Saudi Critical Care Journal

CASE REPORT
Year
: 2018  |  Volume : 2  |  Issue : 2  |  Page : 27--28

Delayed detection of esophageal intubation: Nasogastric tube was the cause?


Neeraj Kumar1, Amarjeet Kumar1, Prakash K Dubey2, Sanjeev Kumar3,  
1 Department of Trauma and Emergency, AIIMS, Patna, Bihar, India
2 Department of Anaesthesia, IGIMS, Patna, Bihar, India
3 Department of CTVS, AIIMS, Patna, Bihar, India

Correspondence Address:
Neeraj Kumar
Department of Trauma and Emergency, AIIMS, Patna, Bihar
India

Abstract

Unrecognized misplacement of the endotracheal tube (ETT) during endotracheal intubation and ventilation, has a reported incidence of 2.9%–16.7% and is a frequent cause of morbidity and mortality in emergency intubations. Accidental esophageal intubation is a common mistake in inexperienced anesthetists, but unrecognized esophageal intubation is, fortunately, a rare event because, in anesthetic malpractice claims, it frequently resulted in death or brain damage. The most common factors contributing to delayed detection were not using, ignoring, or misinterpreting CO2 readings.



How to cite this article:
Kumar N, Kumar A, Dubey PK, Kumar S. Delayed detection of esophageal intubation: Nasogastric tube was the cause?.Saudi Crit Care J 2018;2:27-28


How to cite this URL:
Kumar N, Kumar A, Dubey PK, Kumar S. Delayed detection of esophageal intubation: Nasogastric tube was the cause?. Saudi Crit Care J [serial online] 2018 [cited 2022 Aug 20 ];2:27-28
Available from: https://www.sccj-sa.org/text.asp?2018/2/2/27/245945


Full Text



 Introduction



The consequences of inadvertent and unrecognized esophageal intubation can be fatal. Unrecognized misplacement of the endotracheal tube (ETT) during endotracheal intubation and ventilation, has a reported incidence of 2.9%–16.7% and is a frequent cause of morbidity and mortality in emergency intubations.[1],[2],[3] A correct positioning of the tube is simple in most cases, and correct tube position can be ensured by using techniques aiming to improve tube placement (such as direct visualization of the vocal cords) and by techniques to check the position of the tube after placement (such as observation of chest expansion, chest auscultation, capnography, spirometry, or more advanced methods such as ultrasound or flexible bronchoscopy). Each of these methods has limitations and is often less reliable or even impractical in the emergency setting, and requires significant training for proper interpretation. Accidental esophageal intubation is a common mistake in inexperienced anesthetists, but unrecognized esophageal intubation is, fortunately, a rare event because, in anesthetic malpractice claims, it frequently resulted in death or brain damage.

 Case Report



A 50-year-old female patient presented with complaints of high-grade fever and altered sensorium. On further neurological examination, her Glasgow coma scale (GCS) was E2V1M4 considering low GCS physician immediately intubated using cuffed ETT 7.5 mm ID. She has 16G nasogastric (NG) tube in place and was fixed at the right nostril for initiation early enteral feeding. The patient had signs of aspiration pneumonia so after intubation bilateral bronchial sound was heard. Then, the patient was kept on pressure control ventilation + Mode with following settings (18 cm H2O/positive end-expiratory pressure 6 cm H2O/45%) for ventilation. After few minutes, arterial-blood gas was done which showed PH 7.25, PO2: 73 mmHg, PCO2:43 mmHg, and HCO3: 19 mmHg. The vitals recorded was heart rate: 123 bpm, SpO2: 93%, respiratory rate: 23/min, and temp: 39.2°C. We immediately ordered for chest X-ray (CXR) -anteroposterior view. On close observation, we noticed that some air was leaking from the NG tube. This was synchronizing with ventilator. One of our junior residents was in doubt that the NG tube was not in the stomach as the continuous air was leaking from the NG tube, so immediately NG tube was removed thinking that it might be in the trachea. However suddenly on removing the NG tube, the patient oxygen saturation was started falling from 93% to 88% and then, patient trachea was reintubated by a trained anesthesiologist under direct visualization of the vocal cord. After 15 min, CXR showed esophageal intubation with NG tube lying in the stomach and on close observation the NG tube distal tip was in the stomach with its proximal portion was traversing over the tip of the ETT at an acute angle [Figure 1].{Figure 1}

 Discussion



Three cognitive factors contributing to the delayed detection of esophageal intubation were commonly observed, and they are fixation error, confirmation bias, and overconfidence.[4] Air flowing through a tube in the esophagus, especially with the faster gas flows and higher tidal volumes during mechanical ventilation, may be misinterpreted as breath sounds in the lungs on auscultation as well as this air leaking through the NG tube prevented gastric distension[5] Training and education, workplace strategies, forcing functions to prevent confirmation bias and fixation errors, and improvement of anesthesiologists nontechnical skills[6] have the potential to reduce catastrophic patient injury from esophageal intubation. In our case, occurrence of delayed detection related to lack of end-tidal CO2 (ETCO2) monitoring devices in our ICU, so it suggests that there must be the availability of ETCO2 monitoring devices in all locations, especially outside the operation room leading to prevention of catastrophic injury that occurred due to delayed detection of esophageal intubation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Sayre MR, Sakles JC, Mistler AF, Evans JL, Kramer AT, Pancioli AM, et al. Field trial of endotracheal intubation by basic EMTs. Ann Emerg Med 1998;31:228-33.
2Jones JH, Murphy MP, Dickson RL, Somerville GG, Brizendine EJ. Emergency physician-verified out-of-hospital intubation: Miss rates by paramedics. Acad Emerg Med 2004;11:707-9.
3Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Ann Emerg Med 2001;37:32-7.
4Stiegler MP, Tung A. Cognitive processes in anesthesiology decision making. Anesthesiology 2014;120:204-17.
5Birmingham PK, Cheney FW, Ward RJ. Esophageal intubation: A review of detection techniques. Anesth Analg 1986;65:886-91.
6Flin R, Maran N. Basic concepts for crew resource management and non-technical skills. Best Pract Res Clin Anaesthesiol 2015;29:27-39.