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Twelve hours of gastric ventilation: a recipe for disaster (a suggested remedy)
D E Crockett1, R Tays, J G Brock-Utne
1Stanford University Medical Center, Department of Anesthesia, California 94305, USA.
Insights
A tracheal tube was misplaced in an infant
Area of Science:
- Neonatal intensive care
- Pediatric anesthesia
- Patient safety
Background:
- A 43-day-old infant required intubation in the Neonatal Intensive Care Unit (NICU).
- A nasogastric tube was already in place.
- Tracheal tube (TT) position was unverified before anesthesia induction.
Observation:
- Patient's condition deteriorated after anesthesia induction.
- The tracheal tube was found to be in the esophagus (esophageal intubation).
- A near-catastrophic event was averted by repositioning the TT.
Findings:
- Failure to verify tracheal tube placement before anesthesia induction led to esophageal intubation.
- Abdominal distention, if noted by clamping the nasogastric tube, could have alerted staff to the malposition.
Implications:
- Clamping a pre-existing nasogastric tube may serve as a crucial safety check for tracheal tube placement.
- This simple maneuver could prevent critical events in neonatal and pediatric anesthesia.
- Emphasizes the importance of routine verification of endotracheal tube placement.
Abstract:
A forty-three-day-old infant was intubated by the Neonatal Intensive Care Unit (NICU) staff. A nasogastric tube was in place for the duration. The patient's vital signs remained stable during 12 h of positive pressure ventilation. A Broviac catheter placement was scheduled in the NICU. The position of the tracheal tube (TT) was not verified prior to induction of anaesthesia. After the induction, the patient's condition deteriorated. The TT was found to be positioned within the oesophagus. A near catastrophe was successfully averted by discovering the malpositioned TT and replacing it with a properly positioned TT. We believe that had we clamped the existing nasogastric tube preoperatively, a noticeable abdominal distention would have occurred alerting us to a malpositioned TT. We suggest that clamping a preexisting nasogastric tube may have merit to alert one to a malpositioned TT.