To the Editor

A 2-hour-old, 1400 gm neonate was brought to the OR for gastrochisis repair. After an uneventful, intravenous induction with propofol and rocuronium and easy mask ventilation, we intubated the neonate with a 3.0 uncuffed endotracheal tube styleted with a 6 F Rusch Flexi-Slip™ stylet (Teleflex Medical, Research Triangle Park, NC, USA) without any difficulties. While the resident held on to the endotracheal tube, the stylet was removed with some difficulty. At a glance upon removal, the stylet looked intact. The endotracheal tube placement was confirmed by end-tidal CO₂ and auscultation of bilateral breath sounds. While taping the endotracheal tube in place, we noticed a foreign object in the tube. We removed the tube and returned to mask ventilating the patient. The foreign object was found to be the distal end of the plastic covering of the stylet. The neonate was reintubated without a stylet and the vital signs remained stable throughout. After securing the second endotracheal tube, we reinspected the stylet and noticed that the plastic covering had retracted exposing the metal internal rod. The anesthetic proceeded uneventfully.

The following day, we were able to reproduce the shearing-off of the distal end of the plastic covering of the 6 F Flexi- Slip™ stylet by again using a 3.0 endotracheal tube and holding on tightly to the tube during removal of the stylet.

In discussing this event with colleagues, some of them mentioned that they routinely lubricate the stylet before inserting it in such a small endotracheal tube. Others, though, never use a lubricant because of concerns of residual dried lubricant in an already small endotracheal tube lumen. I did try to reproduce the shearing off of the plastic covering with a lubricated stylet and was not able to do so.

I have intubated a good number of newborns with styleted endotracheal tubes without lubrication and have never experienced any shearing-off of plastic prior to this event. The stylet slides into the 3.0 endotracheal tube easily and only if the tube is held tightly is it difficult to remove. A smaller tube size may increase the chance of difficulties in removing the stylet. This stylet is recommended for use in endotracheal tube sizes of 2.0-3.5.

We have reported this event to the distributor and sent the stylet and sheared off tip to them for an investigation. Additionally, we did inform the FDA/MedWatch Alerts and sent out a safety alert to all pediatric anesthesiologist working at our institution.

The shearing-off of the plastic covering within an endotracheal tube can potentially lead to a serious adverse event. In our case it was recognized early and negative consequences were avoided. Nevertheless, we should all be aware of this potential complication.

Rose Campise Luther, MD
Assistant Professor of Clinical Anesthesia
Medical College of Wisconsin
Children’s Hospital of Wisconsin
Milwaukee, WI

Christina D. Diaz, MD
Assistant Professor of Clinical Anesthesia
Medical College of Wisconsin
Milwaukee, WI