Endlich Yasmin, Fox Thomas P, Culwick Martin D, Acott Christopher J
School of Medicine, The University of Adelaide, Adelaide, Australia.
School of Nursing, The University of Adelaide, Adelaide, Australia.
Anaesth Intensive Care. 2024 Sep;52(5):302-313. doi: 10.1177/0310057X241244809. Epub 2024 Aug 31.
Oesophageal intubations are more common than may be realised and can potentially cause significant patient harm even if promptly identified and corrected. Reports of morbidity due to unrecognised oesophageal intubation continue to present in coroner and media reports. Therefore, it would be helpful to identify mechanisms to prevent these events and implement strategies to avoid and identify incorrect endotracheal tube placement. This analysis of oesophageal intubations reported to webAIRS aims to provide an in-depth analysis of all events in which oesophageal intubation occurred. WebAIRS is a web-based, bi-national incident reporting system collecting voluntarily reported anaesthetic events across Australia and New Zealand, with more than 10,500 incidents registered. A structured search through the webAIRS database identified 109 reports of oesophageal intubation reported between July 2009 and September 2022. A common cause of oesophageal intubation was the misidentification of the larynx due to a poor laryngeal view. Desaturation directly attributed to the misplaced endotracheal tube occurred in 43% of all reports. The authors precisely defined early recognised oesophageal intubation and delayed or unrecognised oesophageal intubation. Most reports (74%) described early recognition of the misplaced intubation, of which 27% led to directly contributed to hypoxia. Cardiovascular collapse as a direct consequence of the late recognition of oesophageal intubation was described in five (18%) of these events. There was inconsistency in end-tidal carbon dioxide monitoring and interpretation of the resulting waveform. Findings show that oesophageal intubation continues to be an issue in anaesthesia. Incidents described confusion in diagnosis, human factors issues and cognitive bias. Clear diagnostic guidance and treatment strategies are required to be developed, tested and implemented.
食管插管比人们意识到的更为常见，即使能及时发现并纠正，也可能对患者造成严重伤害。验尸官报告和媒体报道中仍不断出现因未识别出食管插管而导致发病的案例。因此，确定预防这些事件的机制并实施避免和识别气管内插管错误放置的策略将有所帮助。对报告至网络麻醉事件报告系统（webAIRS）的食管插管案例进行的这项分析，旨在深入分析所有发生食管插管的事件。webAIRS是一个基于网络的双边事件报告系统，收集澳大利亚和新西兰自愿报告的麻醉事件，已登记超过10500起事件。通过对webAIRS数据库进行结构化搜索，确定了2009年7月至2022年9月期间报告的109例食管插管案例。食管插管的一个常见原因是由于喉镜视野不佳而误认喉部。在所有报告中，43%的案例出现了直接归因于气管内插管位置不当的血氧饱和度下降。作者精确界定了早期识别的食管插管以及延迟或未识别的食管插管。大多数报告（74%）描述了对插管位置不当的早期识别，其中27%直接导致了缺氧。在这些事件中有5起（18%）描述了因食管插管识别延迟而直接导致的心血管衰竭。呼气末二氧化碳监测以及对所得波形的解读存在不一致情况。研究结果表明，食管插管在麻醉中仍然是一个问题。案例描述了诊断方面的混乱、人为因素问题和认知偏差。需要制定、测试并实施明确的诊断指南和治疗策略。
