[Unrecognized esophageal intubation. Consideration of prevention in a case]

A case of unrecognized esophageal intubation is presented to point out that auscultation of the chest is not a reliable method for proving the correct position of the endotracheal tube in every case. Because of auscultatory findings in this case of a 47-year-old women, several warning signs were discarded: (1) the surgeons questioned about the possibility of ventilating the stomach during preparation for an abdominal hysterectomy; (2) failure of measuring expired CO2 with an infrared CO2 analyzer, which then was called defective; (3) cyanotic blood at skin incision. All signs were denied by the anesthesiologist after having repeatedly auscultated the chest and being sure of hearing normal breath sounds. Although in his 1st year of anesthesia training, he did not feel it was necessary to call the supervising anesthesiologist. At the time of cardiac arrest about 15 min after intubation, the incorrect tube position was discovered and corrected. Despite successful cardiac resuscitation, the patient did not regain consciousness and died 9 months later. The only reliable means of being sure that tube position is correct is to repeat direct laryngoscopy and visualize the tube inside the glottis or, alternatively, to perform expiratory CO2 measurement.(ABSTRACT TRUNCATED AT 250 WORDS)