An unusual foreign body in the oral cavity: a case report from a patient safety point of view and literature review

Accidental foreign bodies (FBs) in the oral cavity, airway, esophagus and breathing circuit associated with anesthetic procedures are rare but can cause serious and life-threatening complications. We here present a case in which an unusual FB in the oral cavity was found after emergence from general...

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Veröffentlicht in:Journal of anesthesia 2022-08, Vol.36 (4), p.564-571
Hauptverfasser: Ito, Mariko, Watanabe, Natsuko, Sawado, Yuko, Ishida, Kumiko, Yoshiyama, Yuki, Ishida, Takashi, Fuseya, Satoshi, Tanaka, Satoshi, Kawamata, Mikito
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container_end_page 571
container_issue 4
container_start_page 564
container_title Journal of anesthesia
container_volume 36
creator Ito, Mariko
Watanabe, Natsuko
Sawado, Yuko
Ishida, Kumiko
Yoshiyama, Yuki
Ishida, Takashi
Fuseya, Satoshi
Tanaka, Satoshi
Kawamata, Mikito
description Accidental foreign bodies (FBs) in the oral cavity, airway, esophagus and breathing circuit associated with anesthetic procedures are rare but can cause serious and life-threatening complications. We here present a case in which an unusual FB in the oral cavity was found after emergence from general anesthesia. The FB was later identified as a melted cap of a felt-tip pen. We investigated the cleaning process for reusable materials and concluded that the FB was accidentally placed in the inner lumen of the reusable bite block during the cleaning process. We then performed a review of the literature on FBs other than those of dental origin which were entrapped in the oral cavity, pharynx, larynx, trachea, esophagus, and anesthetic breathing circuit due to anesthetic procedures. From our case and 53 cases found in the search, we concluded that 1) use of disposable medical devices is recommended, 2) FBs can easily migrate into the oral cavity and airway during anesthesia, 3) delayed FB recognition may be associated with difficult intubation situations, and 4) more attention should be paid to the possibility of any medical or non-medical device becoming an FB during anesthesia.
doi_str_mv 10.1007/s00540-022-03087-y
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source SpringerNature Journals
subjects Anesthesia
Anesthesiology
Care and treatment
Clinical Report
Critical Care Medicine
Emergency Medicine
Intensive
Medical equipment
Medicine
Medicine & Public Health
Pain Medicine
Patients
Physiological apparatus
Remifentanil
title An unusual foreign body in the oral cavity: a case report from a patient safety point of view and literature review
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