Gamlin F, Caldicott L D, Shah M V
Department of Anaesthesia, Leeds General Infirmary.
Anaesthesia. 1994 Oct;49(10):883-5. doi: 10.1111/j.1365-2044.1994.tb04266.x.
A patient developed sepsis syndrome with shock 7 h after an anaesthetic for a shoulder replacement. Tracheal intubation had been difficult and required the use of a stylet and gum-elastic bougies. A gastrografin swallow subsequently demonstrated an oesophageal perforation and mediastinitis was diagnosed at surgical exploration. She survived after a prolonged period of intensive care treatment.