Throat Pack Research Articles

Airway obstruction following palatoplasty of a patient with sleep disturbance

Airway obstruction following palatoplasty of a patient with sleep disturbance

Cuff Perforation by Dislocated Electrodes of an Clectromyogram Tube

To the Editor We describe a case of cuff perforation and possible tracheal injury from the electrodes of an electromyogram endotracheal tube (EMG tube) in a 47-year-old female patient undergoing hemithyroidectomy. To monitor recurrent laryngeal nerve integrity, an EMG tracheal tube (Medtronic Xomed, Jacksonville, FL) was to be inserted at the behest of the surgeon. After induction of anesthesia and paralysis (rocuronium 25 mg), conventional laryngoscopy with a Macintosh blade 3 (Macintosh KL 2000, Medicon, Tuttlingen, Germany) revealed an anterior view of the vocal cords (grade 1–2). We were unable to direct the very flexible EMG tube (internal diameter 6 mm) into the relative anterior centrally positioned larynx, even with the use of a Rüsch 5.6 mm stylet (Rüsch, Teleflex, Germany) in a flexed shape. A second attempt with the GlideScope (Verathon, Bothell, WA) was also unsuccessful. Only after the third attempt using the GlideScope and Rüsch stylet was the trachea intubated. After several minutes of uneventful ventilation, tidal volumes began to vary and cuff leakage was diagnosed. To reduce gas leakage, a throat pack was placed allowing surgery to proceed, and no further problems were observed. When the trachea was extubated, blood was aspirated from the oropharynx, the cuff was covered with blood, and inspection of the tube revealed that the cuff was perforated by 1 pair of electrodes that was bent at right angles with the long axis (Fig. 1). No respiratory problems occurred postoperatively, no pharyngeal complications were reported, and the patient recovered without problems.Figure 1: The cuff is perforated by dislocated electrodes.Esther de Kant-Pariama, MD Benedikt Preckel, MD, PhD Wolfgang S. Schlack, MD, PhD Department of Anesthesiology Amsterdam Medical Center [email protected] Els J. M. Nieveen van Dijkum, MD, PhD Department of Surgery Academic Medical Center Amsterdam, the Netherlands

Endoscopic Removal of Throat-Packing Gauze Swallowed During General Anesthesia

Throat packing is commonly placed in the pharynx before starting oral and maxillofacial surgery under general anesthesia to protect the airway from aspiration of blood and surgical debris. Complications such as airway obstruction may arise if any of the throat packing is retained after extubation, and less commonly, swallowing of the throat packing has been reported. We report endoscopic removal of throat packing gauze swallowed during general anesthesia.

Poster 07: Three-Dimensional Facial Analysis Versus Extraoral Impression Casting for Initial PNAM Measurements: A Methodological Comparison

Cleft lip and palate (CLP) is invariably associated with some degree of nasal deformity. Presurgical nasoalveolar molding (PNAM) has been used to reduce the severity of nasolabial deformity prior to surgical repair both in patients with unilateral (UCLP) and bilateral CLP (BCLP). Intraoral (maxillary) and extraoral (nasal) impressions are taken shortly after birth to facilitate fabrication of the PNAM appliance and to provide baseline measurements for comparison to post-PNAM results. General anesthesia with oral intubation and throat packing is often used to obtain these impressions due to risk of airway obstruction in the unintubated neonate.

Throat packs in neuroanaesthesia

Throat packs in neuroanaesthesia

Targeted Distribution of the National Patient Safety Agency Safer Practice Notice on Throat Packs

Using an electronic questionnaire, we tested the effectiveness of professional networks for distributing a National Patient Safety Agency Safer Practice Notice, 'Reducing the risk of retained throat packs after surgery', issued in April 2009. Using professional networks for the targeted distribution of guidance to specific professional groups was found to be effective.

Novel Method to Prevent the Inadvertent Retention of Throat Pack

To the Editor A hazard of throat packs used during surgery in the mouth and pharynx is retention of the pack after tracheal extubation and subsequent total airway obstruction. Several methods to reduce the likelihood of throat pack retention have been described.1–6 Usually, the responsibility for removal of the pack rests with the person inserting it, unless of course a change of anesthesia personnel has occurred. Several remedies to the problem of the retained throat pack include allowing the end of the pack to hang outside of the mouth and also perhaps fastening it to the tracheal tube.2,3 However, the dangling end may result in instruments being caught in the pack,1 and attaching the pack to the tracheal tube makes intubation somewhat more difficult. Placing a suture through the pack has been suggested, but in craniofacial procedures, the suture may not be easily viewed.1 Finally, affixing a label to the patient or to the ventilator announcing the presence of the throat pack has been suggested, but may be difficult because of sterile preparation of the skin or movement of the patient to a different intensive care unit.4 The following describes our method that is simple to apply, adds no cost, and is free of limitations associated with previously described solutions to this problem. After placing the throat pack (usually a 150-cm length, 3-inch gauge) into the pharynx, the free end of the pack protruding from the mouth is tied around the end of the tracheal tube. In addition, a label identifying the pack as a “throat pack in” is affixed to both the throat pack and tracheal tube (Fig. 1). Because both the tube and the throat pack are thus connected to the label, removing the tracheal tube at the end of the case eliminates the likelihood of a retained throat pack and need for laryngoscopy for removal of the throat pack.Figure 1: Showing free end of the throat pack fastened to the tracheal tube and a printed label stating “THROAT PACK IN” is secured with transparent tape to both the tracheal tube and the throat pack.Our suggested method is especially useful in circumstances in which tracheally intubated patients are transferred directly from the operating room to the intensive care unit. Sudhakar Kinthala, MD, FNCA Rajashekar Mudaraddi, MD Kimberly T. Johnny, MBBS Department of Anesthesiology and Surgical Intensive Care Queen Elizabeth Hospital St. Michael, Barbados [email protected]

Reducing the risk of retained throat packs after surgery

Reducing the risk of retained throat packs after surgery

Current Practice and Opinions Regarding the Use of Oropharyngeal Throat Packs in the United Kingdom

: The aim of this study was to establish the current practice and opinions regarding responsibilities when using OPTPs in the United Kingdom. : A total of 330 anonymous questionnaires exploring the use, attitudes, opinions, and experiences of surgeons (n = 180) and anesthetists (n = 150) were disseminated. : The response rate was 82%. Just less than one-third of surgeons and just more than one-third of anesthetists rarely or never use OPTP. Just more than half of the surgeons responding were aware of 1 to 4 nonfatal adverse events. Two surgeons and 1 anesthetist were aware of 1 to 4 fatalities relating to a retained OPTP. There was a marked difference in opinions regarding OPTP removal and whose ultimate responsibility it is to remove. : The use of the OPTP is not routine in the United Kingdom, and adverse incidents occasionally occur when used. It would also seem that, despite the recent publicity and advice documents during the last few years, theater teams may still be at variance with regard to related responsibilities. As such, although objective data emerge, we support a unified practice and policy at the Trust and national level that all teams should adhere to when appropriate.

Anaesthesia for dacryocystorhinostomy

Excessive tearing due to obstruction of the nasolacrimal duct is a common ophthalmic problem. Dacryocystorhinostomy (DCR) is the procedure designed to treat primary or secondary adult anatomical obstruction. External DCR is the traditional surgical approach, however endoscopic DCR can be done. In the past, general anaesthesia (GA) has been considered as the gold standard for DCR surgery; endotracheal intubation and throat pack offer an important function as protective mechanisms of the patient’s airway against blood aspiration. Head up position, hypotensive anaesthesia, incision infiltration with lidocaine/epinephrine together with insertion of nasal pack soaked in decongestant solution are a routine measures to guard against intraoperative bleeding that may hinder surgical site visualization. Increase awareness of regional anaesthesia efficacy contemplated the surgeons towards the use of such techniques. The basic concept of local anaesthesia for DCR involves blockade of infratrochlear, infraorbital and anterior ethmoidal nerves either by separate injections or by local infiltration along with intranasal preparation. It has been found that DCR under regional anaesthesia minimizes intraoperative bleeding, inpatient stay and reduce health care expenditure. Further, many patients prefer regional anaesthesia due to less postoperative pain. These benefits are desirable particularly in elderly population in whom GA constitute a threat for their life.

Throat packs: in your face?

Throat packs: in your face?

Laryngeal mask airway vs. uncuffed endotracheal tube for nasal and paranasal sinus surgery: paediatric airway protection

Risks are anticipated for laryngeal mask airway (LMA) anaesthesia during nasal and sinus surgeries because blood can trickle posteriorly into the hypopharynx and contaminate the airway. This study was conducted to determine whether a LMA could provide adequate airway protection from the expected intraoperative bleeding. After obtaining ethics committee approval, 60 children ASA status I or II, 1-12 years of age, and scheduled for nasal and sinus surgery were randomized to one of two groups, endotracheal tube (ETT) or LMA, with 30 patients in each. Topical lidocaine with adrenaline was used in all patients, and throat packs were used for the ETT group. The airway was examined using a fibreoptic endoscope in order to determine whether blood or tissue debris soiled the supraglottic airway or trachea. After extubation, LMAs and ETTs were examined for soiling by blood and graded on a scale of 0-3. For ETT, the grades were 0, none; 1, contamination above the mark for vocal cord depth; 2, contamination below the mark for vocal cord depth; and 3, contamination interiorly. For LMA, they were 0, no staining; 1, staining on the anterior aspect of the cuff of the LMA; 2, staining inside the cup of the LMA; and 3, staining found in the tube. Blood stains were found in the larynx of one child in the LMA group. In the ETT group, there were three cases of staining (two supraglottic and one in the trachea, P = 0.161). With the LMA, 12 (40%) and 18 (60%) patients had visual contamination scores of 0 and 1, respectively. With the ETT, 14 (46.7%), 10 (33.3%), and six (20%) patients had visual contamination scores of 0, 1, and 2, respectively (P = 0.0123). LMA is a suitable method for paediatric patients undergoing sinonasal surgery because it offers airway protection from blood contamination comparable to that of a standard uncuffed ETT with throat pack.

The current use of oropharyngeal throat packs in the UK

The current use of oropharyngeal throat packs in the UK

One-lung ventilation in a patient with tracheobronchomegaly: a case report and literature review

One-lung ventilation in a patient with tracheobronchomegaly: a case report and literature review

Flexible Laryngeal Mask Airway for Cleft Palate Surgery in Children: A Randomized Clinical Trial on Efficacy and Safety

To evaluate the efficacy of a flexible laryngeal mask airway in children undergoing palatoplasty. Prospective, randomized, single-center study. Jawaharlal Institute of Postgraduate Medical Education and Research. Sixty-six children (American Society of Anesthesiologists physical status 1 and 2) scheduled to undergo palatoplasty were assigned randomly to an endotracheal intubation group (RAE group, n = 33) and a flexible laryngeal mask airway group (FLMA group, n = 33). Peak airway pressure, inspired and expired tidal volume, end-tidal carbon dioxide, lung compliance, and airway resistance were continuously measured after placement of the assigned airway. The percentage leak around the airway was quantified as the leak fraction. Parametric data between groups were analyzed using an unpaired Student's t test and within groups using a one-way analysis of variance. Nonparametric variables were analyzed using the Fisher exact test. In two children, the flexible laryngeal mask airway was displaced from its original position; whereas, one endotrachial tube advanced endobronchially. The leak fraction was significantly higher in the RAE group when compared with that in FLMA group (13.34% +/- 13.74% versus 5.96% +/- 3.78%, p < .05) until the throat pack was applied. Peak airway pressure and resistance were significantly higher in the RAE group compared with the FLMA group at all time intervals, p < .05. During emergence, frequency of coughing, desaturation, and laryngospasm were increased in the RAE group. A flexible laryngeal airway mask is suitable for maintaining the airway and helps in smooth emergence in children undergoing palatoplasty.

Review of the use of throat packs in nasal surgery

Throat packs are employed in nasal surgery to prevent contamination of the upper aerodigestive tract. Their use is thought to reduce the risk of aspiration and post-operative nausea and vomiting. However, use of throat packs may also be accompanied by increased throat pain. In order to inform our clinical practice, the evidence base for throat pack insertion was reviewed. A search was made of the Pubmed database from the 1950s to March 2008. Four randomised, controlled, clinical trials were reviewed. All the trials had significant methodological weakness. In all but one, no power calculations were done. There were inconsistencies in the measurement of pain and heterogeneity of rhinological procedures. The one adequately powered trial could not demonstrate a difference in post-operative nausea and vomiting with the use of throat packs (beta error = 20 per cent). Further, adequately powered trials are required involving patients undergoing rhinological procedures with a higher risk of blood contamination (e.g. functional endoscopic sinus surgery), in order to provide definitive evidence on the morbidity of throat packs in rhinological procedures.

S245 – Pulmonary Complications after Coblation Tonsillectomy

Objectives 1) Evaluate an institutional experience with postoperative pulmonary complications using the Coblator (ArthroCare Corp, Sunnyvale, CA), for pediatric tonsillectomy. 2) Understand how to minimize and prevent pulmonary complications following coblation tonsillectomy. Methods Case series of 4 tonsillectomy patients who developed clinical signs of aspiration following surgery, from October 2006 to January 2008. Results 4 pediatric patients were reported in this case series. All 4 experienced perioperative fever, tachycardia, pulmonary desaturation, and cough following tonsillectomy using the Coblator. In 1 case, the patient had course respirations, a chest x-ray demonstrating diffuse pulmonary infiltrates, and was unable to maintain his oxygen saturations without supplemental oxygenation. In all cases, the symptoms, to include fever, resolved by post-operative day 2. No long-term sequelae were noted. In all cases, the patients were intubated using an uncuffed endotracheal tube. Conclusions Pulmonary aspiration is a possible adverse consequence of oropharyngeal pooling of saline while performing a tonsillectomy using the Coblator. Pediatric patients in whom an uncuffed endotracheal is used are more likely to aspirate the irrigation. Recognition of this potential complication allows the surgeon to take the necessary precautions to avoid this complication by using a throat pack, trendelenberg positioning, and avoidance of pooling of irrigation in the oropharynx.

Recovery profile of patients undergoing nasal surgical procedures: a comparison between sevoflurane and propofol

To compare the recovery profile of sevoflurane and propofol in nasal surgical procedures. A prospective, double blind, randomized study King Abdul Aziz University Hospital, Riyadh, Saudi Arabia, a tertiary care teaching hospital, attached with King Saud University, Riyadh Saudi Arabia. 60 ASA I-II patients age between 18-35 years, and weighing 50-80 kg, scheduled for nasal surgical procedures. Patients were assigned randomly to one of the two groups, the Sevoflurane Group-S (n = 30) & the Propofol Group-P (n = 30). Anesthetic induction was carried out using propofol 2.0mg/kg.in both the groups. Cis-atracurium 0.15mg/kg was given for intubation. Airway was protected with a throat pack around the endo-tracheal tube. Fentanyl 1microgram/kg was given as bolus followed by infusion at a rate of 1 microgram/kg/ hour. Anesthesia was maintained with sevoflurane 2% in Group-S, and propofol infusion at a rate of 200 microgram/kg/min. in Group-P. 50% oxygen in nitrous oxide was given in both the groups. At the end of surgery, patients were extubated after reversal of the neuromuscular block. Immediate recovery was assessed by recording the time to breathe spontaneously, time to extubation, and time of spontaneous eyes movements from the time of giving reversal. Ketoprofen 1.5mg/kg intramuscularly was given to all patients before transfer to (PACU). In PACU, sedation score was assessed for 45 min. Intermediate recovery was assessed by TDT and DSST at 15, 30 and 45 min. Time taken to state name and father's name was recorded. Patients in Group-S breathed significantly earlier than those in Group-P. Group-P showed significantly better performance with TDT at 45 min and with DSST at 30 and 45 min. We conclude that both sevoflurane and propofol provide early and comparable post anesthesia recovery for patients undergoing nasal surgical procedures.

Retained throat packs: results of a national survey and the application of an organisational accident model

Throat packs are commonly placed in the patient's pharynx before oral surgical procedures under general anaesthesia. The pack is thought to protect the airways from aspiration of surgical debris, but if it is retained after extubation it can obstruct the airway. Adverse incidents after retention of throat packs have been reported anecdotally, but to our knowledge the risk management practices undertaken and common events surrounding retention of throat packs, have not been published before. We investigated the management of throat packs in 2007, by sending a questionnaire to maxillofacial surgeons and anaesthetists in the UK. We discuss the results and apply them to an organisational accident model.

Nasogastric tubes again. Another insertion tip: the throat pack

Nasogastric tubes again. Another insertion tip: the throat pack