Delayed detection of esophageal intubation: Thai Anesthesia Incidents Study (THAI Study) database of 163,403 cases

Even though esophageal intubation is a common event in anesthesia practice, frequently it is easily detected and resolved. However delayed detection of esophageal intubation (DDEI) can lead to many serious adverse events such as severe hypoxemia, cardiac arrhythmia, cardiac arrest and brain death.

To analyze the incidence of DDEI during general anesthesia with endotracheal intubation and to identify its risk factors, especially patients factors and anesthetic techniques, as well as suggested strategies to prevent it.

Prospective observational study.

All reported DDEI incidents were identified from the Thai Anesthesia Incidents Study (THAI Study) database conducted between February 1, 2003, and January 31, 2004. Data were analyzed by using descriptive statistics.

Forty four cases of DDEI were reported from total of 85,021 cases underwent general anesthesia with endotracheal intubation (5.2: 10,000). The incidence was highest in tertiary care hospital (11.6:10,000). Infant patients (< or = 1 year of age), emergency operation and technique of rapid sequence induction with cricoid pressure were identified as risk factors of DDEI. Detection of DDEI was mainly based on clinical examination. The incidents with extremely low SpO2 level were reported but most of them were adequately managed without long term consequences and only one patient suffered from severe permanent brain damage.

The overall incidence of DDEI in Thailand was 5.2:10,000. Contributing factors included infant patients, emergency operation, and rapid sequence induction with cricoid pressure. Increased awareness and additional training are suggested as preventive strategies.