The Agency for Healthcare Research and Quality has a section called case and commentary some of which are of interest to anesthesiologists. In October 2009 they presented a case that I briefly summarize as follows:
One day after a vascular bypass procedure on the right upper extremity that started under MAC but was converted to general endotracheal anesthesia, this 70 year old man complained that whenever “he tried to drink any liquid it would come right out his nose.” He promptly demonstrated this phenomenon when the surgical team expressed their skepticism. The patient took a gulp of orange juice with the physicians present and they witnessed that most of the juice came out of his nose and spilled onto his hospital gown; he demonstrated this a number of times showing its repeatability. Concerned about a pharyngeal fistula or some other anatomic abnormality the surgical team consulted an Otorhinolaryngologist who discovered a nasopharyngeal airway lodged within the nasal cavity (not visible externally) which apparently acted as a retrograde conduit of fluid. Chart review revealed that a nasopharyngeal airway had been used during the MAC portion of the patient’s surgery the previous day. The article notes that aspirated nasal airways have been associated with a number of complications including airway obstruction and that symptom may not present immediately. They noted one case in which an aspirated nasal airway was not discovered for weeks and was only discovered after investigation for persistent cough and recurrent chest infections (the device was lodged within the trachea near the right mainstem bronchus). The typical nasopharyngeal airway has no radio-opaque strip, RFID tag, or suture tail. Anesthesia devices are not typically “counted” so the only person who may know that a nasopharyngeal airway was used is the person who placed it. It would seem prudent to make sure that insertion and removal of nasopharyngeal airways are clearly noted on the anesthesia record, that the presence of nasopharyngeal airways are part of any “handoffs", and that changes in anesthetic plan are accompanied by a reevaluation of the need for any nasopharyngeal airways or other support devices that may have been placed.
The entire presentation can be found at http://webmm.ahrq.gov/case.aspx?caseID=208 along with a very nice discussion by Christopher R. Lee M.D. from the Department of Anesthesiology and Pain Medicine, University of Washington Medical Center. The home page for the most recent case is at http://webmm.ahrq.gov/index.aspx. There is also a link to their case archive http://webmm.ahrq.gov/caseArchive.aspx
David S. Smith, M.D., Ph.D.