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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 247-249

Accidental extubation owing to internal displacement of an armored endotracheal tube during craniosynostosis surgery in a pediatric patient

Department of An aesthesiology and Critical Care, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission17-Sep-2019
Date of Acceptance02-Dec-2019
Date of Web Publication27-Jun-2020

Correspondence Address:
MBBS, MD, PDCC Mridul Dhar
Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249202
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/roaic.roaic_6_19

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How to cite this article:
Dhar M, Hari Haran G, Talawar P. Accidental extubation owing to internal displacement of an armored endotracheal tube during craniosynostosis surgery in a pediatric patient. Res Opin Anesth Intensive Care 2020;7:247-9

How to cite this URL:
Dhar M, Hari Haran G, Talawar P. Accidental extubation owing to internal displacement of an armored endotracheal tube during craniosynostosis surgery in a pediatric patient. Res Opin Anesth Intensive Care [serial online] 2020 [cited 2020 Oct 28];7:247-9. Available from: http://www.roaic.eg.net/text.asp?2020/7/2/247/287995


A 2-year-old 10-kg female child was scheduled to undergo surgery for correction of craniosynostosis (scaphocephaly) by the reconstructive surgery department of our institute. Preoperative evaluation revealed no history suggestive of any other associated anomalies or increased intracranial pressure. Airway examination was unremarkable with no signs of airway difficulty; except an anteroposteriorly (AP) elongated head, with AP diameter being more than the mid-coronal diameter ([Figure 1]). Rest of the systemic examination and biochemical parameters were normal. A preoperative computed tomography scan of the head revealed fused sagittal suture resulting in synostotic scaphocephaly. The patient was planned for a craniectomy and suturectomy.
Figure 1 Scaphocephaly with anteroposteriorly elongated head.

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On the day of surgery, after age-appropriate preparation of the operation theater, the child was routinely induced with inhalational agent (sevoflurane), and the trachea was intubated and secured with a 4.0-mm ID-armored uncuffed endotracheal tube (ETT), as a 4.5-mm ETT was tight fitting in the glottis without any leak. The ETT was inserted under vision with the black mark crossing the glottic opening and was fixed at 12 cm at the teeth. The tube position was checked by auscultation and end-tidal capnography in both flexion and extension. A loosely fitted throat pack soaked with lignocaine was also inserted. Anesthesia was maintained with sevoflurane and intermittent atracurium on a Dräger Primus workstation using volume-controlled mode. Tidal volume and respiratory rate were adjusted to maintain adequate minute ventilation and end-tidal carbon dioxide (ETCO2) between 32 and 35 mmHg. Nitrous oxide was avoided. Age-appropriate alarm parameters were set (minute ventilation, airway pressure, and ETCO2).

The surgery involved burr hole drilling and removal of bone flap, which was remodeled and repositioned on the skull bones. This involved regular movement and handling of the head by the surgeons. The airway parameters and ETCO2 were intensely monitored during manipulation of the head. Approximately 3 h into the surgery at the time of approximation of fixing wires to the refashioned skull bones, the apnea alarm suddenly erupted along with loss of ETCO2 trace. A prompt and swift check of the ventilator circuit up till the patient was done, which was intact. Examination under the drapes revealed that the tube was still secured and in place at the point of fixation on the mouth. No breath sounds could be heard on auscultation. The surgical field was covered with a sterile drape to facilitate a check laryngoscopy, which revealed that the distal end of the ETT had slipped out into the oropharynx. Using a Magill’s forceps, the tube was reinserted into the trachea, and patient was oxygenated with 100% oxygen before resuming anesthetic gasses. The tube was refixed slightly deeper at 13 cm, and the surgeon was requested to continue with the surgery. The whole event was managed within a few minutes with no compromise of hemodynamics or airway parameters, including desaturation. Rest of the surgery and the postoperative period were uneventful ([Figure 2]).
Figure 2 Intraoperative management of the case.

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Anesthetic management of cases of craniosynostosis broadly involves management of volume status and prevention of venous air embolism. Airway management is not generally considered difficult unless there are obvious facial anomalies or syndromic associations. Management of such cases having Crouzon syndrome and Apert syndrome has been mentioned in literature [1],[2]. Otorhinolaryngeal, dental, and maxillo-facial surgeries along with reconstructive surgeries like cleft palate generally involve sharing the airway with the surgeon. The use of specialized retractors and mouth gags used in such cases tends to provide an extra layer of protection to secure the ETT in place. Continuous visual assessment of the ETT by the surgeon in the surgical field also adds to the monitoring by the anesthesiologist. This advantage might become a handicap in surgeries involving the head such as the present case where the ETT is generally covered under the drapes and involves excessive handling and manipulation of the head. Head and neck surgeries of the pediatric age group are perhaps a special subset of surgeries where extra caution has to be maintained in this regard.

Use of uncuffed ETT along with the appropriate size and depth of insertion is another important factor. Marking on the ETT to guide the depth of insertion has been shown to be generally appropriate to prevent inadvertent extubation and endobronchial displacement and correlate well with formulas available for the same [3],[4]. However, most data conclude with stressing on clinical assessment and analysis of tube placement and confirmation.

Numerous techniques and precautions to avoid extubation during such surgeries have been mentioned including checking tube position in neck flexion and extension, nasotracheal route of intubation and fixation, surgical suture or wire fixation of the tube, and use of preformed ETT [1],[5]. In the present case, the ETT got displaced internally despite prior checking of neck movements, despite appropriate depth of insertion, and in spite of a throat pack being place. This further reiterates the unpredictable extent of surgical handling of the head and requirement of extreme caution on the part of the anesthesiologist.

In the event that such a situation arises, one should immediately ask the surgeon to stop the surgery and should call for help urgently. Priority should be to maintain oxygenation and ventilation rather than resecuring the tube. There is a risk of surgical site sterility being compromised at the time of laryngoscopy especially during the stressful situation of loss of airway. Appropriate sterile precautions should be taken if the airway is under control.

In the present case, managing the event was relatively easy, but in cases of pre-existing difficult airway, consequences could be disastrous if appropriate precautions and strict vigilance is not maintained. Good communication between surgeon and anesthesiologist and special caution at the back of the mind will prevent avoidable airway complications during such surgeries.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Thomas K, Hughes C, Johnson D, Das S. Anaesthesia for surgery related to craniosynostosis: a review. Part 1. Paediatr Anaesth 2012; 22:1033–1041.  Back to cited text no. 1
Koh JL, Gries H. Perioperative management of pediatric patients with craniosynostosis. Anaesthesiol Clin 2007; 25:465–481.  Back to cited text no. 2
Weiss M, Knirsch W, Kretschmar O, Dullenkopf A, Tomaske M, Balmer C et al. Tracheal tube-tip displacement in children during head-neck movement—a radiological assessment. Br J Anaesth 2006; 96:486–491.  Back to cited text no. 3
Pek JH, Tan EM, Hao Y, Ong GY. Comparison of formulae for orotracheal intubation depth in the paediatric population. Ann Acad Med Singapore 2018; 47:138–142.  Back to cited text no. 4
Pearson A, Matava CT. Anaesthetic management for craniosynostosis repair in children. BJA Educ 2016; 16:410–416.  Back to cited text no. 5


  [Figure 1], [Figure 2]


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