All neonatal intensive care unit (icu) endotracheal tube (et) tube holders were recalled and as such, we had to remove them from stock immediately.Et tube holders were changed to elastoplast tape for security.Infant noted to be desaturating on monitor.Upon examination she was very dusky with rapidly decreasing heart rate and spo2 reading.Determined infant self-extubated and oscillator became disconnected which ended all respiratory support.Heart rate fell to low of 40 bpm and spo2 23%.New ett securement tape was no longer sticky and came off infant's face leading to ett dislodgement.Immediately enlisted aide of 2 additional rn's, 1 rt, and 2 fellows on duty.Ppv began and continued through successful re-intubation.Immediate chest/abdomen x-ray obtained to confirm placement.Infant without adequate oxygenation for this 16- minute event.
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