Misplaced and Knotted Nasogastric Tubes in Infants and Children: Report of Two Cases

Nasogastric (NG) tubes are frequently placed during intraoperative care to decompress the gastrointestinal tract and prevent postoperative complications in patients with gastrointestinal obstruction or ileus. Although placement during anesthetic care is generally straightforward, misplacement or knotting of the NG tube may occur. We present two cases in pediatric-aged patients where difficulties were noted with passing and/or removal of the NG tube. Techniques for placement of NG tubes are reviewed, previous reports of misplacement or difficulties with placement presented, and strategies to prevent these complications discussed.