LARYNG-O-JET

Description of Event or Problem

THE CANNULA OF THE LARYNG-O-JET BROKE DURING LIDOCAINE INJECTION AND MIGRATED INTO THE PT'S RIGHT BRONCHUS. THE CRNA PLACED THE CANNULA AND INJECTED THE LIDOCAINE. THE CRNA DID NOT REPORT ANY RESISTANCE DURING CANNULA PLACEMENT. AFTER THE CRNA WITHDREW THE CANNULA, ONE OF THE STAFF NOTICED THAT THE CANNULA WAS BROKEN. THE CRNA LOOKED IN THE MOUTH AND DID NOT SEE THE DEVICE. THE CRNA AND ANESTHESIOLOGIST USED A FLEXIBLE BRONCHOSCOPE TO IDENTIFY THE LOCATION OF THE CANNULA. THE CANNULA WAS FOUND IN THE RIGHT BRONCHUS. THE ANESTHESIOLOGIST USED GRASPER TO RETRIEVE THE DEVICE. THE ANESTHESIOLOGIST WAS NOT SUCCESSFUL. ENT WAS PAGED TO THE OR FOR AN EMERGENT REMOVAL OF THE CANNULA. THE ENT USED A STIFF BRONCHOSCOPE AND FORCEPS TO RETRIEVE THE CANNULA. AFTER TWO ATTEMPTS, THE ENT RETRIEVED THE DEVICE. A CHEST X -RAY WAS PERFORMED. THE BRONCHUS WAS CLEAR. THE PATIENT DID NOT SHOW ANY HARM. THE MANUFACTURER WAS INFORMED OF THE EVENT ON THE DAY OF THE EVENT.