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
Affiliation :
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 (cid:976)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 (cid:976)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 dif(cid:976)icult 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
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