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Pulsatile lavage irrigator tip, a rare radiolucent retained foreign body in the pelvis: a case report.

Connelly CL, Archdeacon MT - Patient Saf Surg (2011)

Bottom Line: Retained foreign bodies after surgery have the potential to cause serious medical complications for patients and bring fourth serious medico-legal consequences for surgeons and hospitals.Despite these precautions, radiolucent objects and uncounted components/pieces of instruments are at risk to be retained in the surgical wound.Revision surgery was required in order to remove the retained object, and the patient had no further complications.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Orthopaedic Surgery, University of Cincinnati, P,O, Box 670212, Cincinnati, OH, 45267-0212, USA. archdemt@ucmail.uc.edu.

ABSTRACT
Retained foreign bodies after surgery have the potential to cause serious medical complications for patients and bring fourth serious medico-legal consequences for surgeons and hospitals. Standard operating room protocols have been adopted to reduce the occurrence of the most common retained foreign bodies. Despite these precautions, radiolucent objects and uncounted components/pieces of instruments are at risk to be retained in the surgical wound. We report the unusual case of a retained plastic pulsatile lavage irrigator tip in the surgical wound during acetabulum fracture fixation, which was subsequently identified on routine postoperative computed tomography. Revision surgery was required in order to remove the retained object, and the patient had no further complications.

No MeSH data available.


Related in: MedlinePlus

An end-on view of the pulsatile lavage nozzle with the central filter cap (arrow).
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Figure 7: An end-on view of the pulsatile lavage nozzle with the central filter cap (arrow).

Mentions: Following this event, a root cause analysis was performed to determine the precipitating factors, and to prevent recurrence of this complication. The first issue identified was a process-related error involving surgical equipment modification. In the experience with the Interpulse Powered Lavage System (Stryker, Kalamazoo, MI) at our institution, it was perceived that the irrigation time in operating room was longer than desired. It was also noted that by removing the central "filter cap" in the tip of the irrigator (Figure 7 and Figure 8, white arrow) that a higher flow could be achieved, reducing irrigation time. In operating room time trials this difference was determined to be approximately 45 seconds for each 3-liter bag of saline. Thus, it had become standard practice in our operating rooms to remove this component on the back table, prior to use. However, in light of this event, we have discontinued this practice. We suspect that the central filter cap may add some stability to the fixation of the nozzle tip on the lavage apparatus. Thus, removing this piece may have contributed to the dislodgment of the tip within the pelvic wound. Still, we are not aware of any other events or close-calls with a dislodging irrigator nozzle tip at our institution or in the literature.


Pulsatile lavage irrigator tip, a rare radiolucent retained foreign body in the pelvis: a case report.

Connelly CL, Archdeacon MT - Patient Saf Surg (2011)

An end-on view of the pulsatile lavage nozzle with the central filter cap (arrow).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3117682&req=5

Figure 7: An end-on view of the pulsatile lavage nozzle with the central filter cap (arrow).
Mentions: Following this event, a root cause analysis was performed to determine the precipitating factors, and to prevent recurrence of this complication. The first issue identified was a process-related error involving surgical equipment modification. In the experience with the Interpulse Powered Lavage System (Stryker, Kalamazoo, MI) at our institution, it was perceived that the irrigation time in operating room was longer than desired. It was also noted that by removing the central "filter cap" in the tip of the irrigator (Figure 7 and Figure 8, white arrow) that a higher flow could be achieved, reducing irrigation time. In operating room time trials this difference was determined to be approximately 45 seconds for each 3-liter bag of saline. Thus, it had become standard practice in our operating rooms to remove this component on the back table, prior to use. However, in light of this event, we have discontinued this practice. We suspect that the central filter cap may add some stability to the fixation of the nozzle tip on the lavage apparatus. Thus, removing this piece may have contributed to the dislodgment of the tip within the pelvic wound. Still, we are not aware of any other events or close-calls with a dislodging irrigator nozzle tip at our institution or in the literature.

Bottom Line: Retained foreign bodies after surgery have the potential to cause serious medical complications for patients and bring fourth serious medico-legal consequences for surgeons and hospitals.Despite these precautions, radiolucent objects and uncounted components/pieces of instruments are at risk to be retained in the surgical wound.Revision surgery was required in order to remove the retained object, and the patient had no further complications.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Orthopaedic Surgery, University of Cincinnati, P,O, Box 670212, Cincinnati, OH, 45267-0212, USA. archdemt@ucmail.uc.edu.

ABSTRACT
Retained foreign bodies after surgery have the potential to cause serious medical complications for patients and bring fourth serious medico-legal consequences for surgeons and hospitals. Standard operating room protocols have been adopted to reduce the occurrence of the most common retained foreign bodies. Despite these precautions, radiolucent objects and uncounted components/pieces of instruments are at risk to be retained in the surgical wound. We report the unusual case of a retained plastic pulsatile lavage irrigator tip in the surgical wound during acetabulum fracture fixation, which was subsequently identified on routine postoperative computed tomography. Revision surgery was required in order to remove the retained object, and the patient had no further complications.

No MeSH data available.


Related in: MedlinePlus