A RARE AND FATAL COMPLICATION OF ESOPHAGOSCOPY - ANESTHETIC IMPLICATIONS

A 3.5-year-old child developed a tight oesophageal stricture following ingestion of caustic soda. At the end of the fourth anaesthetic for o esophageal dilatation, laryngospasm and difficulty in mask ventilation was followed by cyanosis, bradycardia, and cardiac arrest. Chest X ra y showed a large pneumopericardium, which was immediately aspirated bu t unfortunately resuscitation was unsuccessful. It was presumed that d uring attempted manual ventilation of the lungs in the presence of a c losed glottis, air had been accidentally forced into the pericardium t hrough a small tear in the fragile oesophagus.