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BMJ Case Rep. 2010; 2010: bcr0220102725.
Published online 2010 July 16. doi:  10.1136/bcr.02.2010.2725
PMCID: PMC3034211
Learning from errors

A sheared stylet

Description

Neonatal intubating stylets (figure 1) are frequently used to assist intubation of preterm infants. Complications have been reported before.1 We report an episode in which the plastic sheath of the stylet sheared during its removal from a 2.5 mm endotracheal (ET) tube inserted into a 520 g 24- week infant shortly after delivery. As the infant's condition improved following intubation no problem with the ET tube was initially suspected. At 60 min of age, due to moderate respiratory acidosis, the ET tube was removed. A 6 cm sheared plastic sheath was visible within it (figure 2) and ventilation parameters improved dramatically following re-intubation. We urge caution with the use of intubating stylets and would suggest the stylet is always checked for intactness after removal from the ET tube—particularly when removal has been difficult.

Figure 1
Neonatal intubating stylet.
Figure 2
6 cm of sheared plastic sheath was visible within the stylet.

Footnotes

Competing interests None.

References

1. Boyd RL, Bradfield HA, Burton EM, et al. Fluoroscopy-guided retrieval of a sheared endotracheal stylet sheath from the tracheobronchial tree in a premature infant. Pediatr Radiol 1999;29:575–7. [PubMed]

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