NHS England case study: Potential for aspiration of absorbent haemostatic gauze (24 July 2026)

Summary

This case study is one in a set of patient safety ‘how we acted on patient safety issues you recorded’ case studies which show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm.

Content

Through its core work to review recorded patient safety events, the National Patient Safety Team identified an incident describing a ventilated tracheostomy patient whose oxygen levels dropped after their trachea was obstructed by a piece of absorbent haemostatic gauze.

Following unsuccessful attempts to ventilate the patient, a bronchoscopy was performed and a piece of woven synthetic material, obstructing the base of the trachea, was removed. This was considered likely to be absorbent haemostatic gauze.

Absorbent haemostatic gauze is effective at stemming bleeding and is designed to break down and be absorbed by the body. However, a potential risk to the airway may occur when these products break down and separate into smaller pieces, which could be aspirated into the airway. 

Manufactures of these gauzes caution against its use for packing wounds, advise removal of the product when bleeding has stopped, and that precautions should be taken to assure that none of the material is aspirated. 

NHS England contacted clinical expert groups who routinely use these products and it was agreed that guidance would be useful to direct the use and post operative management of absorbent haemostatic gauze. Consequently, The Faculty of Intensive Care Medicine (FICM) and The Royal College of Surgeons of England are collaborating to produce clinical guidance, aiming for consistent, safer practice. FICM also included this issue in their January 2023 edition of ‘Safety Incidents in Critical Care’.