was nowhere to be seen in the oral cavity, even after thorough searching and suctioning. Immediately, a decision to defer extubation was taken. Fiberoptic bronchoscopy was performed through the endotracheal tube with the patient still under anesthesia. There was no airway foreign body and the throat pack was not found. In the meantime, an otorhinolaryngologist was called to perform a rigid esophagoscopy until the lower end of the esophagus. Again, the throat pack could not be found. It was hypothesized that, as the throat pack was not there in the respiratory tract or the esophagus, it could have migrated further down the digestive tract. After extensive discussions, it was decided to extubate the patient and to send her for further investigations (endoscopy and scanning) to trace the throat pack in consultation with a gastroenterologist. As per the standard procedure, intravenous reversal agent was given after return of spontaneous ventilation and endotracheal tube was removed after thorough suctioning. All this while, the patient's vital parameters were within normal limits. Within minutes of extubation, the patient had a bout of vomiting and she vomited out the entire throat pack in her vomitus. Immediately, the patient was turned to lateral position; suctioning was performed; and the vomited throat pack was collected and preserved. Once patient had recovered, she was shifted to the postanesthesia care unit for monitoring. Postoperative course was uneventful and the patient was discharged after 3 days in a stable condition.

Throat packing has been performed from time immemorial for soaking blood and secretions during surgery as well as for minimizing air-leak around tracheal tubes. There are several case reports that discourage the use of throat packs because of the attendant complications such as trauma during insertion, postoperative persistent sore throat, and retained throat packs [1,2]. Although throat pack is used, it should be anchored or taped [3,4] so that it is not inadvertently displaced. The use of a radio-opaque strip [5] in the pack is beneficial in detecting its position on C-arm. In our case, as the throat pack did not have any radio-opaque strip, intraoperative radiograph could not have helped to trace the pack. It can also get misplaced during surgery and can even go undetected, if not properly recorded or forgotten [6,7]. Swallowing and respiratory movements can cause displacement of the throat pack. Proper precautions should be taken to prominently display and promptly record all inserted oral packs as part of the safety check list, so that they are remembered to be removed before extubation. If at all oral pack goes missing, then every possible effort should be taken to search and retrieve it, without compromising patient safety.


  Acknowledgements Top


 
  References Top

1.Crawford BS. Prevention of retained throat pack. BMJ 1977; 49:1029.  Back to cited text no. 1
    
2.Gray H, Brett C, Worthington J. Retained throat packs represent a potentially catastrophic airway hazard. Anaesth Intensive Care 2006; 34:119-120.  Back to cited text no. 2
[PUBMED]    
3.Najjar MF, Kimpson J. A method for preventing throat pack retention. Anesth Analg 1995; 80:204-212.  Back to cited text no. 3
    
4.Scheck PA. A pharyngeal pack fixed onto the tracheal tube. Anaesthesia 1981; 36:892-895.  Back to cited text no. 4
[PUBMED]    
5.To EWH, Tsang WM, Chan YM. A missing throat pack. Anaesthesia 2001; 56:383.  Back to cited text no. 5
    
6.Burden RJ, Bliss A. Residual throat pack - a further method of prevention? Anaesthesia 1997; 52:806.  Back to cited text no. 6
    
7.Stone JP, Collyer J. Aide-memoir to pharyngeal pack removal. Anesth Analg 2003; 96:304.  Back to cited text no. 7
[PUBMED]    



This article has been cited by
1 Systematic review of benefits or harms of routine anaesthetist-inserted throat packs in adults: practice recommendations for inserting and counting throat packs
V. Athanassoglou,A. Patel,B. McGuire,A. Higgs,M. S. Dover,P. A. Brennan,A. Banerjee,B. Bingham,J. J. Pandit
Anaesthesia. 2018;
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