Unintentionally Retained Foreign Objects: A Descriptive Study of 308 Sentinel Events and Contributing Factors.

OBJECTIVE: Unintentionally retained foreign objects (URFOs) remain the sentinel events most frequently reported to The Joint Commission. The objective of this study was to describe reports of URFOs, including the types of objects, anatomic locations, contributing factors, and harm, in order to make recommendations to improve perioperative safety. METHODS: A retrospective review was undertaken of events involving URFOs reported to The Joint Commission from October 2012 through March 2018. Inclusion criteria were events meeting Joint Commission definitions of URFO and sentinel event. Exclusion criteria were sponges used intraoperatively and guidewires. Event reports included patients undergoing surgery, child birth, wound care, and other invasive procedures. RESULTS: A total of 308 events involving URFOs were reported: instruments (102), catheters and drains (52), needles and blades (33), packing (30), implants (14), specimens (6), and other items (71). Many of the instruments were used in minimally invasive or orthopedic surgery. Items were most frequently retained in the abdomen or the vagina. Most URFOs occurred in the operating room. A total of 1,156 contributing factors were identified, most frequently in the categories human factors, leadership, and communication. In the majority of reports, the harm was categorized as unexpected additional care/extended stay. Five patients died as a result of the URFO. CONCLUSION: We describe events involving URFOs voluntarily reported to The Joint Commission. The variety of retained items, the departments involved, and the large number of contributing factors demonstrate the complexity of patient care and the need for a multifaceted plan for prevention. We make recommendations based on these findings.

Death as a Consequence of Foreign Body Aspiration in Children.

AIM: To analyze the rate of mortality in children with foreign body aspiration (FBA). METHODS: We outlined a retrospective review of hospital data of patients between 1971 and 2013. FBA occurring in children 0 year to 14 years was considered for inclusion (patient ages ranged from 0.6 to 15 years, with a median age of 2.2 years). The gender structure within the investigated cases was 75.8% males and 24.2% females. During the study period, 772 patients undergoing rigid bronchoscopy with the diagnosis of FBA were included. Deaths on arrival were excluded. RESULTS: Total rate of mortality (for whole investigated period) was 0.785. For last fifteen years of the investigated period the rate of mortality was zero. CONCLUSION: For prevention of foreign body aspiration in children and its mortality should be taken two strategies: non-medical (alterations in product design and public education campaigns) and medical (education of medical staff and improvement of equipment).

Lithium batteries: A technological advance with unintended injury consequences.

Lithium-ion (Li-ion) batteries have been powering portable electronic equipment since the mid-1990s. Today, they are ubiquitous in portable electronics, with more than four billion manufactured each year. However, Li-ion batteries are also associated with a spectrum of injuries related to the type of device as well as the person using the device. These injuries range from cutaneous injuries due to flame burns and explosions to corrosion injuries from ingestion. This article describes how the composition of Li-ion batteries can cause injury, the types and extent of Li-ion battery-related injuries, and suggests strategies for prevention.

Morbidity and mortality in children undergoing bronchoscopy for foreign body removal.

OBJECTIVES/HYPOTHESIS: Analyze morbidity and mortality among children undergoing bronchoscopy for foreign body removal. STUDY DESIGN: Multicenter retrospective review using the American College of Surgeons Pediatric National Surgical Quality Improvement Program from 2014 and 2015. METHODS: Patients were identified using Current Procedural Terminology code 31635. Demographics, time to surgery, operative times, hospitalization time, and complications were collected. Multivariate logistic regression was used to identify predictive factors for major adverse events. RESULTS: Three hundred thirty-four patients were included (mean age 3.7 years, 59.0% male). Preoperative sepsis syndrome was present in 5.7% of patients and 8.1% had asthma. Of the patients, 5.1% percent of patients had a tracheostomy. Bronchoscopy was performed by an otolaryngologist (65.4%) or a pediatric surgeon (33.1%). Mean operative time was 27.4 minutes, whereas mean total operating room time was 54.6 minutes. Airway foreign bodies were located in 269 patients (80.5%), with 62.5% being located in the mainstem bronchus. Operative time was longer when foreign bodies were in the mainstem bronchus or distal to it. Mean time to surgery from admission was 0 days, and mean duration of hospitalization was 1 day. One patient (0.3%) required reoperation for respiratory reasons, and three (0.9%) required readmission for related reasons. No patients remained hospitalized at 30 days. Two (0.6%) had a postoperative pneumonia, and two (0.6%) required reintubation. One patient death (0.3%) occurred within 2 weeks of bronchoscopy. No significant differences were identified in operative time, time to surgery, or hospitalization time based on age, gender, presence of a tracheostomy, or surgical specialty. CONCLUSIONS: Bronchoscopy for identification and removal of airway foreign bodies had minimal morbidity in this group. LEVEL OF EVIDENCE: 2b. Laryngoscope, 128:1226-1229, 2018.

Risk Factors for Death in Dogs Treated for Esophageal Foreign Body Obstruction: A Retrospective Cohort Study of 222 Cases (1998-2017).

BACKGROUND: Limited data exist describing risk factors for death, and long-term outcomes in dogs with esophageal foreign body (EFB) obstruction. HYPOTHESIS/OBJECTIVES: To evaluate short- and long-term outcomes, and analyze risk factors for death in dogs with EFB obstruction. We hypothesized duration of entrapment and treatment type would affect outcome. ANIMALS: A total of 222 dogs were treated for EFB obstruction at an emergency and referral hospital between March 1998 and March 2017. METHODS: Medical records for dogs with EFB were retrospectively evaluated. RESULTS: Foreign material most frequently was osseous (180/222 [81%]), with distal esophagus the most common location (110/222 [49.5%]). Duration of clinical signs was not associated with risk of death (OR = 1.08, 95% CI 0.99-1.17; P = 0.2). Entrapment was treated by endoscopy (204/222 [91.8%]), surgery after endoscopic attempt (13/222 [5.9%]), and repeat endoscopy after surgery was recommended but declined (5/222 [2.3%]). In-hospital case fatality rate was 11/222 (5%). Risk of death was significantly higher with surgery (OR = 20.1, 95% CI 3.59-112.44; P = 0.001), and 5/5 (100%) of dogs died if undergoing endoscopy after surgery was recommended but declined. Increasing numbers of postprocedural complications (OR = 3.44, CI 2.01-5.91; P < 0.001), esophageal perforation (OR = 65.47, CI 4.27-1004.15; P = 0.003), and postprocedure esophageal hemorrhage (OR = 11.81, CI 1.19-116.77; P = 0.04) increased in-hospital risk of death. Esophageal strictures were reported in 4/189 (2.1%) of survivors available for follow-up. CONCLUSIONS AND CLINICAL IMPORTANCE: Death is uncommon in canine EFB; however, treatment type affects outcome, and these data should be used to guide decision-making in dogs with EFB.

Foreign body aspiration in children: A study of children who lived or died following aspiration.

Foreign body aspiration (FBA) is a preventable cause of mortality and morbidity in children. We conducted a chart review of children who presented to a university hospital due to FBA in the period 1999-2014. Children were either managed with bronchoscopy for removal of the foreign body or died due to FBA. A total of 103 children were seen due to FBA including 27 deaths. The majority of children were boys and were less than 3 years old. Most aspirated foreign bodies were food-related, mainly peanuts. The majority of children presented with acute choking incidents, a smaller number presented with recurrent chest infections, and few children's choking incidents were unwitnessed. X-ray had a high rate of false negatives and bronchoscopy was the gold standard technique for assessment and management. Aspiration of foreign bodies is a preventable, life-threatening condition that calls for increased parent education and awareness.

Airway foreign bodies in pediatric patients: anatomic location of foreign body affects complications and outcomes.

BACKGROUND: Airway foreign bodies (FB) are a common medical emergency within the pediatric population. While deaths are not uncommon, the in-hospital mortality rates and correlation with anatomic location of the airway foreign body have not been previously reported. METHODS: The KID database was reviewed for 2003, 2006, 2009, and 2012 for pediatric patients with a discharge diagnosis of airway foreign body using ICD-9 codes (933.1, 934.x). RESULTS: 11,793 patients, ages 0-17, were found to have an airway FB. Of patients admitted for airway FB 21.2 % required mechanical ventilation during their hospitalization, and the overall mortality rate was 2.5 %. Location of the airway FB was dependent on age (p < 0.01). Use of mechanical ventilation was dependent on the location of the airway FB (p < 0.01) and being transferred from another hospital (OR 2.59, p < 0.01). Univariate analysis demonstrated differences in in-hospital mortality based on location (p < 0.01), use of a ventilator during hospitalization (OR 24.4, p < 0.01), and transfer from another hospital (OR 2.11, p < 0.01). CONCLUSIONS: The in-hospital mortality rate for airway foreign bodies is 2.5 %. The anatomic location of airway FB in pediatric patients varies by age, and affects the need for mechanical ventilation and in-hospital mortality.

Risk factors for complications associated with upper gastrointestinal foreign bodies.

AIM: To investigate predictive risk factors associated with complications in the endoscopic removal of foreign bodies from the upper gastrointestinal tract. METHODS: We retrospectively reviewed the medical records of 194 patients with a diagnosis of foreign body impaction in the upper gastrointestinal tract, confirmed by endoscopy, at two university hospital in South Korea. Patient demographic data, including age, gender, intention to ingestion, symptoms at admission, and comorbidities, were collected. Clinical features of the foreign bodies, such as type, size, sharpness of edges, number, and location, were analyzed. Endoscopic data those were analyzed included duration of foreign body impaction, duration of endoscopic performance, endoscopic device, days of hospitalization, complication rate, 30-d mortality rate, and the number of operations related to foreign body removal. RESULTS: The types of upper gastrointestinal foreign bodies included fish bones, drugs, shells, meat, metal, and animal bones. The locations of impacted foreign bodies were the upper esophagus (57.2%), mid esophagus (28.4%), stomach (10.8%), and lower esophagus (3.6%). The median size of the foreign bodies was 26.2 ± 16.7 mm. Among 194 patients, endoscopic removal was achieved in 189, and complications developed in 51 patients (26.9%). Significant complications associated with foreign body impaction and removal included deep lacerations with minor bleeding (n = 31, 16%), ulcer (n = 11, 5.7%), perforation (n = 3, 1.5%), and abscess (n = 1, 0.5%). Four patients underwent operations because of incomplete endoscopic foreign body extraction. In multivariate analyses, risk factors for endoscopic complications and failure were sharpness (HR = 2.48, 95%CI: 1.07-5.72; P = 0.034) and a greater than 12-h duration of impaction (HR = 2.42, 95%CI: 1.12-5.25, P = 0.025). CONCLUSION: In cases of longer than 12 h since foreign body ingestion or sharp-pointed objects, rapid endoscopic intervention should be provided in patients with ingested foreign bodies.

Retained weapon injuries: experience from a civilian metropolitan trauma service in South Africa.

INTRODUCTION: Retained weapon (RW) injuries are uncommon, but there is no current consensus on the best management approach. METHODS: We reviewed our experience of 102 consecutive patients with non-missile RWs in a high-volume metropolitan trauma service managed over a 10-year period. RESULTS: Of the 102 patients, 95 were males (93%), 7 were females (7%), and median age was 24 (21-28) years. Weapons: 73% (74/102) knives, 17% (17/102) screwdrivers, 5% spears, 6% (6/102) others [axe (1), glass fragment (1), stick (1), sickle blade (1), wire (1) and stone (1)]. LOCATION: 8% (8/102) head, 20% (20/102) in the face, 9% (9/102) neck, 14% (14/102) thorax, 25% (26/102) abdomen, 23% (23/102) upper limb, 2% (2/102) lower limb. Four per cent (4/102) were haemodynamically unstable and proceed immediately to the operating theatre for operative exploration and weapon extraction. Imagining: 88 (86%) plain radiographs, 65 (64%) non-contrast CT scans, 41 (40%) contrast CT angiography, 4 (4%) formal angiography. Seventy-two underwent simple extraction, and 29 underwent extract plus open operation. One patient absconded. Specialist surgeons involved in extraction: trauma surgeons (74), neurosurgeons (10), ophthalmic surgeons (11) and ENT surgeons (4). Overall, 92% (94/102) survived to discharge. CONCLUSIONS: The vast majority of patients with RWs will be admitted in a stable condition and haemodynamic instability was almost exclusively seen in the anterior thorax. The most common site was the posterior abdomen. Detailed imagining should be used liberally in stable patients and unplanned extraction in an uncontrolled environment should be strongly discouraged.

A comparative study of small intestinal perforation secondary to foreign body and other non-traumatic causes.

BACKGROUND: Little was known about gastrointestinal perforation secondary to foreign body in adults, which was only documented by several case series reports. The aim of this study was to characterize it with comparative methods. METHODS: A retrospective study was conducted on twenty patients with the diagnosis of gastrointestinal perforation secondary to foreign body between January 2003 and October 2013. The perforations were all located in the small intestine and compared to eighty-seven patients with non-traumatic small intestinal perforation. RESULTS: 35% of the patients in the foreign body group were over 65 years of age, which is much higher than the local elderly population ratio (p=0.002). In the foreign body group, more patients presented without diffuse abdominal physical signs (p=0.008) and preoperational CT scans had higher accuracy (p=0.027). Perforation repair was performed more often (p=0.024). Mean MPI was 19.9 and the morbidity rate was 35%, significantly lower than in the cases of other causes (p=0.001, 0.041). Mean duration of hospitalization was 11.5 days and was shorter compared to other causes (p=0.038). CONCLUSION: Clinical performance of small intestinal perforation secondary to foreign body is atypical, and preoperative diagnosis relies on CT scans. Primary perforation closure is safe and effective, and relatively better outcomes can be achieved.

Retained Foreign Body: "Needle in a Haystack".

Retained foreign bodies remain an area of potential patient harm. This case describes a retained needle from distant surgery discovered at the time of the needle count after myomectomy.

An audit of morbidity and mortality associated with foreign body aspiration in children from a tertiary level hospital in Northern India.

BACKGROUND: There is paucity of data regarding the morbidity and mortality of rigid bronchoscopy in children for foreign body (FB) retrieval from India. The aim was to audit data regarding anaesthetic management of rigid bronchoscopy in children and associated morbidity and mortality. MATERIALS AND METHODS: Hospital records of all patients below 18 years of age undergoing rigid bronchoscopy for suspected FB aspiration (FBA) between January 1, 2002 and December 31, 2011 were audited to assess their demographic profile, anaesthetic management, complications, and postoperative outcomes. The children were divided into early and late diagnosis groups depending on whether they presented to the hospital within 24 hours of FBA, or later. RESULTS: One hundred and forty children, predominantly male (75%), with an average age of 1-year and 8 months, presented to our hospital for rigid bronchoscopy during the study period. Majority of children presented in the late diagnosis group (59.29% vs. 40.71%). The penetration syndrome was observed in 22% of patients. Majority of patients aspirated an organic FB (organic: Inorganic FB = 3:1), with peanuts being the most common (49.28%). A significantly higher number of children presented with cough (P = 0.0001) and history of choking (P = 0.0022) in the early diagnosis group and crepitations (P = 0.0011) in the late diagnosis group. Major complications included cardiac arrest (2.1%), pneumothorax (0.7%), and laryngeal oedema (9.3%). The average duration of hospitalization in our series was 3.08 ± 0.7 days. CONCLUSIONS: Foreign body aspiration causes considerable morbidity, especially when diagnosis is delayed.

Diagnosis and treatment of tracheobronchial foreign bodies in 1024 children.

OBJECTIVE: This study sought to summarize the experience of diagnosis and treatment of tracheobronchial foreign bodies in children to effectively reduce complications and mortality. METHODS: The medical records of 1024 pediatric patients admitted to our hospital from January 1997 to September 2011 and diagnosed with clinically suspected tracheobronchial foreign body aspiration were retrospectively analyzed. RESULTS: Of the 1024 children patients, 674 were boys (65.8%) and 350 girls (34.2%). Two died of respiratory and circulatory failure (foreign bodies detected upon bronchoscopy but not retrieved) before surgery, 65 patients underwent direct bronchoscopic removal of foreign bodies due to their critical status, and 957 received chest radiographs and chest fluoroscopy or multidetector spiral computed tomographic scans (941 positive). Foreign bodies were expectorated before surgery in 3 cases. There were 953 cases of bronchoscopically proven airway foreign body aspiration, with a diagnostic accuracy of 94.5%. Ninety-eight foreign bodies were lodged in the main bronchus and/or bilateral bronchi, 506 in the right main bronchus, and 349 in the left main bronchus. Atelectasis was noted in 42 patients, including 11 with pulmonary consolidation, whose lungs were re-expanded by endobronchial lavage and sputum aspiration. In 3 patients with bronchiectasis, conservative treatment following foreign body removal was followed by no improvement, and pulmonary lobectomy was performed. Foreign bodies were successfully extracted at the first bronchoscopic attempt in 948 cases, accounting for 99.7% of the total. However, 3 patients had to undergo another bronchoscopy to remove the foreign bodies. The most common types of foreign bodies were peanuts, melon seeds, and beans. CONCLUSIONS: Timely accurate diagnosis and treatment of tracheobronchial foreign bodies in children can avoid delay in treatment and effectively reduce complications and mortality.

Frequency of tracheobronchial foreign bodies and their management in urban population of Sindh.

OBJECTIVE: To assess the common foreign bodies in urban areas of Sindh, and the presentation, problems and complications during their removal through rigid bronchoscopy. METHODS: The descriptive study was conducted at the Ear, Nose and Throat Department and the Department of Head and Neck Surgery of Liaquat University Hospital, Hyderabad, and Abbasi Shaheed Hospital, Karachi, from April 2009 to October 2010. Fifty patients with strong suspicion of foreign body inhalation in whom rigid bronchoscopy was done were included in the study. A definitive diagnostic protocol was applied and rigid bronchoscopy was done to search and remove the foreign bodies. The data was fed into SPSS version 15 for descriptive analysis. RESULTS: In our study,28(56%) cases were male and 22(44%) were female. The age range was 1-7 years. Most of the victims (n=21; 42%) were over 3 years of age. Commonest symptom of presentation was dyspnoea (n=34; 68%) and the commonest sign of presentation was decreased unilateral air entry (n=25; 50%). Most of the foreign bodies were impacted in the right main bronchus (n=26; 52%). The most retrieved foreign body was betel nut (n=23; 46%). The commonest complication of bronchoscopy was airway oedema which occurred in 13 (26%) patients. The successful removal of exogenous foreign body was achieved in 41 (82%), and the mortality rate was 3 (6%). CONCLUSION: Delay in the diagnosis of foreign body inhalation translates into a higher risk of complications. Therefore, early bronchoscopy should be done on suspicion. Early recognition at both parental and clinical levels should be promoted through public awareness.

Radiopaque foreign body inhalations.

BACKGROUND: The most frequent cause of accidental household death in children under 6 years of age is inhalation of a foreign body. Delayed management is blamed for death. The absence of a recognizable penetration syndrome complicates and delays not only the diagnosis but also the treatment of foreign body inhalation. OBJECTIVE: This report aimed to highlight the problem of radiopaque foreign body inhalation and analyze part of our experience in the treatment of such cases. METHODS: A multicenter experience in the management of radiopaque inhaled foreign bodies in 3 centers in Egypt and Saudi Arabia was reviewed retrospectively, including old and new techniques to remove the foreign body. The study included data from 136 cases. RESULTS: The majority of patients were female (91.17%). The mean age was 12 years. More than one-third of the inhaled foreign bodies were found on the left side. A positive history of chocking was reported in more than 95%. Almost 87% presented in the first 24 h after inhalation. CONCLUSION: Early rigid bronchoscopic extraction of inhaled radiopaque foreign bodies can be achieved with acceptable results. Video-assisted bronchoscopic removal of an inhaled foreign body may be safer.

[Non-ulcerous duodenal perforations: a clinical analysis of 23 cases]. / Perforatiile neulceroase ale duodenului: analiza a 23 de cazuri.

Non-ulcerous duodenal perforations are a rare and seldom studied pathology. The present retrospective study analyses a group of 23 patients, over a 10 year period (Jan 1st 2000 - Dec 31st 2009) with this pathology. The most frequent etiology was iatrogenic (52.17 % after ERCP and 17.39% after upper gastrointestinal endoscopy). Other rare etiologies included were tumoral perforations, penetrating wounds, and ingestion of foreign bodies. The lesions vary from millimetric perforations to total necrosis of the wall of a duodenal segment and are often associated with other complex lesions. The overall mortality was 52.17%, a little lower for the post ERCP injuries (40%). Usually the iatrogenic lesions are diagnosed earlier (ex. 54.54% of the post ERCP lesions undergo surgery during the first 24 h), probably increasing the chance of surviving. 43.47% of cases undergo surgery in the condition of severe sepsis, with multiple organ failure, thus aggravating the prognosis. Sometimes the patient required multiple interventions (with a maximum of 8 in our group). In 26% of the cases the primary intervention was just paraduodenal and/or retroperitoneal drainage, suture of the duodenum (6 cases - 26%), usually under the protection of a gastro-enteroanastomosis (4 cases - 17.39%), suture of the duodenum around a decompression tube (26%), sometimes suture of the duodenum with a jejunal serous patch or duodeno-jejunal anastomosis. The bile drainage and the jejunostomy were associated sometimes. The procedures in this pathology have a significant morbidity, with a high rate of reinterventions (30.4%).

Management of button battery-induced hemorrhage in children.

OBJECTIVES: Button battery ingestions are potentially life threatening for children. Catastrophic and fatal injuries can occur when the battery becomes lodged in the esophagus, where battery-induced injury can extend beyond the esophagus to the trachea or aorta. Increased production of larger, more powerful button batteries has coincided with more frequent reporting of fatal hemorrhage secondary to esophageal battery impaction, but no recommendations exist for the management of button battery-induced hemorrhage in children. MATERIALS AND METHODS: We reviewed all of the reported pediatric fatalities due to button battery-associated hemorrhage. Our institution engaged subspecialists from a wide range of disciplines to develop an institutional plan for the management of complicated button battery ingestions. RESULTS: Ten fatal cases of button battery-associated hemorrhage were identified. Seven of the 10 cases have occurred since 2004. Seventy percent of cases presented with a sentinel bleeding event. Fatal hemorrhage can occur up to 18 days after endoscopic removal of the battery. Guidelines for the management of button battery-associated hemorrhage were developed. CONCLUSIONS: Pediatric care facilities must be prepared to act quickly and concertedly in the case of button battery-associated esophageal hemorrhage, which is most likely to present as a "sentinel bleed" in a toddler.

Risk factors and outcomes for foreign body left during a procedure: analysis of 413 incidents after 1 946 831 operations in children.

OBJECTIVE: To determine risk factors and outcomes associated with a foreign body left during a procedure in a population of pediatric surgical patients. DESIGN: Case-control study. SETTING: The Nationwide Inpatient Sample and Kids' Inpatient Database were used to identify hospitalized pediatric surgical patients in the United States (aged 0-18 years) from 1988 to 2005. PATIENTS: After data from 1 946 831 hospitalizations in children were linked to the Agency for Healthcare Research and Quality Pediatric Quality Indicator (PDI) software, 413 pediatric patients with foreign bodies left during a procedure (PDI 3) were identified. A 1:3 matched case-control design was implemented with 413 cases and 1227 controls. Cases and controls were stratified into procedure categories based on diagnosis related group procedure codes. MAIN OUTCOME MEASURES: To examine the relationship between PDI 3 and procedure category, as well as the outcomes of in-hospital mortality, length of stay, and total hospital charges. RESULTS: Logistic regression analysis revealed a statistically significant higher odds of PDI 3 in the gynecology procedure category (odds ratio, 4.13; P = .01). Multivariable regression analysis revealed that patients with PDI 3 had an 8-day longer length of stay (95% confidence interval, 5.6-10.3 days; P < .001) and $35 681 higher total hospital charges (95% confidence interval, $22 358-$49 004; P < .001) but were not more likely to die (odds ratio, 1.07; P = .92). CONCLUSIONS: Among pediatric surgical admissions, a foreign body left during a procedure was observed to occur with highest likelihood during gynecologic operations. The occurrence of this adverse event was associated with longer length of stay and greater total hospital charges, but not with increased mortality.