1 Department of Anesthesiology, Division of Neonatology, Strong Children's Medical Center, University of Rochester, Rochester, NY 14642
2 Department of Pediatrics, Strong Children's Medical Center, University of Rochester, Rochester, NY 14642
Failure to recognize esophageal intubation can result in hypoxia and may lead to permanent neurologic injury. Clinical criteria commonly used to comfirm endotracheal intubation can fail to identify esophageal misplacement.1-9 The risk of this error has been reduced in the operating room by using capnography, which is both sensitive and specific for correct endotracheal intubation.4,6,7,10-12 Capnography is able to identify errant tube placements more rapidly and specifically than clinical indicators alone.10 We report here a novel cause of error in the capnographic findings at intubation in a neonate.
CASE REPORT
A 26-week gestational age, 690-g neonate was accidentally extubated during routine care.
Submitted on February 4, 1994