Sengstaken-Blakemore Tube Placement 

Updated: Nov 13, 2018
Author: Richard Treger, MD; Chief Editor: Vikram Kate, MBBS, MS, PhD, FRCS, FACS, FACG, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS 

Overview

Background

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):

  • Gastric balloon
  • Esophageal balloon
  • Gastric suction port
Sengstaken-Blakemore tube. Image courtesy of Richa Sengstaken-Blakemore tube. Image courtesy of Richard Treger, MD.

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).[4]

Linton-Nachlas tube. Image courtesy of Richard Tre Linton-Nachlas tube. Image courtesy of Richard Treger, MD.

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

Indications for placement of a Sengstaken-Blakemore tube include the following:

  • Acute life-threatening bleeding from esophageal or gastric varices that does not respond to medical therapy (including endoscopic hemostasis and vasoconstrictor therapy) [10, 11, 12, 13]
  • Acute life-threatening bleeding from esophageal or gastric varices when endoscopic hemostasis and vasoconstrictor therapy are unavailable

Chen et al 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.[14]

A novel use of a Sengstaken-Blakemore tube to tamponade oropharyngeal hemorrhage during exploration of a carotid injury was reported by Bensley et al.[15]

Contraindications

Contraindications for placement of a Sengstaken-Blakemore tube include the following:

  • Variceal bleeding stops or slows
  • Recent surgery that involved the esophagogastric junction

Outcomes

In a study aimed at determining the effect of controlling variceal hemorrhage with a balloon tamponade device (eg, Minnesota or Sengstaken-Blakemore tube) on patient outcomes, Nadler et al assessed survival to discharge, survival to 1 year, and development of complications.22 Approximately 59% of patients survived to discharge, and 41% were alive after 1 year. One complication, esophageal perforation, was noted; it was managed conservatively.

 

Periprocedural Care

Equipment

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)
  • Soft restraints
  • Water-soluble lubricating jelly
  • Scissors for emergency balloon decompression
Y-tube connector. Image courtesy of Richard Treger Y-tube connector. Image courtesy of Richard Treger, MD.
Lopez valve. Image courtesy of Richard Treger, MD. Lopez valve. Image courtesy of Richard Treger, MD.
Pulley device for traction. Image courtesy of Rich Pulley device for traction. Image courtesy of Richard Treger, MD and Stanley Dea, MD.
Sphygmomanometer. Image courtesy of Richard Treger Sphygmomanometer. Image courtesy of Richard Treger, MD.
Vacuum suction device. Image courtesy of Richard T Vacuum suction device. Image courtesy of Richard Treger, MD.

Patient Preparation

Topical anesthetic (spray and jelly) is used for the oropharynx. (For more information, see Anesthesia, Topical.) Intubation and sedation are indicated for most patients.

Elevate the head of the bed to 45°, and position the patient on the bed. The left lateral decubitus position is an acceptable alternative.

 

Technique

Placement of Sengstaken-Blakemore Tube

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.

In view of the extremely high risk of regurgitation and aspiration, the threshold for performing endotracheal intubation should be low. To minimize this risk, nasogastric (NG) lavage and maximal stomach evacuation should be carried out before placement of 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.)

Setup for measuring gastric or esophageal balloon Setup for measuring gastric or esophageal balloon pressure. Image courtesy of Richard Treger, MD.

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 (eg, a Minnesota tube). (See the image below.)

NG tube tied along Sengstaken-Blakemore tube. Imag NG tube tied along Sengstaken-Blakemore tube. Image courtesy of Richard Treger, MD.

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.)

Air being suctioned from gastric balloon using 60- Air being suctioned from gastric balloon using 60-mL syringe. Image courtesy of Richard Treger, MD.

Clamp the balloon ports or insert the plastic plugs into the lumens (if provided with the tube). (See the image below.)

Plastic plug being inserted into lumen of balloon Plastic plug being inserted into lumen of balloon port. Image courtesy of Richard Treger, MD.

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.)

Illustration of placement of Sengstaken-Blakemore Illustration of placement of Sengstaken-Blakemore tube. Image courtesy of CR Bard, Inc.

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 0.45-0.9 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.)

Pulley device for traction. Image courtesy of Rich Pulley device for traction. Image courtesy of Richard Treger, MD and Stanley Dea, MD.

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.)

Illustration of setup for inflating and measuring Illustration of setup for inflating and measuring pressure in esophageal balloon. Image courtesy of CR Bard, Inc.

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.

Pearls

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.

Complications

Aspiration[11]  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.[16]

Asphyxiation[17, 18]  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[19, 13]  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.

Tracheal rupture can follow misplacement of the tube in the trachea.[20]  

Minor complications include the following:

  • Pain
  • Pharyngeal and gastroesophageal erosions and ulcers caused by local pressure effects
  • Pressure necrosis of the nose, lips, and tongue; rarely, pressure ulcers can develop over the facial skin where the Sengstaken-Blakemore tube is secured [21]