Incorrect Intubation Technique Causes Fatal Complication During Cardiac Surgery

Case Overview

This case involves an elderly female patient with a history of mini stroke-like symptoms who was scheduled for a carotid endarterectomy. Prior to the procedure, the anesthesiologist sedated and intubated the patient. However, the anesthesiologist didn’t start the anesthesia induction until almost two hours after intubation and didn’t monitor patient’s vital signs during this time. When monitoring finally started, the patient had no C02 number. The anesthesiologist extubated and reintubated the patient, however, the reintubation went into the patient’s esophagus rather than trachea. The patient was without oxygen for 26 minutes and subsequently passed away.

Questions to the General Surgery expert and their responses

How frequently are you involved in the management of patients undergoing carotid endarterectomies?

I am a certified operating room nurse and have over 34 years of perioperative experience. I have been involved in 100+ procedures involving patients undergoing carotid endarterectomies.

What is the standard of care, if any, for the surgical nurse during induction and initiation of anesthesia?

In this case, the surgical nurse absolutely has an obligation to be present and aware during induction and initiation of anesthesia. First, the nurse has a duty to make sure all the equipment in the room is functioning before allowing the patient to be admitted to the operating room and check the anesthesia machine with the anesthesiologist. Once the patient is admitted into the operating room, the nurse either connects or assists with connecting the patient to all the monitors. The nurse should be present during sedation and must monitor the same screen that the rest of the clinical team is looking at to make sure that vital signs are being displayed and are in the appropriate range. The nurse also has a duty to communicate with the medical team if there are signs that indicate there is the absence of a waveform/no number for CO2. It is unfathomable that the patient did not have oxygen for 26 minutes without anyone noticing the placement of the tube was incorrect. The bottom line is, the nurse and the rest of the clinical team had a duty to the patient and the standard of care was not met.

About the expert

This expert is a registered nurse with over 30 years of experience. She completed an AA at Cypress College, a BS at California State University Long Beach, and her MBA at the University of New Haven. She is an active member of the American Society of Perianesthesia Nurses and the Association of Operating Room Nurses. She has previously held administrative positions at multiple facilities, including in perioperative services at the VA in New Haven, as well as in surgical services at Broward General and Columbia Hospitals. Her areas of clinical nursing expertise include PACU, orthopedics, and pre and post-anesthesia care. She currently works as a nursing consultant and clinical perioperative nurse in Nevada.