Accidental Extubation in the Prone Position during Surgery in a Patient with a Difficult Airway: Case Report
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Abstract
Unintentional extubation during prone-position surgery is a rare but critical airway emergency in anesthetic practice. We report a case of a 41-year-old obese female with predictors of a difficult airway undergoing elective lumbar laminectomy. Intraoperative dislodgement of the endotracheal tube, likely due to inadequate fixation, was promptly identified. Prone mask ventilation with an oropharyngeal airway maintained oxygenation until safe repositioning and reintubation were achieved. This case highlights the importance of rapid recognition, effective prone ventilation, and coordinated team response in managing airway emergencies in non-supine positions to optimize patient outcomes.
[1] Lester A, Paluska MR, Falcon R, Petersen TR, Shetty AK, Soneru C. Successful Rescue Ventilation of an Infant With a Laryngeal Mask Airway After Accidental Extubation in the Prone Position During Open Calvarial Reconstruction of a Craniosynostosis: A Case Report. Cureus. 2023; 15(10):e47064.
[2] De Cosmo G, Congedo E. Unintentional tracheal extubation during prone position: What is the best rescue airway device? J Emerg Trauma Shock. 2017; 10(1):2-3.
[3] Wu J, Liu Z, Shen D, Luo Z, Xiao Z, Liu Y, et al. Prevention of unplanned endotracheal extubation in intensive care unit: An overview of systematic reviews. Nurs Open. 2023; 10(2):392-403.
[4] Raphael J, Rosenthal-Ganon T, Gozal Y. Emergency airway management with a laryngeal mask airway in a patient placed in the prone position. J Clin Anesth. 2004; 16(7):560-1.
[5] Spond M, Burns T, Rosenbaum T, Lienhart K. Crisis Management of Accidental Extubation in a Prone-Positioned Patient with Klippel-Feil Syndrome. A A Case Rep. 2016; 6(12):383-6. Erratum in: A A Case Rep. 2017; 8(4):91.
[6] Thiel D, Houten J, Wecksell M. Accidental tracheal extubation of a patient in the prone position. A A Case Rep. 2014; 2(2):20-2.
[7] Rajaleelan W, Tuyishime E, Plitman E, Unger Z, Venkataraghavan L, Dinsmore M. Emergency airway management in the prone position: an observational mannequin-based simulation study. Adv Simul (Lond). 2024; 9(1):14.
[8] Yamamoto N, Ishii A, Miyashita T, Goto T. Airway management strategy for accidental tracheal extubation in the prone position: A simulation study. J Clin Anesth. 2020; 63:109786.
[2] De Cosmo G, Congedo E. Unintentional tracheal extubation during prone position: What is the best rescue airway device? J Emerg Trauma Shock. 2017; 10(1):2-3.
[3] Wu J, Liu Z, Shen D, Luo Z, Xiao Z, Liu Y, et al. Prevention of unplanned endotracheal extubation in intensive care unit: An overview of systematic reviews. Nurs Open. 2023; 10(2):392-403.
[4] Raphael J, Rosenthal-Ganon T, Gozal Y. Emergency airway management with a laryngeal mask airway in a patient placed in the prone position. J Clin Anesth. 2004; 16(7):560-1.
[5] Spond M, Burns T, Rosenbaum T, Lienhart K. Crisis Management of Accidental Extubation in a Prone-Positioned Patient with Klippel-Feil Syndrome. A A Case Rep. 2016; 6(12):383-6. Erratum in: A A Case Rep. 2017; 8(4):91.
[6] Thiel D, Houten J, Wecksell M. Accidental tracheal extubation of a patient in the prone position. A A Case Rep. 2014; 2(2):20-2.
[7] Rajaleelan W, Tuyishime E, Plitman E, Unger Z, Venkataraghavan L, Dinsmore M. Emergency airway management in the prone position: an observational mannequin-based simulation study. Adv Simul (Lond). 2024; 9(1):14.
[8] Yamamoto N, Ishii A, Miyashita T, Goto T. Airway management strategy for accidental tracheal extubation in the prone position: A simulation study. J Clin Anesth. 2020; 63:109786.
| Files | ||
| Issue | Article in Press |
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| Section | Case Report(s) | |
| Keywords | ||
| Accidental extubation Prone position Difficult airway Mask ventilation. | ||
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How to Cite
1.
Moradi A, Charmchi R, MoradiMajd P, Jamshidi M. Accidental Extubation in the Prone Position during Surgery in a Patient with a Difficult Airway: Case Report. Arch Anesth & Crit Care. 2026;.
