Medical malpractice during endotracheal intubation can result in catastrophic complications. However, there are no reports on these severe complications in South Korea. We aimed to investigate the severe complications associated with endotracheal intubation occurring in South Korea, via medicolegal analysis.
We retrospectively analyzed the closed judicial precedents regarding complications related to endotracheal intubation lodged between January 1994 and June 2020, using the database of the Supreme Court of Korea. We collected clinical and judicial characteristics from the judgments and analyzed the medical malpractices related to endotracheal intubation.
Of 220 potential cases, 63 were included in the final analysis. The most common event location was the operating room (n = 20, 31.7%). All but 3 cases were associated with significant permanent or more severe injury, including 31 deaths. The most common problems were failed or delayed intubation (n = 56, 88.9%). Supraglottic airway device was used in 5.2% (n = 3) cases of delayed or failed intubation. Fifty-one (81%) cases were ruled in favor of the plaintiff in the claims for damages, with a median payment of Korean Won 133,897,845 (38,000,000, 308,538,274). The most common malpractice recognized by the court was that of not attempting an alternative airway technique (n = 32, 50.8%), followed by violation of the duty of explanation (n = 10, 15.9%).
Our results could increase physicians’ awareness of the major complications related to endotracheal intubation and help ensure patient safety.
Endotracheal intubation is an important airway procedure to secure airway patency and ensure adequate ventilation in patients with respiratory depression or those undergoing general anesthesia [
Previous closed claims analyses related to airway management, including endotracheal intubation, have been mainly performed in the field of anesthesiology [
However, to the best of our knowledge, no reports have focused on severe complications resulting from medical malpractice related to endotracheal intubation in South Korea. Therefore, we aimed to examine the rare but severe complications and possible medical malpractice associated with endotracheal intubation via the analysis of medical malpractice legal judgments.
We analyzed closed judicial precedents from the publicly available judgment database of the Supreme Court of Korea. We searched all civil proceedings that were decided by the court between January 1, 1994 and June 31, 2020 using the following terms: ‘endotracheal’ and ‘intubation.’ We included medical malpractice litigation cases related to endotracheal intubation itself. We excluded cases related to airway procedures other than endotracheal intubation. We also excluded cases related to complications that occurred during an intubated state or extubation. The Institutional Review Board of Seoul National University Hospital (No. 02010-075-1163) approved this retrospective study. Since the judgments were provided to the researcher after de-identification, the need for informed consent was waived.
This analysis was conducted in a similar manner as our previous medicolegal studies [
Descriptive statistical analysis was performed using MedCalc version 19.5.3 (MedCalc Software Ltd., Belgium). We did not perform comparative statistics because our data could not represent all complications caused by endotracheal intubation in South Korea, and we could not know the accurate denominators. Continuous data are described as medians and interquartile ranges, and categorical data are described as numbers and percentages.
A total of 220 cases from 408 judgments were reviewed for eligibility. Among them, 157 were excluded and 63 cases were included in the final analysis. The general characteristics of the cases are presented in
The type of problems identified by researchers are provided in
The legal outcomes of the malpractice claims related to intubation are shown in
In this study, we analyzed 63 judicial precedents associated with endotracheal intubation complications in the Korean court system. The main finding was that the majority of cases were related to delayed intubation, and the most common type of malpractice recognized by the court was that of no attempt of alternative airway technique, followed by violation of the duty of explanation. All but 3 cases were associated with major permanent injuries, and approximately 50% of the patients died. To the best of our knowledge, this is the first study to focus on malpractice cases related to endotracheal intubation in South Korea, providing important information to mitigate medical liability and ensure patient safety.
In South Korea, there have been 2 closed claims analyses related to this issue in the field of anesthesiology. According to the analyses of anesthesia-related medical disputes using the Korean Society of Anesthesiologists database, >50% of the anesthesia-related disputes were associated with airway management [
In other countries, previous medicolegal studies on malpractice related to endotracheal intubation have been reported [
In our study, the most common types of malpractice contended by plaintiffs and recognized by the court were that of no attempt of alternative airway technique. In the cases related to delayed or failed intubation, there were ≥ 3 laryngoscopic attempts in approximately 60% of cases. Repetitive attempts can worsen intubation conditions and delay intubation [
Additionally, if a difficult airway is expected, physicians should be prepared to perform rescue airway techniques following failure of the primary method [
Violations of the duty of explanation was the second most common type of malpractice contended by plaintiffs and recognized by the court. To avoid such malpractice, the anesthesiologist should be aquainted with the following aspects. First, according to the Medical Service Act in Korea, possible complications related to the scheduled procedures should be notified to the patient in advance [
Physician inexperience was the third most common type of malpractice contended by plaintiffs and recognized by the court. There is a learning curve for successful endotracheal intubation, and previous studies have reported that > 50 endotracheal intubation procedures were required for a success rate of > 90% [
We also performed a subgroup analysis in pediatric patients. The most common types of malpractice contended by plaintiffs and recognized by the court in these patients were that of no attempt of alternative airway techniques and no use of SAD in cases related to delayed intubation. In addition, we were able to identify predictors of difficult tracheal intubation in only about half of pediatric patients. There could be technical airway difficulties in pediatric patients as their airway anatomy is different from that of adults [
There are several limitations to this study. First, since our data were skewed toward rare and severe complications due to the nature of the study, our cases did not represent the comprehensive features of endotracheal intubation. Second, the clinical information described in the precedent text was limited, particularly in dismissed cases. Third, despite the relatively long study period (26 years), we could not investigate the temporal trends of malpractices related to tracheal intubation due to the small number of cases. One retrospective study reported the decline in the incidence of difficult tracheal intubation over a 14-year period, and this result might be due to advances in airway management [
In conclusion, physicians should be prepared to avoid serious adverse events that may arise from delay in or failure of endotracheal intubation. To this end, physicians should be well-acquainted with the latest difficult airway guideline [
None.
No potential conflict of interest relevant to this article was reported.
Hye-Yeon Cho (Data curation; Formal analysis; Writing – original draft)
SuHwan Shin (Data curation; Formal analysis; Writing – review & editing)
SangJin Lee (Data curation; Formal analysis)
Susie Yoon (Data curation; Writing – review & editing)
Hojin Lee (Conceptualization; Formal analysis; Supervision; Writing – original draft; Writing – review & editing)
General characteristics of the cases in pediatric patients
Type of alleged problems in pediatric patients
Detailed information of the cases related to delayed or failed intubation in pediatric patients
Judicial characteristics in pediatric patients
General Characteristics of the Cases in This Study
Characteristics | Total (n = 63) |
---|---|
Sex (Male/Female/Not described) | 25 (39.7)/22 (34.9)/16 (25.4) |
Age at the time of event, years | 15 (23.8)/3 (4.8)/24 (38.1)/4 (6.3)/17 (27.0) |
(<10/10−19/20−59/≥60/Not described) | |
Institution (Local clinic/Hospital) | 8 (12.7)/55 (87.3) |
Location of event | |
Operating room | 20 |
Emergency room | 15 (23.8) |
General ward | 13 (20.6) |
Intensive care unit | 9 (14.3) |
Diagnostic procedure room | 4 |
Post-Anesthesia Care Unit | 2 (3.2) |
Cause of intubation (Respiratory depression/General anesthesia) | 48 (76.2)/15 (23.8) |
Clinical outcomes | |
High (NAIC score 6–9) | 60 |
Medium (NAIC score 3–5) | 2 (3.2) |
Low (NAIC score 0–2) | 1 (1.6) |
Values are presented as number (%). NAIC: National Association of Insurance Commissioners.
Causes of intubation at operating room: general anesthesia, n = 15 (23.8); respiratory depression during local anesthesia, n = 2 (3.2); respiratory depression after extubation, n = 1 (1.6); respiratory depression immediately after birth, n = 2 (3.2).
Esophagogastroduodenoscopy, n = 3 (4.8); bronchoscopy, n = 1 (1.6).
This included 31 deaths.
Type of Alleged Problems
Classification |
Total (n = 63) |
---|---|
Delayed intubation | 56 |
Aspiration of gastric contents | 4 (6.3) |
Upper airway trauma | 4 |
Accidental bronchial intubation | 2 (3.2) |
Failed intubation | 2 (3.2) |
Bronchospasm after intubation | 1 (1.6) |
Values are presented as number (%).
There were 5 cases involving 2 or more events: 3 cases of delayed intubation and aspiration of gastric contents; 1 case of delayed intubation, aspiration of gastric contents, and upper airway trauma; and 1 case of delayed intubation and bronchial intubation.
Tooth injury, n = 2 (3.2); laryngeal injury, n = 1 (1.6); vocal cord injury, n = 1 (1.6).
Detailed Information of the Cases Related to Delayed or Failed Intubation
Characteristics | Total (n = 58) |
---|---|
Failed intubation | 2 (3.4) |
Predictors of difficult tracheal intubation | 43 (74.1) |
Airway obstruction from any cause | 33 |
Limited mouth opening | 13 (22.4) |
Short neck | 12 (20.7) |
Secretions/blood in airway | 5 (8.6) |
History of cervical operation | 3 (5.2) |
History of cervical irradiation | 1 (1.7) |
Swollen tongue | 2 (3.4) |
Mallampati grade III or IV | 1 (1.7) |
Number of predictors (0/1/≥2) | 15 (25.9)/21 (36.2)/ 22 (37.9) |
Department of the first intubation attempter (Anesthesiologist/Internal medicine doctor/Emergency medicine doctor/Pediatrician/Others/Not described) | 18 |
Calling for help | 14 (24.1) |
Number of endotracheal intubation attempts (1/2/≥3/Not described) | 7 (12.1)/14 (24.1)/34 (58.6)/3 (5.2) |
Alternative airway intervention (Tracheostomy/Cricothyroidotomy/Supraglottic airway device) | 11 (19.0)/5 (8.6)/3 (5.2) |
Duration from the determination of intubation to airway securement (min) |
20 (14, 35) |
Values are presented as median (Q1, Q3) or number (%).
Causes of airway obstruction: upper airway edema, n = 21 (36.2); neck abscess, n = 5 (8.6); neck hematoma, n = 5 (8.6); tracheal stenosis, n = 2 (3.4).
Received a request for help in 3 cases.
General physician, n = 4 (6.9); neurosurgeon, n = 2 (3.4); orthopedic surgeon, n = 1 (1.7); obstetrician, n = 1 (1.7); family medicine doctor, n = 1 (1.7).
Two failed intubation cases were excluded.
Judicial Characteristics
Characteristics | Total (n = 63) |
---|---|
Claim conclusion | |
Dismissal/Settlement/Recognition of violation | 12 (19.0)/11 (17.5)/40 (63.5) |
Violation of the duty of care (contended by plaintiffs/recognized by the court) | |
No attempt of alternative airway technique | 47 (74.6)/32 (50.8) |
Physician inexperience | 15 (23.8)/8 (12.7) |
No confirmation of endotracheal intubation | 9 (14.3)/7 (11.1) |
Inappropriate tube size | 7 (11.1)/6 (9.5) |
Pulmonary aspiration | 4 (6.3)/4 (6.3) |
Upper airway trauma | 4 (6.3)/2 (3.2) |
Absence of intubation instruments |
2 (3.2)/1 (1.6) |
Inappropriate management of bronchospasm | 1 (1.6)/1 (1.6) |
Violation of the duty of explanation related to complications following intubation (contended by plaintiffs/recognized by the court) | 19 (30.2)/10 (15.9) |
Amount for damage—Korean Won | |
Claims of plaintiffs (n = 63) | 393,759,292 (162,046,444, 699,732,701) |
Recognition of the court (n = 51) | 133,897,845 (38,000,000, 308,538,274) |
Values are presented as median (Q1, Q3) or number (%).
No endotracheal tube, n = 1 (1.6); no endotracheal tube for pediatric patient, n = 1 (1.6).