Esophageal Intubation in Pediatric Patient Leads to Death

This case study examines a tragic incident involving a three-year-old patient who succumbed to complications following an unrecognized esophageal intubation.

ByExpert Institute


Published on February 6, 2024

Anesthesiologist performs intubation

Case Overview

This case study examines a tragic incident involving a three-year-old patient admitted for Hemolytic Uremic Syndrome following exposure to E Coli O157:H7. The child’s condition deteriorated, necessitating intubation and extracorporeal membrane oxygenation (ECMO).

Allegedly, an esophageal intubation occurred during this process, which was unnoticed for approximately eight minutes before being corrected. Unfortunately, the child died. An expert in pediatric intubation is needed to provide insight into the standard of care expected in such situations.

Questions to the expert and their responses


How often do you perform intubations on pediatric patients?

As a board-certified pediatric anesthesiologist with 14 years’ experience at a major pediatric hospital, I perform intubations on patients around this age daily.


How should a provider reduce the chances of esophageal intubation when intubating pediatric patients?

Reducing esophageal intubation risk involves several key steps.

Firstly, it’s crucial to have an expert in pediatric airway management who knows endotracheal intubation. Proper laryngoscope selection, correct positioning, appropriate monitor use, and suitable medications are all vital components. Direct visualization of the vocal cords and insertion of the Endotracheal Tube (ETT) into the trachea is preferred. This can be achieved with a standard laryngoscope or video adjuvants.


How should esophageal intubation be deemed necessary in pediatric patients?

Esophageal intubation can be identified through several methods – direct visualization, auscultation, evidence of end-tidal CO2 (if the patient isn’t asystolic), maintaining and raising O2 sats, Chest X-Ray (CXR), Arterial Blood Gas (ABG) analysis.


Have you ever reviewed a similar case before? If yes, please explain.

I have been clinically active in Georgia during the time period noted. I have been called to consult on difficult airways in-house, in the ICU, in the ED, and in the OR. I would be happy to review this case. The specialty requested in this case was Pediatric Intubation Best Practices.

About the expert

This expert is a highly experienced anesthesiologist, specializing in pediatric anesthesiology, with 15 years of practice. They have undergone extensive training and education, including a fellowship in pediatric anesthesiology at a renowned university's School of Medicine. Currently serving as an attending pediatric anesthesiologist, practice director, and section chief at a children's hospital, they also contribute to academia through publications and presentations on anesthesiology topics.

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