The Throat Pack Debate: A Review of Current Practice in UK and Ireland Cleft Centers.

INTRODUCTION: The use of throat packs during oropharyngeal surgery has long been a topic of debate among cleft surgeons. The advantage of inserting an absorbent tulle within the pharynx must be weighed against the risk of unintended retention postoperatively. Despite safety check mechanisms in place, retention may occur with potentially life-threatening consequences. We present a comprehensive review of throat pack use in all cleft units within the United Kingdom and Ireland. METHODS: All 20 cleft surgery units in the United Kingdom and Ireland were surveyed on their use of throat packs in children aged 6 months to 2 years undergoing elective cleft palate surgery. RESULTS: The response rate to the survey was 100%. Seventy-five percent of units currently use throat packs; in 40%, they are used in addition to cuffed endotracheal tubes (ETTs). Inclusion of the throat pack in the surgical swab count was perceived as the safest mechanism employed to avoid retention. 26.1% of respondents were aware of at least 1 incident of pack retention in their unit. DISCUSSION/CONCLUSION: The reported UK and Irish experience demonstrates that three-quarters of units routinely use packs. Notably, a quarter of respondents to the survey have experience of an incident of throat pack retention. Nevertheless, the majority of respondents considered the perceived risk of retaining a pack to be low. The growing use of microcuffed ETTs in UK cleft units paired with a low incidence of perioperative complications when a throat pack is not introduced might prompt cleft surgeons to review routine pharyngeal packing.

Consent in the time of COVID-19.

The COVID-19 pandemic crisis has necessitated widespread adaptation of revised treatment regimens for both urgent and routine medical problems in patients with and without COVID-19. Some of these alternative treatments maybe second-best. Treatments that are known to be superior might not be appropriate to deliver during a pandemic when consideration must be given to distributive justice and protection of patients and their medical teams as well the importance given to individual benefit and autonomy. What is required of the doctor discussing these alternative, potentially inferior treatments and seeking consent to proceed? Should doctors share information about unavailable but standard treatment alternatives when seeking consent? There are arguments in defence of non-disclosure; information about unavailable treatments may not aid a patient to weigh up options that are available to them. There might be justified concern about distress for patients who are informed that they are receiving second-best therapies. However, we argue that doctors should tailor information according to the needs of the individual patient. For most patients that will include a nuanced discussion about treatments that would be considered in other times but currently unavailable. That will sometimes be a difficult conversation, and require clinicians to be frank about limited resources and necessary rationing. However, transparency and honesty will usually be the best policy.