The following are actual cases of unrecognised oesophageal intubation, the details of which are publicly available. These cases are provided to enhance airway practitioners’ understanding of how such events occur and the importance of adopting the strategies advocated to prevent them. The intent of highlighting these cases is to highlight common themes and foster appreciation of how any airway practitioner might become vulnerable to taking similar actions in situations of stress, not to invite criticism of the individuals involved. We extend our sympathy to the family and friends of the patients harmed in these tragic incidents.

Anonymous

2021/22

Emergency intubation on ward: the following is a summary of the information in the Safe Anaesthesia Liason Group Report (Oct 2021 - Mar 2022, Pg 4) available at the link above.

The patient, who was being treated with CPAP on the ward for COVID-19 became agitated and removed their mask, leading to a sudden fall in SpO2 to 34%.

Emergency rapid sequence intubation was performed on the ward using propofol, rocuronium and a bougie. A peri-intubation cardiac arrest occurred and cardiopulmonary resuscitation was commenced. Capnography monitoring was not available at the time of intubation and it was estimated not to have been connected until approximately 10 minutes later. An arterial blood gas showed a PO2 of zero.

The tube was found to be placed in the oesophagus. The tube was removed and the patient reintubated but they did not improve subsequently, so resuscitation efforts were ceased.

Emma currell

2020

Intubation following seizure: the following is a summary of the information in the news report available at the link above.

During transport home from the hospital in an ambulance following dialysis, the patient suffered a seizure. She was taken back to the hospital where, in the emergency department, she suffered a second seizure. She had bitten her tongue, which was swollen, and was bleeding from her mouth.

An anaesthetic trainee intubated the patient, reporting being able to obtain a partial view of the glottis but carbon dioxide was not detected in the exhaled gas. The anaesthetic trainee and a technician both expressed concerns that the tube was not correctly positioned. A senior anaesthetic colleague was asked to check the position of the tube but was occupied with other tasks. The anaesthetic trainee performed repeat laryngoscopy but was unable to confirm correct positioning of the tube due to an increase in tongue swelling. Several doctors including the senior anaesthetic doctor listened to the patient’s chest and were confident they could hear breath sounds. The senior anaesthetic doctor was concerned that removing the tube might be dangerous.

It is now accepted that the tube had been placed in the oesophagus. The absent carbon dioxide trace was not acted on for a considerable period of time during which the patient suffered a cardiac arrest and died.

Glenda Logsdail

2020

General anaesthesia for acute appendicitis: the following is a summary of the findings of the prevention of future deaths report, an editorial and correspondence discussing the case in the journal Anaesthesia, an article on the Association of Anaesthetists website and news reports available via the links above.

An otherwise well 61 year old patient was anaesthetised for an emergency laparoscopic appendicectomy. Induction of anesthesia took place in the anaesthetic room rather than the operating room. Following preoxygenation, the patient was induced and as part of an impromptu training session, the airway assistant made the first attempt at intubation under the supervision of the consultant anaesthetist, though the airway assistant’s role did not require them to be able to intubate. This took about a minute and was unsuccessful. The consultant anaesthetist then attempted intubation, reporting a grade 1 Cormack-Lehane view at laryngoscopy. Direct laryngoscopy with a Macintosh blade was used for both intubations.

Waveform capnography was in use from the outset but despite a deterioration in the patient’s condition after intubation, no confirmatory checks of tube position appeared to have been undertaken. Shortly after intubation the patient’s oxygen saturation deteriorated markedly and they suffered a cardiac arrest. The consultant anaesthetist attributed the deterioration to anaphylaxis and treatment for this was initiated. Help was summoned and multiple staff responded. Based on the consultant anaesthetist’s calm demeanour and confidence in the diagnosis of anaphylaxis, the other staff present assumed this to be correct, hindering consideration of alternative diagnoses. A hierarchical authority gradient was also felt to have inhibited other staff members voicing their concerns, compounded by medical staff having titles that might have obscured their relative levels of experience. As the crisis unfolded there was considerable confusion and lack of role clarity, including the absence of a team leader, resulting in compromised team function and a sense of chaos. The limited physical space in the anaesthetic room was thought to have created further difficulties by restricting the movement of the numerous staff who attended to assist.

An anaesthesia/intensive care trainee arriving to assist noted a low oxygen saturation but mistook the ventilator pressure waveform for a normal capnography trace, when in fact the capnography trace was flat. Variable configurations of the parameters on displayed on monitors throughout the hospital and the fact that the monitor in the operating theatre did not display a waveform capnograph by default (buttons needed to be pressed to display the capnograph trace) were thought to have contributed to this error. When a second consultant anaesthetist arrived to assist they were initially delegated to an ‘irrelevant task’, which distracted them from assessing the situation for 1-2 minutes. The second consultant anaesthetist then queried the tube position and it was recognised to be placed in the oesophagus, 11 minutes after the onset of cardiac arrest. The second anaesthetist replaced the tube, successfully intubating the trachea without difficulty, again using direct laryngoscopy. Spontaneous circulation was restored shortly afterwards.

The patient suffered irreversible hypoxic brain damage during the period of interrupted ventilation and died 5 days later.

Graham Hargreaves

2020

 
 

Return to theatre for video assisted thoracoscopic surgery: the following is a summary of the news reports available via the links above.

The patient was anaesthetised for video assisted thoracoscopic surgery following a deterioration 5 days post right pneumonectomy, due to possible infection or bleeding. The anaesthetist stated he clearly saw the vocal cords when passing the double lumen tube and that it had been fitted correctly. Following intubation, no capnography trace was present and the patient’s abdomen became distended. The patient suffered a cardiac arrest and died prior to commencement of surgery but the surgeon and anaesthetist had conflicting recollections about whether this occurred before or after the intubation.

The coroner accepted that the tube had been inserted into the oesophagus and that the resulting lack of oxygen was a contributory factor in the patient’s death.

Aksharan Sivaruban

2018

Elective paediatric hernia repair: the following is a summary of the findings of the news report available via the link above.

The 3 month old patient underwent a general anaesthetic and intubation for an elective hernia repair. Carbon dioxide was not detected. Cardiac arrest occurred after intubation. The patient had 2 small cardiac septal defects which were assumed to be the cause of the cardiac arrest. Post-mortem the tube was found to be in the oesophagus.

Sharon Grierson

2016

Laryngospasm post-extubation following elective surgery: the following is a summary of the findings of the prevention of future deaths report available via the link above.

The 44 year old patient was intubated for elective surgery to remove a polyp from her vocal cord. The surgery was uneventful but following extubation, while still anaesthetised, she had an episode of laryngospasm and desaturated. As part of the management of laryngospasm, the patient was administered a neuromuscular blocking agent and re-intubated.

Shortly afterwards the patient suffered a cardiac arrest and cardiac life support was initiated. Capnography readings did not show exhaled carbon dioxide despite the presence of good quality cardiac compressions. During the process of inserting an orogastric tube, the tracheal tube was found to be placed in the oesophagus. The tube was removed and replaced but the capnography continued to display abnormal readings. A flexible bronchoscope was used to evaluate the position of the tube and it was again found to be oesophageal and removed. A third intubation attempt successfully placed the tube in the trachea. The duration of the incident was approximately one hour, during which 4 consultant anaesthetists, 2 other doctors and a number of other trained theatre staff were in attendance.

The patient suffered hypoxic brain injury during the period of interrupted ventilation, resulting in her death 3 days later.

Peter saint

2016

Unplanned intubation during elective knee replacement surgery: the following is a summary of the findings of the prevention of future deaths report and news reports available via the links above.

The 71 year old patient underwent an elective knee replacement under a general anaesthesia with a supraglottic airway. The patient was obese but otherwise well. Approximately 40 minutes into the surgery, the patient’s oxygen saturation deteriorated in association with increased ventilation pressure. Gastric fluid was noted when the supraglottic airway was removed. The patient was tilted head down, suction was applied and a second generation supraglottic airway inserted. Lung ventilation with the second generation supraglottic airway did not produce any capnography trace and around 15 minutes later, the second generation supraglottic airway was removed and the patient was intubated with some difficulty, which was attributed to their body habitus.

Shortly afterwards the patient arrested and cardiac life support was commenced. No carbon dioxide trace was evident following intubation which the primary consultant anaesthetist attributed to the cardiac arrest. The Operating Department Practitioner assisting with airway management raised concerns about the position of the tube based on the absence of a capnography trace and significant distention of the patient’s stomach but despite this neither the primary consultant anaesthetist, nor the consultant anaesthetist and anaesthetic registrar who attended to assist, recognised that the tube was in the oesophagus. Oesophageal placement of the tube was only identified about 25 minutes after intubation. The patient was not ventilated for a total period of approximately 38 minutes.

The patient suffered extensive hypoxic brain damage and died 5 days later.

Joanne Lockham

2007

General anaesthetic for emergency caesarian section: the following is a summary of the findings of the news report available via the link above.

The 45 year old patient underwent a general anaesthetic for emergency caesarian section for foetal bradycardia. Three attempts were made to intubate. The final attempt was believed to be successful. Carbon dioxide detection was not used to confirm the position of the tube. The patient started to move at one point, so a second dose of neuromuscular blocking agent was given. Shortly after delivery, the patient suffered a cardiac arrest. A consultant anaesthetist who arrived at the hospital to assist, identified that the tube was misplaced and reintubated successfully. The patient had been deprived of oxygen for 30 minutes.

The patient was transferred to the intensive care unit but was certified dead 2 days later due irreversible brain damage from hypoxaemia.