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Extubation in an intensive care unit was possibly associated with a reduction in postoperative complications.

An investigation was conducted on the frequency of accidental extubations at Shizuoka Children's Hospital during the past 12 years. The study was performed on 150 randomly selected patients who received respiratory support for more than 24 hr. Fifteen accidental extubations occurred in 9 patients. Most of them (87%) occurred in the neonatal intensive care unit (NICU), and the rate was 1 per 54 days of intubation. The time at which these accidents happened varied, although they were more common during the day-time. The reasons of accidental extubation could not be specified in two-thirds of the cases. It became clear that more immature babies were more likely to suffer accidental extubation, perhaps reflecting the fact that most of the immature babies in the NICU were intubated orally, and that a larger proportion of them required a longer period of respiratory support. Therefore, early weaning from respiratory support is recommended if it is possible. In conclusion, increased surveillance and more secure methods of taping of endotracheal tubes are crucial for preventing life-threatening accidental extubations during respiratory support.

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Sir,Epidermolysis bullosa (EB) is a rare inherited disorder characterized by excessive susceptibility of the skin and mucosae to separate from the underlying tissues after trivial mechanical trauma). Insufficient post-operative analgesia in a child with EB will result in an unsettled child who will pull at his/her dressing and be more prone to new bullae formation (1). Patient-controlled analgesia is difficult for a patient with EB because of limited finger function or syndactyly from skin lesions.We present the successful management with continuous epidural block of a 13-year-old girl with EB using subcutaneous tunnelling of the epidural catheter.A 124-cm, 20-kg, 13-year-old girl with dystrophic EB underwent splenectomy and cholecystectomy. She had been suffering from anaemia and chronic cholelithiasis with gallstones as a result of hereditary spherocytosis. She was induced with fentanyl 30 mg, propofol 40 mg and vecuronium 3 mg. Induction, monitoring and maintenance of anaesthesia were handled to avoid skin lesions. Epidural anaesthesia was performed under general anaesthesia. A 20-gauge Touhy needle was inserted from the Th 7-8 intervertebral space to a depth of 2.5 cm using the loss of resistance technique. A 22-gauge epidural catheter was advanced 6.0 cm cephalad and fixed by subcutaneous tunnelling (Fig. 1). The epidural catheter was then covered with gauze. Twelve millilitres of epidurally administered 0.5% ropivacaine with 2.0 mg of morphine and a total of 100 mg of intravenous fentanyl produced excellent anaesthesia during the operation for a total of 3.5 h. Continuous epidural analgesia was accomplished by 0.2% ropivacaine at 3 ml/h with morphine at 5 mg/kg/h over 20 h, followed by a continuous epidural infusion of 0.2% ropivacaine at 3 ml/h until the third post-operative day. No bullae, skin lesions or infections occurred at the insertion point of the epidural catheter or around the subcutaneous tunnel. The patient was discharged at the eighth post-operative day without any sequelae.Adhesive tape should be avoided. Chronic epidermal infection may cause an epidural abscess. Subcutaneous tunnelling with direct suturing without adhesive tape has been reported (4, 5). Our experience confirms this to be an alternative for decreasing the risk of migration and local infection. bullosa in children: pathophysiology, anaesthesia and pain management. Paediatr Anaesth 2002; 12 (5): 388-97. 2. Carl P, Crawford ME, Ravlo O. Fixation of extradural catheters by means of subcutaneous tissue tunnelling. Br J Anaesth 1984; 56 (12): 1369-71. 3. Aram L, Krane EJ, Kozloski LJ, Yaster M. Tunneled epidural catheters for prolonged analgesia in pediatric patients. Direct Suturing Catheter Insertion Site Subcutaneous Tunnel Fig. 1. The tunnel was made by inserting an 18-gauge intravenous catheter from the puncture site to 3 cm away from the site for use as a guide. The hub of the intravenous catheter was removed leaving only part of the catheter. The epidural catheter was then threaded in and the guide was removed. The epidural ...