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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 201-204

Aspirated nasal gauze: An avoidable nightmare!


Department of Anaesthesiology, IMS-BHU, Varanasi, Uttar Pradesh, India

Date of Submission01-Aug-2021
Date of Acceptance06-Sep-2021
Date of Web Publication08-Oct-2021

Correspondence Address:
Dr. Reena
Department of Anaesthesiology, IMS-BHU, Varanasi - 221 005, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/arwy.arwy_44_21

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  Abstract 


Nasal packs are used in a variety of nasal surgeries. Anaesthesiologists should be aware of the numbers used and their appropriate placements. Accidental tracheobronchial aspiration of a nasal gauze can be catastrophic, resulting in increased patient morbidity and mortality. Rapid diagnosis and quick management should be initiated by maintaining a high index of suspicion and resorting to immediate bronchoscopic removal of the aspirated material.

Keywords: Airway obstruction, aspiration, fibreoptic bronchoscopy, nasal pack, retained surgical items, rigid bronchoscopy


How to cite this article:
Rath A, Reena. Aspirated nasal gauze: An avoidable nightmare!. Airway 2021;4:201-4

How to cite this URL:
Rath A, Reena. Aspirated nasal gauze: An avoidable nightmare!. Airway [serial online] 2021 [cited 2022 Jan 27];4:201-4. Available from: https://www.arwy.org/text.asp?2021/4/3/201/327817




  Introduction Top


A retained surgical item that can hinder patient safety is not so common nowadays.[1] Retained surgical items refer specifically to surgical materials (such as instruments, supplies and equipment) which are used by the surgeon, anaesthesiologist and nurse during any surgery. If inadvertently left in situ, patients can suffer major harm.[1] Retained surgical items have been reported for decades from all across the world and various surgical items such as sponges, needles or instruments have been inadvertently left behind in various body cavities after surgical procedures. Early recognition of such incidents and institutional practices to prevent them can help in avoiding potential complications which may range from benign to life-threatening. If the incident involves the tracheobronchial tree, then complications manifest immediately with an urgent need to initiate life-saving interventions. We describe such a case of dislodgement of a gauze that was left in the nasal cavity during the surgery which was aspirated into the left primary bronchus.


  Case Report Top


A 45-year-old male arrived to the outpatient department with complaints of purulent nasal discharge, nasal obstruction and headache for 1 year. Based on clinical and radiological examination, the patient was diagnosed to be a case of bilateral antrochoanal polyp and functional endoscopic sinus surgery was planned under general anaesthesia. A preanaesthetic evaluation revealed an unremarkable medical history. Airway assessment revealed reduced bilateral nasal patency but no features of any anticipated airway difficulty. The patient was instructed regarding fasting and premedication drugs were administered as per our institutional protocol. The patient was asked to breathe through the mouth after regaining consciousness as the nose would be packed at the end of surgery. Informed and written consent was obtained from the patient.

On arrival in the operation theatre, electrocardiogram, noninvasive blood pressure, pulse oximeter and capnograph were established. The patient had a heart rate of 76/min, blood pressure of 124/70 mm Hg and saturation of 100% on room air. The patient was preoxygenated with 100% oxygen and given intravenous (IV) midazolam 2 mg and fentanyl 100 μg followed by propofol 100 mg and vecuronium 5 mg. He was intubated orally with an 8.0 mm ID cuffed polyvinyl chloride endotracheal tube (ETT) and a throat pack was placed and documented in the anaesthesia record by the anaesthesiologist. Anaesthesia was maintained with nitrous oxide, oxygen and isoflurane. At the end of the surgery, laryngoscopy was done to check for haemostasis and the throat pack was removed after gentle oral suctioning. After establishment of spontaneous breathing, residual neuromuscular blockade was antagonised with IV neostigmine and glycopyrrolate. Once the patient established adequate spontaneous breathing, he was extubated in a deep plane and oxygen administered through facemask. Suddenly, the patient developed stridor with abnormal breathing pattern and a fall in oxygen saturation. Bag-mask ventilation was immediately started with 100% oxygen. As auscultation revealed bilateral rhonchi, we assumed that the patient had developed bronchospasm due to trickling of secretions and appropriate management was initiated. Positive pressure ventilation was given after administering 20 mg propofol IV and gentle suctioning of oral cavity was performed. To break the bronchospasm, bronchodilator drugs were injected and IV hydrocortisone 100 mg was given to reduce the inflammatory response. In spite of all these measures, the saturation did not improve and stayed around 75%–80%. A repeat laryngoscopy was performed to check for secretions or ongoing bleeding which could be continuously trickling into the airway. To our surprise, we found a gauze hanging from the posterior nasopharynx into the oropharynx which suddenly got dislodged into the oral cavity. The gauze was retrieved with the help of Magill's forceps. It was around 1.5–2 inches in size and completely soaked with blood. As the saturation continued to drop, we reintubated the patient with an 8.0 mm ID ETT and started ventilating with 100% oxygen. On auscultation, there was reduced air entry and reduced chest movement over the left lung fields. We considered the possibility of dislodgement and aspiration of another gauze which might have been left in the nasal cavity during surgery and been further pushed into left main bronchus during reintubation. The surgeons informed that they had left two adrenaline-soaked gauze pieces in addition to the ribbon gauze in the nasal cavity for haemostasis which unfortunately was not intimated to the anaesthesiologist. Fibreoptic bronchoscopy was done by the cardiothoracic surgeon through the endotracheal tube and a gauze piece was visualised in the left primary bronchus. A flexible biopsy forceps was inserted through the suction channel and the gauze was grasped. As it was not possible to remove the relatively big gauze through the ETT, it was firmly held by the forceps and brought up to the lower end of the ETT. Under fibreoptic bronchoscopic control, the ETT along with the gauze, now held firmly by the forceps, was removed as a single unit. During the entire procedure, the haemodynamics remained stable, but oxygen saturation did not rise above 80%. Bronchoscopic removal of the gauze took around 5 min. The patient was intubated with a fresh 8.0 mm ID ETT and ventilated with 100% oxygen. The oxygen saturation quickly rose to 100%. The patient was shifted to the intensive care unit where a chest X-ray revealed collapse of the lateral basal segment of the left lung. We electively ventilated the patient and extubated him after 4 h when his condition improved.

The next day, a meeting was held between the surgical team, anaesthesia team and operation theatre staff. The already existent institutional protocol was reiterated to prevent such a catastrophe in the future. The importance of communication between all team members was emphasised. An additional checklist specifying the do's and don'ts during the perioperative period was created.


  Discussion Top


Retained surgical items have become relatively uncommon nowadays due to better surgical practices, accounting standards and technologies. Several case reports have mentioned retained surgical items inside body cavities. While various items such as sponges, gauze, needles, blades, scalpels or scissors have featured among retained items, the most common are gauze pieces accounting for 48%–69% of all items.[2],[3],[4]

Nasal packs form an integral part of nasal surgery. They are used to reduce postoperative bleeding from the nasal cavity. While a ribbon gauze is generally used to pack the nasal cavity, two adrenaline-soaked gauze pieces were used in addition by the surgeon to obtain haemostasis. The practice of using unaccounted small gauze pieces should be highly discouraged. Dislocation of such haemostatic gauzes may occur independent of the size and type used as long as they are able to pass through the choana.[5] Moreover, placement of packs and their removal should be the joint responsibility of the surgeon, anaesthesiologist and scrub nurse to avoid such potentially catastrophic events.

At the start of the event, rhonchi were heard bilaterally. Hence, we started positive pressure ventilation as a result of which the gauze might have got dislodged and pushed into the tracheobronchial tree, eventually migrating into the left main bronchus. A flexible fibreoptic bronchoscopy was performed to rule out the presence of another gauze. As the flexible fibreoptic bronchoscope and grasping forceps were available, we were able to remove the gauze as described. Alternately, rigid bronchoscopy would have been our option. The availability of proper infrastructure and open lines of communication between all team members plays a major role in the management of such events.

We planned for deep extubation to avoid emergence agitation, the incidence of which is up to 22% following nasal surgeries.[6] The absence of a protective cough and swallowing reflex in deeper planes may have led to an unprotected airway and a subsequent unnoticed inhalation of a nasal gauze directly into the tracheobronchial tree.[5]

These incidences can have a profound impact on professional practices, including medicolegal consequences to healthcare providers. Along with medical errors come huge financial burdens, both for the hospital and the patient. Rarely, instances have been observed where the gauze piece placed at one intended site for therapeutic purposes gets dislodged to another site and causes health risk.[6] Hence, medical personnel should be vigilant enough and avoid placement of unconventional packs. Moreover, a meticulous count of instruments and items such as packs/gauze should be the joint responsibility of the surgeon, anaesthesiologist and scrub nurse. Such steps are mandated in modern surgical practice and need to be followed without fail. Above all, a 3-way communication between the surgeon, anaesthesiologist and scrub nurse (often in conjunction with the floor nurse) encompasses good surgical protocol. We wish to reiterate the importance of debriefing following such an incident. Such follow-up action will not only help the team to assess and analyse the probable cause of a near miss, but will also help to formulate safe guidelines and checklists to prevent such incidents in the future.


  Conclusion Top


A high index of suspicion should be maintained for dislodgement and inhalation of nasal packs if a patient develops rapid desaturation not responding to 100% oxygen and positive pressure ventilation following nasal surgeries. A quick and coordinated response by the anaesthesiology and surgical team to identify such potentially life-threatening events and initiation of timely action can go a long way in ensuring safe surgeries.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
NoThing Left Behind: A National Surgical Patient Safety Project to Prevent Retained Surgical Items; 2021. Available from: http://www.nothingleftbehind.org. [Last accessed on 2021 Jul 26].  Back to cited text no. 1
    
2.
Cima RR, Kollengode A, Garnatz J, Storsveen A, Weisbrod C, Deschamps C. Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg 2008;207:80-7.  Back to cited text no. 2
    
3.
Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med 2003;348:229-35.  Back to cited text no. 3
    
4.
Lincourt AE, Harrell A, Cristiano J, Sechrist C, Kercher K, Heniford BT. Retained foreign bodies after surgery. J Surg Res 2007;138:170-4.  Back to cited text no. 4
    
5.
Novoa E, Junge H. Nasal packing: When a routine practice becomes a life-threatening emergency. Clin Case Rep 2020;8:2638-40.  Back to cited text no. 5
    
6.
Kim HJ, Kim DK, Kim HY, Kim JK, Choi SW. Risk factors of emergence agitation in adults undergoing general anesthesia for nasal surgery. Clin Exp Otorhinolaryngol 2015;8:46-51.  Back to cited text no. 6
    




 

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