Original Article Esophageal Intubation in the First 2,000 Incidents Reports of Perioperative and Anesthetic Adverse Events in Thailand [PAAd Thai] Study Prok Laosuwan MD1, Somkhuan Dechasilaruk MD2, Thanist Pravitharangul MD3, Tanyong Pipanmekaporn MD4, Pathomporn Pin-on MD4, Phongpat Sattayopas MD5, Duangporn Tanatanud MD6, Kwankamol Boonsararuxsapong MD7, Athitarn Earsakul MD1 1 Department of Anesthesiology, Faculty of Medicine and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Chulalongkorn University, Bangkok, Thailand 2 Department of Anesthesiology, Buddhachinaraj Hospital, Pitsanulok, Thailand 3 Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand 4 Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand 5 Department of Anesthesiology, Nakornping Hospital, Chiang Mai, Thailand 6 Department of Anesthesiology, Lampang Hospital, Lampang, Thailand 7 Department of Anesthesiology, Chiangrai Prachanukroh Hospital, Chiang Rai, Thailand Background: Esophageal intubation [EI] is one of the most common events in perioperative airway management especially in anesthesia training situations. Objective: To examine incidents and contributing factors including corrective strategies of EI in the Perioperative and Anesthetic Adverse Events in Thailand [PAAd Thai] Study, hosted by the Royal College of Anesthesiologists of Thailand. Materials and Methods: A multi-center prospective observational study was conducted between January and December 2015. All EI incidents from the irst 2,000 incident reports from 22 participating hospitals across Thailand were reported and analyzed using descriptive statistics. Results: One hundred sixty-nine EI incidents (8.45%) were reported from the irst 2,000 incident reports in the PAAd Thai database. The incidence of delayed detection of EI was rare (0.28:10,000). Practice with trainees is a common situation (55.6%), however, most cases were early detection by clinical examination and/or capnometer without physiologic sequelae. Pediatric patients, cesarean section, and dificult intubation may lead to oxygen desaturation, with few cases of oxygen desaturation and bradycardia. Conclusion: While the EI incidence rates in Thailand remained constant, the incidence of delayed detection was dramatically reduced because of increased availability of end-tidal carbon dioxide monitoring. Vigilance, additional training, and more equipment availability are recommended. Keywords: Esophageal intubation, Incident report, Outcome, Monitoring, Adverse events, Complication J Med Assoc Thai 2018; 101 (1): 103-9 Website: http://www.jmatonline.com Esophageal intubation [EI] is a common situation for early detection. It also improves the reliability of in routine anesthesia practice especially for trainees. clinical signs(4). Fortunately, most cases are detected early by vigilant According to a THAI-study, a multicentered trainers and patients are not affected. On the other survey study of anesthesia incidents in Thailand in hand, delayed detection of EI is more catastrophic and 2005, the registry revealed that the capnometer use rate may lead to lawsuits(1-3). Sensitivity and specificity of was only 19% in daily practice(5). Without end-tidal various methods of detection of EI have been proposed. carbon dioxide, the detection of tracheal tube depends End-tidal carbon dioxide is the most reliable method on observation of chest movement, listening of breath sounds at the stomach area, vapor of water condensation Correspondence to: in the tracheal tube, and audible rattle around the Laosuwan P. Department of Anesthesiology, Faculty of Medicine and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, tracheal tube during ventilation. All of these clinical Chulalongkorn University, Bangkok 10330, Thailand. signs require experienced individual healthcare Phone: +66-2-2564215, Fax: +66-2-2564294 Email: [email protected] personnel and reliability is often limited. How to cite this article: Laosuwan P, Dechasilaruk S, Pravitharangul T, Pipanmekaporn T, Pin-on P, Sattayopas P, et al. Esophageal intubation in the irst 2,000 incidents reports of perioperative and anesthetic adverse events in Thailand [PAAd Thai] study. J Med Assoc Thai 2018;101:103-9. JOURNAL OF THE MEDICAL ASSOCIATION OF THAILAND | 2018 103 The aims of this study were to determine the detected early by clinical sigus and confirmed later incidence of early and delayed detection of EI in the by capnometer. Delayed detection of EI was reported Perioperative and Anesthetic Adverse Events in in only six cases (3.6%). The rate of end-tidal carbon Thailand [PAAd Thai] Study(6,7). It is also to determine dioxide monitoring during intubation period was the benefits and availability of capnometer in anesthetic 64.5%. However, clinical diagnosis of EI was achieved practice. Analyses of risks, contributing factors, factors before capnometer in 90 cases (53.3%). On the other minimizing incident, and suggested corrective strategies hand, 19 incidents (11.2%) were diagnosed with tracheal was also done. misplacement by monitoring only or monitoring before clinical diagnosis. End-tidal carbon dioxide monitoring Materials and Methods was not used in 36 cases (21.3%). The PAAd-Thai Study is a multi-center prospective One hundred forty-eight cases (87.6%) were observational study conducted at 22 hospitals across considered as preventable and due to human error. Thailand between January and December 2015. Data Errors were classified as rule-based (5.3%), knowledge- of all EI from the first 2,000 cases in each specific based (46.7%), skill-based (37.9%), and combined incident were sent for analysis(7). The study protocol (2.4%). However, 20 cases (12.43%) were considered was approved by each institutional ethics committee spontaneous or unpreventable. Incident related factors before collection. All EI incident record forms were considered by reviewers are demonstrated in Table 2. reviewed by three anesthesiologists for completion, According to system analysis, contributing factors, identifying mechanisms, contributory factors, factors factors minimizing incident, and suggested corrective minimizing incident, and suggested corrective strategies are shown in Table 3. strategies. Any controversy was discussed to achieve a consensus(7). Descriptive statistics were used to present the data by SPSS version 22. Table 1. Demographic data and details of events and outcomes Delayed detection of EI was defined as (n = 169) misplacement of tracheal tube that was detected late Demographic data or Details of events n (%) until clinical hypoxia or oxygen saturation of less Age group than 85% developed. Patients less than 15 years old Pediatric (<15 years) 21 (12.4) were assigned to the pediatric group. Patients who Adult (≥15 years) 148 (87.6) had at least one difficult intubation characteristic Type of hospitals were considered as suspected difficult intubation. University 57 (33.7) In addition, patients in the unexpected difficult Non-university 112 (66.3) intubation group were assigned from the details of Time to detection of EI events. Those with pulse oximeter showing less than Early 163 (96.4) Delayed 6 (3.6) 85% or 90% for three minutes were considered as Airway assessment oxygen desaturation(7). Normal 128 (75.7) Unexpected dificult intubation 17 (10.1) Results Suspected dificult intubation 24 (14.2) In the PAAd Thai database, there were 216,179 Use of capnometer cases of general anesthesia. One hundred seventy-four Not available in the case 36 (21.3) Presented during intubation period 109 (64.5) cases of EI were collected. Five cases were excluded Omitted 24 (14.2) due to irrelevance according to the definition. Nature of practice Therefore, 169 cases of EI were enrolled. Ninety-four Training 94 (55.6) cases (55.6%) occurred in training situations and 75 Non-training 75 (44.4) cases (44.4%) in non-training practice. Incidents Frequency of EI in each case were reported from non-university hospitals with 1 145 (85.8) 112 (66.3%) and 57 (33.7%) from university hospitals 2 19 (11.2) 3 3 (1.8) as shown in Table 1. Age ranges were classified as >3 2 (1.2) pediatric and adult groups. The number of pediatric Outcomes and adult cases were 21 (12.43%) and 148 (87.57%), Oxygen desaturation 23 (13.6) respectively. Bradycardia 5 (3.0) One hundred sixty-three cases (96.4%) were EI = esophageal intubation 104 J Med Assoc Thai | Vol.101 | No.1 | 2018 Table 2. Incident-related factors and preventability considered (4%) of EI resulting in six deaths (64% mortality rate) by reviewers (n = 169) and one brain injury(10). In airway-related claims against Factors or outcomes n (%) Canadian anesthesiologists between 1993 and 2003 Incident-related factor dataset, nine of 33 claims (27%) were EI in which six Patient 46 (27.2) cases resulted in death or permanent brain damage(11). Surgical 2 (1.2) Anesthetic 147 (87.0) A publication on anesthesia claimed that the dataset Preventability from the United Kingdom in 1995 to 2007 revealed four cases (6% of airway claims) of EI incident Preventable 149 (88.2) (12) Unpreventable 20 (11.8) and high morbidity and mortality rates . In contrast, Human errors the Australian Incident Monitoring Study [AIMS] Rule-based 9 (5.3) accounted for only 1.75% of all incident reports and Knowledge-based 79 (46.7) only one death(13). Skill-based 64 (37.9) Combination 4 (2.4) Compared to the Thai Anesthesia Incident (13) Surgical Safety checklist may prevent 10 (5.9) Monitoring Study [Thai