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

## TL;DR

This paper reports two cases of misplaced or knotted nasogastric tubes in children and discusses strategies to prevent such complications.

## Contribution

The paper adds to the clinical literature by presenting real-world pediatric cases of NG tube misplacement and offering prevention strategies.

## Key findings

- Two pediatric cases of NG tube misplacement or knotting were identified during clinical care.
- Review of techniques and prior reports highlights the need for improved placement strategies in children.
- Preventive measures are suggested to reduce the risk of NG tube complications in pediatric patients.

## Abstract

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.