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A Journal on Anesthesiology, Resuscitation, Analgesia and Intensive Care

Official Journal of the Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care
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Minerva Anestesiologica 1998 November;64(11):521-8

language: Italian

Anesthesiologic incidents caused by esophageal intubation. Medico-legal evaluation of three cases

Ronchi E. 1, Tommasino C. 2, Molendini L. O. 1, Lugani D. 2

1 Università degli Studi - Milano, Istituto di Medicina Legale e delle Assicurazioni;
2 Università degli Studi - Milano, Cattedra di Anestesia e Rianimazione, IRCCS H San Raffaele


Undiagnosed esophageal intubation is still prominently in anesthesia-related morbidity and mortality. Three cases of undiagnosed esophageal intubation taken into consideration for possible anesthesiologic malpractice are presented. A review of the international anesthetic-related morbidity and mortality statistics indicates that this misadventure remains a problem even among anesthesia personnel, a medical population specifically trained in such a procedure. It is not only the frequency of this misadventure but the potential catastrophic consequences for the patient that underline the importance of being able to recognise and correct an esophageal intubation. The reliability of commonly prescribed methods of assessing tracheal tube position is reviewed and the conclusion is drawn that continuous end-tidal carbon dioxide measurement during anesthesia is perhaps the most reliable means under all circumstances for determining proper tube position and should be employed routinely whenever possible.

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