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PERIOPERATIVE GRAND ROUNDS

Who Nose Where the Airway Is?


The Case:
A 70-year-old man with peripheral vascular disease was brought to the OR to undergo vascular bypass surgery on his right upper extremity. Because the surgery was expected to involve only the arm, the procedure was started by using local anesthesia. A certied RN anesthetist (CRNA) was present to monitor the patient and to provide IV medications for anxiety, sedation, and pain control (ie, monitored anesthesia care). The CRNA was supervised by an attending anesthesiologist, but the anesthesiologist was not physically present. During the procedure, the patient expressed that he had generalized discomfort and anxiety, which required increased doses of opiates and benzodiazepines. The patient became sleepy but remained arousable. To maintain a patent airway, the CRNA placed a nasopharyngeal airway (NPA). After two hours of surgery, the vascular surgeon decided that he would need to use a vein from the patients leg to replace a blood vessel in the upper extremity. This was expected to be a long and relatively complicated procedure, so the decision was made to switch to general anesthesia, which would require endotracheal intubation and mechanical ventilation. The CRNA contacted the supervising anesthesiologist to help convert the case to general anesthesia. The two clinicians exchanged very little information, and the anesthesiologist intubated the patient without complication. The CRNA managed the anesthesia, and the remainder of the surgery was uneventful. The patient was successfully extubated. The day after surgery, the patient noted to health care providers that when he tried to drink liquid it would come out of his nose. The patient took a gulp of orange juice, and, to their astonishment, most of the juice owed out of his nose onto his hospital gown. The surgeons were concerned that a pharyngeal stula or other anatomic abnormality might be present, and they consulted an otolaryngologist. On examination, the otolaryngologist discovered that the NPA placed during the initial surgery was still in the patients nose. The tube had become lodged in the nasal cavity with nothing extruding from the nose. Presumably, this occurred when the patient was intubated by the anesthesiologist. The otolaryngologist removed the tube, and the patient was discharged later that day. The patient had no signicant consequences, but he did require an additional day in the hospital.

Discussion:
This case highlights a hazard of airway management: airway device aspiration. A number of different devices are used to maintain patent airways during surgical procedures but among the most common is an NPA. In the course of perioperative airway management, it is possible for the NPA to be aspirated or become lodged in the airway. Although the incidence of airway device aspiration is not known from any (continued on page 550)

This content is adapted from AHRQ WebM&M (Morbidity & Mortality Rounds on the Web) with permission from the Agency for Healthcare Research and Quality. The original commentary was written by Christopher R. Lee, MD, and was adapted for this article by Nancy J. Girard, PhD, RN, FAAN, consultant/owner, Nurse Collaborations, San Antonio, TX. (Citation: Lee CR. Who Nose Where the Airway Is? AHRQ WebM&M [serial online]. October 2009. http://www.webmm.ahrq.gov/case.aspx?caseID 208. Accessed February 26, 2011.) Dr Girard has no declared afliation that could be perceived as posing a potential conict of interest in the publication of this article.

doi: 10.1016/j.aorn.2011.02.007

642

AORN Journal

May 2011

Vol 93

No 5

AORN, Inc, 2011

May 2011

Vol 93

No 5

PERIOPERATIVE GRAND ROUNDS


Second, responsibility for the airway shifted back and forth between the CRNA and the anesthesiologist during the procedure. Communications during transitions of care are of vital importance. A structured hand off between the CRNA and the anesthesiologist would have identied the presence of the NPA. The hand off to the nurse in the postanesthesia care unit was also an opportunity to discover the missing NPA. The failure of usual individual practice to identify the retained NPA illustrates the need for a more systems-based approach. Checklists and other tools exist that can be used or modied for such a situation.7 More importantly, however, caregivers must take responsibility for the care they deliver.

(continued from page 642) systematic study, published case reports1-4 and anecdotal evidence suggest that this case is not unique. Specic risk factors for NPA aspiration are not known. Patients who have aspirated airway devices can have different clinical presentations, depending on the degree of airway occlusion. The aspiration of an NPA may not be obvious because the open lumen of the airway device may allow air to pass with little or no obvious obstruction.1-3 Providers should be aware that patients who have undergone procedures that involved NPAs are at risk for immediate and delayed airway complications. In one case, the discovery of the aspirated NPA was delayed for weeks after the event and was discovered only after a persistent cough and recurrent chest infection triggered further evaluation.1 One death was reported in a case of an aspirated airway, although the death occurred in the context of signicant underlying respiratory failure.4 Strategies to prevent these types of events include both device modications and changes in practice to allow for early recognition of an airway aspiration or retained object. Two basic NPA designs exist: one with a xed ange at the distal end of the device and the other with a movable ange to allow for more individualized tting. It has been suggested that the adjustable ange may increase the risk of aspiration,2 but aspiration events have been reported with both designs. Device modication suggestions include attachments to the external portion of the NPA that would rest outside of the patients nose, the use of a safety pin,5 or the use of an endotracheal tube connector.6 During airway management, the person managing the airway is responsible for the equipment being used on the patient. Two aspects in this case complicated the situation. First, there was an unplanned change in airway management. Changes in airway management should trigger a reassessment of the patient and formulation of a new airway plan. It is difcult to ascertain when the NPA was lost into the nasopharynx of this patient, but a careful assessment of the patient by the anesthesiologist before he assumed care would have alerted both providers that the NPA was still present. The location of the NPA could have been ascertained, and the NPA could have been removed before or immediately after intubation.
550 AORN Journal

Perioperative Points:

Transitions in care should always be accompanied by a patient assessment. Transitions should include a clear transfer of responsibility and up-to-date information on the care provided thus far.8 Documentation of devices used must be entered on the patients chart and a thorough accounting of invasive devices made when circumstances promote an unplanned change in care. The use of standardized tools or checklists to facilitate hand offs can reinforce a culture of consistent communication.

References
Dhar V, Al-Reefy H, Dilkes M. Case report: an iatrogenic foreign body in the airway. Int J Surg. 2008;6(6): e46-e47. 2. Hayes JD, Lockrem JD. Aspiration of a nasal airway: a case report and principles of management. Anesthesiology. 1985;62(4):534-535. 3. Dua K, Saxena KN, Dua CK. Airway within airway: a case report. Indian J Anaesth. 2004;48(6):486-487. 4. Milam MG, Miller KS. Aspiration of an articial nasopharyngeal airway. Chest. 1988;93(1):223-224. 5. Mobbs AP. Retained nasopharyngeal airway. Reply. Anaesthesia. 1989;44(5):447. 6. Mahajan R, Kumar S, Gupta R. Prevention of aspiration of nasopharyngeal airway. Anesth Analg. 2007;104(5): 1313. 7. Perioperative Patient Hand-Off Tool Kit. AORN, Inc. http://www.aorn.org/PracticeResources/ToolKits/ PatientHandOffToolKit/. Accessed February 26, 2011. 8. Hand-off Communications. AORN, Inc. http://www .aorn.org/docs_assets/55B250E0-9779-5C0D-1DDC 8177C9B4C8EB/44F543CC-17A4-49A8-865FDDF 56132C37B/HandOff_Recommendations.pdf. Accessed February 26, 2011. 1.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

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