A Method for Preventing Throat Pack Retention

Abstract

To the Editor: Recently, at our institution, the issue of postsurgical removal of oropharyngeal throat packs came into focus. A child who had undergone a 12-h reconstructive craniofacial procedure, under general endotracheal anesthesia, was anxious and dyspneic in the postanesthesia care unit. The cause was a pharyngeal throat pack inadvertently left in place after the operation. The problem was promptly recognized and the throat pack removed. The patient's postoperative course was otherwise unremarkable. Multiple teams of anesthesiologists and surgeons are often involved in the care of patients during lengthy surgical procedures. Whenever this situation exists, there is a greater chance that vital information may not be communicated to other members of the operating room team. Despite vigilance and the best of intentions, the potential for this problem always exists when packs are inserted into the oropharynx. We present a method for preventing this potentially catastrophic occurrence. For such operations, we attach a heavy gauge suture to the end of the throat pack (usually a 30-cm length of CONFORM Registered Trademark 2-in. stretch bandage; Kendall Healthcare Products, Mansfield, MA). The purpose of the pack is to decrease the chance that blood and debris will pass into the trachea or esophagus. It is inserted into the oropharynx by the anesthesia team immediately after endotracheal intubation. The suture extends several centimeters outside the mouth. Intraoperatively, it is readily apparent to surgeons, nurses, and anesthesia personnel that there is another foreign object besides the endotracheal tube present in the oropharynx. In addition, the suture facilitates removal of the throat pack at the end of the operation. Simply pull the suture, while stabilizing the endotracheal tube, and the connected pack follows. We do not feel that significant risk, expense, or effort is added as a result of this precaution. Such a system may not be suitable for intraoral procedures in which the attached suture might present an obstacle to the surgeon. In such instances, there is potential for traction on, and displacement of, the endotracheal tube. Other clinicians have suggested suturing the pack to the endotracheal tube or placing a label on a prominent site (i.e., the forehead) to act as a reminder [1,2]. Both of these methods are useful in many situations. It has been noted, however, that the sutured pack/endotracheal tube may be more difficult for inexperienced anesthesia personnel to insert. Further, with our craniofacial procedures, there may be no easily viewed or nonsterile location on the patient to which a label might be affixed. Finally, we have considered allowing the end of the throat pack to protrude from the mouth. However, we do not suggest this because the lacy material might catch on an object intraoperatively.Figure 1: Heavy gauge suture tied to throat pack material.Anytime multiple teams of anesthesia personnel care for a patient, the potential for failing to communicate vital information is magnified. There are many methods for ensuring consistent transmittal of this information. We feel that an extra measure of safety is added by tagging an inserted throat pack with simple suture. This practice is especially well suited to procedures such as lengthy craniofacial reconstruction. Neither author has any commercial association with Kendall Healthcare Products. Michael F. Najjar, MD Jeffrey Kimpson, MD Department of Anesthesiology, Providence Hospital, Southfield, MI 48075