Have we reached the end for throat packs inserted by anaesthetists?

Throat packs have traditionally been placed in order to collect shed blood, bodily or external fluids and other material that may collect in the oropharynx during nose, throat, oral and maxillofacial surgery. They are also inserted, although less commonly, to stabilise an artificial airway, particularly in neuro-anaesthesia and, in children, to reduce a leak around an uncuffed tracheal tube. If a throat pack has been inserted but not removed at the end of a procedure, then the obvious danger is that the retained pack may cause airway obstruction. The U.K. National Patient Safety Agency (NPSA) issued a report in 2009 on ‘Reducing the risk of retained throat packs after surgery’ 1. It produced an algorithm which, if followed, should reduce the likelihood of unintentional throat pack retention. The report recommended at least one visual aid (such as labelling the patient or their airway, attaching the pack to the airway, or having a portion protruding from the mouth) and at least one documented piece of evidence (such as writing on the operating theatre white board or recording the information as part of the swab count). Unintentionally retained throat packs are a ‘Never Event’ as defined by NHS England, i.e. they are medical errors believed to be preventable with appropriate measures 2. Moppett and Moppett 3 surveyed all English acute NHS Trusts to determine the number of Never Events relative to surgical caseload for the years 2011–2014. They calculated that the risk of a Never Event was approximately 1:17,000 operations and noted that there were six retained throat packs over the three-year period. In the 12 months from April 2016 until the end of March 2017, there were three reports of retained throat packs and in the last four months alone there have been a further three cases of retained throat packs 2. It is possible that the unintentional retention of a throat pack is a random event that has happened by chance and ‘does not reflect fundamentally poor care in an organisation’ 4. It is also possible that raised awareness of the danger following publication of the NPSA report has resulted in more open and accurate reporting. Nevertheless, any measures that can be undertaken to reduce the likelihood of a retained throat pack are to be welcomed. Despite the potential danger of airway obstruction due to retained throat packs, there is no doubt that throat pack insertion is common. A survey of neuro-anaesthetists 5 found that the majority used throat packs when the patient was placed prone (in order to stabilise the tracheal tube) or during trans-sphenoidal surgery. According to the survey, throat packs were invariably inserted by the anaesthetist. Another survey of both surgeons and anaesthetists 6, found that although the use of throat packs is not routine, it is common practice. The authors pointed out that policies for insertion and removal are not, but should be, universal. In this issue of Anaesthesia, Athanassoglou et al. 7 report the results of a systematic review of the benefits or harms of throat pack usage. The primary purpose of their research was to question the evidence base for the insertion of throat packs by anaesthetists. Their conclusion was that they no longer recommend the routine insertion of throat packs by anaesthetists. They recommend that throat packs should only be inserted in carefully selected cases, and in these situations it should usually be performed by the surgeon. Athanassoglou et al. argue that a throat pack is rarely absolutely necessary, and we agree that throat pack insertion occurs too often, with little or no evidence for their benefit. The most common reason for inserting a throat pack is to prevent shed blood entering the stomach and causing postoperative nausea and vomiting, yet studies have found no difference in the incidence of nausea and vomiting whether or not a throat pack was used. A common conclusion from these studies is that the presence of a throat pack results in an increase in postoperative sore throat during the recovery period 8, 9 and this is probably related to the coarse material used and/or the insertion technique, with only one study showing no increase in postoperative sore throat when using throat packs 10. In one study, gauze material was compared with tampons, constructed of softer material, for use as throat packs 11. There was less sore throat when the tampons were used; however, a disadvantage of tampons is that they are not radiolucent. In another study 12, dry throat packs were compared with wet throat packs, and no differences were found between the two in terms of postoperative sore throat, nausea or vomiting 13. Despite the lack of evidence for any benefit from throat packs, cases reporting the complications from unintentionally-retained throat packs have appeared over the years and there is no clear pattern as to why this is. One likely reason is when there is a change in personnel (anaesthetist, surgeon or the whole team) during a lengthy procedure and poor/incomplete handover occurs. Another reason might be when staff are distracted 14, for example when critical events occur simultaneously. In addition, there may be poor communication between anaesthetic and surgical teams 15, for example when one person, usually the anaesthetist, inserts the pack and a different person (the surgeon) removes it. The directed review published this month, whilst not strictly a systematic review as described by Smith and Carlisle 16, includes a thorough search for relevant material. The resulting consensus statement is endorsed by the combined authorities of the Difficult Airway Society (DAS), the British Association of Oral and Maxillofacial Surgery (BAOMS) and the British Association of Otorhinolaryngology, Head and Neck Surgery (ENT-UK). It is important, and will almost certainly result in a change in clinical practice. Following its publication, there is likely to be a worldwide reduction in the placement of throat packs, and we are in favour of this. It follows that there will also be a reduction in the absolute number of retained throat packs, clearly a worthwhile aim. However, the problem will not be eliminated completely and the relative rarity of their insertion may possibly make unintentional retention more likely because theatre staff will less commonly encounter a situation when throat packs are inserted. This is a paradox that Smith and Smith have pointed out 17, that as surgical care becomes safer critical incidents become rarer but seem more devastating when they do occur. We do not know exactly how many throat packs are inserted each year, but there has probably already been an overall reduction in their usage over the last fifteen years due to the increased utilisation of supraglottic airway devices that obviate the need for throat packs in both dental surgery and for procedures performed on the nose. In addition, reductions in throat pack usage can, and should, be made in situations as shown in Table 1. For example, they should not be used to stabilise an airway in adults when a visible bite-block can be just as effective. Also, there is no need to insert a throat pack in children in order to maintain a seal around uncuffed tubes with a large air leak; the tube should either be exchanged for a larger one or a cuffed tracheal tube with a high volume, low pressure, cuff should be used instead 18. The protocol, as described by the authors of the new guideline, is that throat packs, when judged necessary, should be sited and removed by the surgeon using gauze swabs with a radiolucent thread that are part of the swab count. We agree that throat packs with a radiolucent thread should be used as this enables them to be identified using radiographs; one case report described locating a throat pack within the stomach 19 and, in another case report, part of a non-radiolucent pack could not be identified and this led to airway obstruction 20. However, one problem with the new protocol is that existing surgical swabs, which are recommended for use, are nowhere near ideal for use as throat packs, small swabs being too small and large swabs being too large, so may be cut and thereby cause confusion at the end of the procedure when the final surgical swab count is performed. We agree with the authors that the person who requests the throat pack should be the one who actually inserts it and should also be responsible for its safe removal. If this is the surgeon, the question then arises as to whether they are competent in requesting, placing and removing a throat pack. For example, are they able to place the material correctly around the tracheal tube without causing trauma or dislodging the airway? Whilst the individual clinician who places a throat pack is legally and ethically responsible for its safe removal, we believe that there is collective responsibility for all members of the operating team to ensure that the unintentional retention of a throat pack never occurs. If a throat pack is deemed necessary, then the whole theatre team should be engaged and have a specific, step-by-step, policy in place. Alongside the recommendations from the NPSA, we would like to see the implementation of other safety measures, such as documentation being a mandatory part of the WHO surgical safety checklist, a tick-box section included on the written anaesthetic chart, as well as an automatic pop-up alert within the electronic patient record. We also recommend a ‘stop’ moment before throat pack insertion; ‘step back before you pack’ similar to the ‘stop before you block’ moment immediately before performing a regional nerve block [https://www.ra-uk.org/index.php/stop-before-you-block]. Whilst the reasons for inserting a throat pack in a particular patient will have been discussed at the team briefing, the ‘step back before you pack’ moment is an opportunity, in the operating theatre, for the person inserting the throat pack to inform all theatre personnel before they actually insert it. A similar ‘stop’ moment should occur at the end of surgery when the throat pack is removed. Although there will never be a fool-proof system in place to prevent complications associated with the use of throat packs, we feel that the new practice recommendations as they stand do not address all the pertinent issues. Sadly, the incidence of retained throat packs does not appear to have reduced despite the warning issued by the NPSA and the introduction of the WHO surgical safety checklist. Whether worldwide clinical practice can be changed on the basis of one literature review is open to debate. However, an important positive effect may be in raising awareness that retained throat packs remain a serious risk within our everyday practice. It is time to ‘unpack’; we rarely need throat packs. When we do, an agreed protocol should be in place to ensure that the throat pack is removed from the patient before tracheal extubation. CB is an Editor of Anaesthesia and JH is member of the International Advisory Panel of Anaesthesia. No other competing interests declared.