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Unplanned intraoperative extubations (UIEs), rare but high-risk events. Unintentional extubations are used as quality improvement metrics in neonatal and pediatric intensive care units, but intraoperative events have received scant attention in the literature. Complexity of patient positioning and proximity of the operative field to anesthesia make neurosurgical procedures unique. UIEs prolong operative time, increase risk of adverse outcomes, including cardiopulmonary collapse, and potentially require additional procedures. Investigating each event is critical to prevention. We aimed to analyze occurrences of UIEs in the pediatric population.We retrospectively reviewed UIE cases (12/2014-4/2017) in pediatric neurosurgical patients at a metropolitan pediatric Level I trauma center. Data were collected on patient demographics, procedure, operating room events before the event, and patient outcomes.Over 27 months, 5 UIEs in pediatric neurosurgical cases occurred, with an event rate of0.3%. Two occurred in patients1 year old. Two UIEs occurred in patients undergoing surgery for epilepsy. Root cause analysis identified varied etiologies of UIE: 2 were attributed to endotracheal tube securement, 2 were attributed to lighter anesthesia planes in epilepsy cases with limb movement, and 1 occurred while supinating a prone patient. Postoperative outcomes for these patients were no different from routine cases.Findings suggest an inverse correlation between patient age and UIE, with patient manipulation and anesthesia depth as risk factors. Meticulous attention to securing the endotracheal tube and streamlined communication between the surgical and anesthesia teams are critical for the goal of zero UIE occurrences.

Somatosensory evoked potentials (SSEPs) are more sensitive to inhalation agents, with decreases in amplitude and increases in latency, compared with intravenous agents, such as propofol, ketamine, dexmedetomidine, and opioids. Ketamine and etomidate may be used to augment SSEPs. Motor evoked potentials (MEPs) are the modality of choice for monitoring motor tract function, are easily abolished by inhalational agents, and negate the use of full neuromuscular blockade. Patients with immature neural pathways or preexisting neuromuscular disease may have abnormal baseline SSEP recordings. Maintenance of adequate physiologic parameters for normal neuronal functioning is critical to intraoperative neuromonitoring (IONM) during scoliosis repair.