Human Error in Throat Pack Management: Report of Two Cases

Throat packs are frequently used after tracheal intubation during ear, nose, and throat surgery. We report 2 cases of complications related to throat packs retained at the end of surgery. Miscommunication between anesthesiology and surgery teams on throat pack management led to an upper gastrointestinal endoscopy examination under general anesthesia in the first case and to severe respiratory distress requiring tracheal reintubation in the second case. Our 2 case reports highlight the importance of good communication between anesthesiology and surgery teams and of standardized procedures and checklists for the management of throat packs to ensure patient safety.