Unintentional Intraoperative Extubation

“When the ETT was slightly withdrawn, the patient was accidentally extubated.”

Case Context    Provider Narrative   Contributing Factors    Lessons Learned

Case Context

Patient: middle-aged adult
Presenting diagnosis: degenerative joint disease
Planned procedure: total hip revision
Past medical history: mild aortic stenosis, hypertension
Other pertinent information: npo X 8 hrs except for a sip of water with antihypertensive med; airway examination: no limitations of head or neck, thyromental distance greater than 6 centimeters, Mallampati score of 2; dentition intact; no known history of difficult intubation
Anesthetic plan: general endotracheal anesthesia (placement of an epidural was discussed, but ruled out due to the patient’s history of aortic stenosis