A 70-year-old man with peripheral vascular
disease was brought to the operating room to undergo vascular
bypass surgery on his right upper extremity. Because the surgery
was expected to involve only the arm, the case was started using
local anesthesia. A certified registered nurse anesthetist (CRNA)
was present to monitor the patient and to provide intravenous
medications for anxiety, sedation, and pain control (monitored
anesthesia care [MAC]). The CRNA was supervised by an attending
anesthesiologist (a physician) but, because the surgery was a
straightforward procedure performed under local anesthesia with
MAC, the anesthesiologist was not physically present and knew very
little about the case.
During the procedure, the patient complained of
generalized discomfort and anxiety, requiring increased doses of
opiates and benzodiazepines (an anti-anxiety medication). With
these medications, the patient became sleepy but remained
arousable. To maintain a patent airway, the CRNA placed a
nasopharyngeal airway, a soft plastic tube inserted into the nose
that extends into the posterior pharynx (Figures). Normally, the tip of this tube remains
outside the nose, where it can be seen by clinicians. After this
insertion, the patient did well with normal respirations and oxygen
After 2 hours of surgery, the vascular surgeon
decided that they would need to use a vein from the patient's legs
to replace a blood vessel in his upper extremity. Because this was
expected to be a long and relatively complicated procedure, the
decision was made to switch the patient to generalized anesthesia,
which would require endotracheal intubation (placement of a plastic
tube through the mouth and down into the lungs) and mechanical
ventilation. The CRNA contacted the supervising anesthesiologist to
help convert the case to general anesthesia. Very little
information was exchanged between the two clinicians, 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 and did well
after the surgery.
The following day, the patient remained stable,
and the physician team was planning on discharging him to home.
Curiously, the patient complained to the team that although he was
feeling well, when he tried to drink any liquid it would come right
out of his nose. To overcome the skepticism of the surgical team,
the patient took a gulp of his orange juice with the physicians
present, and, sure enough, most of the juice flowed out of his nose
onto his hospital gown. To the astonishment of the team, he
repeated the scenario.
The surgeons decided to make the patient NPO
(nothing by mouth) and gave him fluids intravenously. They
consulted otolaryngology (ear, nose, and throat specialists) with
concerns about a pharyngeal fistula or another anatomic
abnormality—there were no obvious abnormalities seen
extruding from the nose. The otolaryngologist discovered that the
nasopharyngeal airway, which had been placed during the initial
surgery, was still in his nose. It was not entirely clear how the
tube had become lodged within the nasal cavity (so that its
external portion was no longer extruding from the nose), but
presumably this occurred when the patient was intubated by the
The plastic tube was
removed, and the patient was discharged home later that day. He
suffered no significant consequences from the event, but he did
require an additional day in the hospital.
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Figure 1a. Proper placement of nasopharyngeal
airway device, a soft plastic tube inserted into the nose that
extends into the posterior pharynx.
Figure 1b. Illustration representing
position of dislodged nasopharyngeal airway device.
Illustrations by Chris Gralapp.