Crisis Management of Accidental Extubation in a Prone-Positioned Patient with Klippel-Feil Syndrome

A A Case Rep. 2016 Jun 15;6(12):383-6. doi: 10.1213/XAA.0000000000000324.


We present the case of an accidental extubation in a prone-positioned patient with a challenging airway because of Klippel-Feil syndrome and previous cervical spine fusions. The surgical procedure was well underway when this occurred, which added substantially to the difficulties produced by this event. We herein highlight the corrective steps we took in our case. We also recommend the need for a comprehensive preoperative briefing with all operating room personnel together with an action plan for how to prevent this particular scenario.

Publication types

  • Case Reports

MeSH terms

  • Adult
  • Airway Extubation / adverse effects*
  • Anesthesia, General / adverse effects
  • Female
  • Humans
  • Intraoperative Complications / diagnosis*
  • Intraoperative Complications / etiology
  • Intubation, Intratracheal / adverse effects*
  • Klippel-Feil Syndrome / diagnosis
  • Klippel-Feil Syndrome / surgery*
  • Patient Positioning / adverse effects*
  • Prone Position*