Twelve hours of gastric ventilation: a recipe for disaster (a suggested remedy).

A forty-three-day-old infant was intubated by the Neonatal Intensive Care Unit (NICU) staff. A nasogastric tube was in place for the duration. The patient's vital signs remained stable during 12 h of positive pressure ventilation. A Broviac catheter placement was scheduled in the NICU. The position of the tracheal tube (TT) was not verified prior to induction of anaesthesia. After the induction, the patient's condition deteriorated. The TT was found to be positioned within the oesophagus. A near catastrophe was successfully averted by discovering the malpositioned TT and replacing it with a properly positioned TT. We believe that had we clamped the existing nasogastric tube preoperatively, a noticeable abdominal distention would have occurred alerting us to a malpositioned TT. We suggest that clamping a preexisting nasogastric tube may have merit to alert one to a malpositioned TT.