Sengstaken-Blakemore

tube

Prepared by: KJEC

Sengstaken-Blakemore tube

Linton-Nachlas tube

DEFINITION

• Sengstaken-Blakemore tube is a 3 lumen tube- one lumen to inflate gastric balloon, a second lumen to inflate oesophageal balloon and a third lumen to aspirate gastric contents. There is no oesophageal suction port. This causes saliva to pool in the oesophagus and thus put patients at risk of aspiration.

• Commonly Minnesota tube is referred to as Sengstaken-Blakemore tube

• A Sengstaken-Blakemore tube is a large red rubber tube which stops or slows bleeding from the esophagus and stomach. It is often called a Blakemore tube for short.

PURPOSE

• The SB tube is inserted to provide temporary control (no more than 24 hours) of blood loss from bleeding oesophageal varices whilst more definitive measures are undertaken. The gastric balloon tamponades the submucosal veins feeding the varices, as they pass the cardia, by virtue of the traction applied to the balloon.

INDICATION

• SB tubes are used for the control of haemorrhage from oesophageal varices. They may simultaneously be used for drainage and decompression of the stomach. The Linton tube does not have an oesophageal balloon, but all other guidelines for insertion and care of the gastric balloon apply to the Linton tube.

PROCEDURE RATIONALE

Prior to insertion aspirate all air fromgastric balloon. Inflate gastric balloonwith 250mls of air. Measure balloonpressure and volume of air inserted onflow chart.

This ensures the balloon is intact.Once inserted the gastric balloon pressureshould be within 15mmHg of pre-insertionpressure.

Estimate the length of tube to be insertedby measuring from the bridge of the noseto the earlobe and adding the distancefrom the nose to the xiphoid process.Ensure balloons are emptied of air.

Sit patient up 30 degrees

Lubricate tube with xylocaine jelly.

Vasoconstrictor nasal drops may be usedif inserting tube nasally to reduce the riskof epistaxis.

This ensures correct tube placement.

This minimises the risk of oesophagealrupture.

Tube should be inserted nasally but maybe inserted orally.

PROCEDURE RATIONALE

Once inserted the gastric balloon shouldbe inflated with 50mls of air. Position isnow confirmed with x-ray or endoscope.Once position is confirmed gastricballoon may be inflated to within 15mmhgof pre-insertion pressure, and the tubegently pulled back until resistance is felt.Check X-ray post application of traction.

Oesophageal balloon is fully aspirated so that it does not contain any air when SBtube is inserted.

Tube position is verified radiologically toensure the balloon is at the cardia and notin the oesophagus, avoiding oesophagealerosion or rupture. These patientssometimes have ineffective loweroesophageal sphincters.

Leukoplast is placed around the tube atinsertion point. Tube position must berecorded on the ICU flow chart.

Tension should be applied to the tubeusing a 1000ml fluid bag.

This allows migration of the tube to quicklybe detected.

The application of traction ensures the tuberemains in the correct position.

PROCEDURE RATIONALE

The Medical Officer will decide if theoesophageal and gastric lumens are tobe placed on low wall suction or freedrainage.

Whilst in-situ it is advised that the SBtube be aspirated hourly and irrigatedevery 1-2 hours with 10mls of water.

Measure and record volume of drainage on ICU flow chart.

This will reduce the risk of the SB tubeblocking.

PRE PREPARATION

The SB tube is normally kept in freezer- it helps insertion by improved stiffness

Keep ready two bladder wash syringes for suctioning the oesophageal and gastric lumen, another bladder wash syringe for inflating the gastric balloon

Stout metal artery forceps for clamping the balloon ports If oesophageal balloon needs to be inflated in addition to the

gastric balloon- You will need: A 50cc Luer Lock syringe An adaptor whose conical end will fit into the oesophageal port

and the Luer lock end will fit into the sphygmomanometer ( the adaptor is available in the chest drain kit )

A three way valve A sphygmomanometer with detachable arm cuff–  to remove the

BP cuff and fit the Luer lock end of the chest drain adaptor to fit there

POST PREPARATION

Aftercare and removal:

Migration of gastric balloon in oesophagus can cause compression of trachea and respiratory distress. Keep a pair of scissors ready at the bedside in case of emergency – to cut the gastric balloon port to let the air escape

Instruction to suction both oesophageal and gastric lumen at intervals of 10 minutes increasing to 30 minutes and after stabilization hourly

Frequent oropharyngeal suction Don’t forget antibiotic prophylaxis and continued

terlipressin for at least 48hrs Pressure in the oesophageal balloon to be relieved for

10minutes every 2hours to prevent pressure necrosis

Repeat endoscopy at 24 hours. The Sengstaken tube should be removed in the endoscopy

room First deflate the oesophageal balloon, then take off the

traction and finally remove the tube Chance of rebleeding when balloon is deflated  is up to 50% On second endoscopy it should be much easier to band or

inject glue as bleeding hopefully would be under control, failing which patient should be referred for urgent TIPSS.

Serious complication can occur up to 15-20% Oesophageal ulceration Aspiration pneumonia