Delayed Detection of Esophageal Intubation in Anesthesia Malpractice Claims: Brief Report of a Case Series

Abstract

This retrospective case series analyzed 45 malpractice claims for delayed detection of esophageal intubation from the Anesthesia Closed Claims Project. Inclusion criteria were cases from 1995–2013, after adoption of identification of CO2 in expired gas to verify correct endotracheal tube position as a monitoring standard by the American Society of Anesthesiologists. Forty-nine percent (95% CI 34%−64%) occurred in the operating room or other anesthesia location where CO2 detection equipment should have been available. The most common factors contributing to delayed detection were not using, ignoring, or misinterpreting CO2 readings. Misdiagnosis, as with bronchospasm, occurred in 33% (95% CI 20%−49%).

Global Capnography Project (GCAP): implementation of capnography in Malawi – an international anaesthesia quality improvement project

“…Many reflected that without the recognition and correction of these critical incidents, the adverse outcomes could have been very serious. This corroborates the experience of when routine capnography was first introduced into high‐income countries from 1986, the incidence of undetected oesophageal intubation causing catastrophic injury notably decreased, and was eventually virtually eliminated . Capnography became mandatory in the US from 1991 (Fig.…”

“…Trends in oesophageal intubation over time. The proportion of claims for delayed detection of oesophageal intubation by year of event in the Anesthesia Closed Claims Project Database . The years 1970–1975 and 2010–2013 were collapsed due to the small total number of claims in the database for those years.…”

Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies*

“…Preventable mortality and serious morbidity from unrecognised oesophageal intubation continue to occur worldwide [ 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 ], despite existing guideline recommendations and widely publicised education programmes [ 31 ] .…”

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“…Despite being recognized by the recent literature as main responsible of airway accidents [ 45 , 46 , 47 , 48 , 49 , 50 ], less attention has been focused on non-technical issues with COVID-19 airway management.…”