Sengstaken blakemore tube

1. Sengstaken -Blakemore tube Prepared by: KJEC

2. Sengstaken -Blakemore tube Linton- Nachlas tube

3. 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

4. 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 .

5. 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.

6. 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.

7. PROCEDURE RATIONALE Prior to insertion aspirate all air from gastric balloon. Inflate gastric balloon with 250mls of air. Measure balloon pressure and volume of air inserted on flow chart. This ensures the balloon is intact. Once inserted the gastric balloon pressure should be within 15mmHg of pre-insertion pressure. Estimate the length of tube to be inserted by measuring from the bridge of the nose to the earlobe and adding the distance from 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 used if inserting tube nasally to reduce the risk of epistaxis . This ensures correct tube placement. This minimises the risk of oesophageal rupture. Tube should be inserted nasally but may be inserted orally.

8. PROCEDURE RATIONALE Once inserted the gastric balloon should be inflated with 50mls of air. Position is now confirmed with x-ray or endoscope. Once position is confirmed gastric balloon may be inflated to within 15mmhg of pre-insertion pressure, and the tube gently 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 SB tube is inserted. Tube position is verified radiologically to ensure the balloon is at the cardia and not in the oesophagus , avoiding oesophageal erosion or rupture. These patients sometimes have ineffective lower oesophageal sphincters. Leukoplast is placed around the tube at insertion point. Tube position must be recorded on the ICU flow chart. Tension should be applied to the tube using a 1000ml fluid bag. This allows migration of the tube to quickly be detected. The application of traction ensures the tube remains in the correct position.

9. PROCEDURE RATIONALE The Medical Officer will decide if the oesophageal and gastric lumens are to be placed on low wall suction or free drainage. Whilst in-situ it is advised that the SB tube be aspirated hourly and irrigated every 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 tube blocking.

10. 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

11. 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

12. 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