Sengstaken-Blakemore Tube Placement
- Author: Richard Treger, MD; Chief Editor: Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS more...
Balloon tamponade of bleeding esophageal varices was described as early as the 1930s. A double-balloon tamponade system was developed by Sengstaken and Blakemore in 1950 and has undergone relatively few changes up to the current day.[1, 2, 3] The three major components of a Sengstaken-Blakemore tube are as follows (see the image below):
The addition of an esophageal suction port to help prevent aspiration of esophageal contents resulted in what is called the Minnesota tube. Another nasogastric (NG) device with a single gastric balloon is most effective at terminating bleeding from gastric varices and is known as the Linton-Nachlas tube (see the image below).
The advent of endoscopy has reduced the use of balloon tamponade, but the use of such devices can still be temporizing or lifesaving, despite their potential for serious complications.[5, 6, 7, 8, 9]
Indications for placement of a Sengstaken-Blakemore tube include the following:
Acute life-threatening bleeding from esophageal or gastric varices when endoscopic hemostasis and vasoconstrictor therapy are unavailable
Chen et al have described a case in which a Sengstaken-Blakemore tube was successfully used for nonvariceal distal esophageal bleeding (from severe ulcerative esophagitis) after conventional medical and endoscopic therapy had failed.
Contraindications for placement of a Sengstaken-Blakemore tube include the following:
Variceal bleeding stops or slows
Recent surgery that involved the esophagogastric junction
Known esophageal stricture
Topical anesthetic (spray and jelly) is used for the oropharynx. (For more information, see Anesthesia, Topical.) Intubation and sedation are indicated for most patients.
Equipment used for placement of a Sengstaken-Blakemore tube includes the following:
Gastroesophageal balloon tamponade tube
Y-tube connector or similar adapter, if not already part of the tamponade balloon ports (see the first and second images below)
Traction device or setup (see the third image below)
Manual manometer or sphygmomanometer (see the fourth image below)
Vacuum suction device with suction tubing and connectors (see the fifth image below)
Tube clamps (4)
Large (60 mL) irrigating syringe (catheter tip)
Water-soluble lubricating jelly
Scissors for emergency balloon decompression
Elevate the head of the bed to 45°, and position the patient on the bed. The left lateral decubitus position is an acceptable alternative.
The following instructions pertain to the Sengstaken-Blakemore and Minnesota tubes. However, the same principles apply to the Linton-Nachlas tube, even though it has only a single gastric balloon.
Control of the patient is essential. Routine use of soft restraints and medications for sedation should be considered in most patients.
The threshold to perform endotracheal intubation should be low, as the risk of regurgitation and aspiration is extremely high. To minimize this risk, perform nasogastric (NG) lavage and maximal stomach evacuation before placing an esophageal tamponade tube.
Ensure that all the appropriate equipment is present. Ensure that the balloons on the tamponade tube are free of leaks; optimally, balloon integrity should be tested while the balloons are submerged under water.
An optional step is as follows: If monitoring gastric balloon pressure, inflate the gastric balloon in increments (typically 100 mL) up to the maximum recommended volume (usually 500 mL) while the pressure is measured with the manometer. Note the pressure at each given volume. (See the image below.)
Another optional step is the following: If the NG tube is used, tie it along the course of the tube with silk sutures, with the tip of the NG tube 3-4 cm proximal to the esophageal balloon. This step is not required if the tube is one that has esophageal aspiration ports (ie, a Minnesota tube). (See the image below.)
Position the patient appropriately, and anesthetize the posterior pharynx and nostrils with a topical anesthetic.
Suction all air from the gastric and esophageal balloons. (See the image below.)
Clamp the balloon ports or insert the plastic plugs into the lumens (if provided with the tube). (See the image below.)
Coat the balloons on the tube with water-soluble lubricating jelly. Pass the tube to at least the 50-cm mark. The tube can be passed through the nostrils or, preferably, through the mouth. The oral route is especially preferred in intubated patients. (See the image below.)
Apply suction to the gastric and esophageal aspiration ports.
A third optional step is as follows: If monitoring gastric balloon pressure, remove the tube clamps (or plastic plugs, if used) from the gastric balloon inflation ports. Introduce increments of air (usually 100 mL) through the gastric balloon inflation port while the pressure is again measured with the manometer. If, at any given increment, the gastric balloon pressure is 15 mm Hg greater than readings previously obtained during testing (ie, before intubation), then deflate the balloon; it may be located in the esophagus.
When the gastric balloon is correctly positioned in the stomach, inflate it with the full recommended volume of air (usually 450-500 mL), then clamp the air inlet and pressure-monitoring outlet. Check proper placement by irrigating the gastric aspiration port with water while auscultating over the stomach. If correct tube placement is at all uncertain or if time permits, obtain a portable chest radiograph.
Pull the tube back gently until resistance is felt against the diaphragm.
Secure the proximal end of the tube using a traction device. A pulley device can be used to maintain the desired 0.45-0.91 kg (1-2 lb) of traction. A 500-mL bag of intravenous fluid can serve as a convenient initial weight. Alternatively, tubes can be secured with tape to the mouth guard of a football helmet. A foam rubber cuff, which is generally included in the package with the tube itself, can be used to maintain traction against the nose if the tube has been inserted through the nostrils. (See the image below.)
If bleeding persists from the gastric aspiration port (or from the esophageal aspiration port on a four-lumen tube), inflate the esophageal balloon to the lowest pressure needed to stop bleeding (usually 30-45 mm Hg), then clamp the port for the esophageal balloon. Check the balloon pressure periodically. (See the image below.)
If bleeding persists from the gastric aspiration port after inflation of the gastric and esophageal balloons, increase the external traction on the tube (to a maximum of 1.1 kg [2.5 lb]). In this case, the bleeding typically originates from a gastric rather than an esophageal varix.
Confirm correct tube position with an immediate portable radiograph.
After bleeding has been controlled, reduce the pressure in the esophageal balloon by 5 mm Hg every 3 hours until 25 mm Hg is reached without bleeding; this pressure is generally maintained for the next 12-24 hours. If bleeding is controlled, deflate the esophageal balloon for 5 minutes every 6 hours to help prevent esophageal necrosis.
Once the tube is satisfactorily positioned, it is generally left in place for 24 hours. If bleeding recurs, the gastric balloon and, if necessary, the esophageal balloon may be reinflated for an additional 24 hours. However, in view of the high mortality among patients who rebleed, alternatives such as sclerotherapy and transjugular intrahepatic portacaval shunting (TIPS) should be considered.
In most cases, the esophageal balloon is not inflated during the initial placement of the tube. Never inflate the esophageal balloon before the gastric balloon.
Keep a pair of scissors near the patient at all times in case the balloons migrate superiorly and obstruct the airway. The whole tube can be cut and removed.
Direct pressure from the tube can cause mucosal ulceration. Perform frequent examinations to ensure that the tube is not placing excessive force on any given surface.
Generally, the esophageal tamponade tube is a temporizing measure and should not be left in place for more than 24 hours.
Aspiration is probably the most frequent major complication of Sengstaken-Blakemore tube placement. The greatest risk of aspiration occurs during insertion. The risk of aspiration can be minimized by evacuating the stomach prior to tube placement and maintaining a low threshold for endotracheal intubation.
Asphyxiation[15, 16] is caused by proximal migration of the tube and can be prevented with endotracheal intubation. If tube migration results in airway obstruction, cutting across all the tube lumens just distal to the points of bifurcation allows immediate extraction of the entire tube.
Esophageal perforation or rupture can occur with inflation of a gastric balloon that is inadvertently placed in the esophagus or can be secondary to esophageal mucosal necrosis that results from excessive or prolonged inflation of the esophageal balloon.
Minor complications include the following:
Pharyngeal and gastroesophageal erosions and ulcers caused by local pressure effects
Pressure necrosis of the nose, lips, and tongue
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