Sengstaken–Blakemore and Minnesota Tubes

OVERVIEW

Sengstaken–Blakemore tube (3 lumen) replaced by Minnesota tube (4 lumen) as allows aspiration of both gastric and oesophageal contents, not just gastric contents

USE

• tamponade of gastro-oesophageal bleeding that is unresponsive to medical and endoscopic treatment (~90% effective)

DESCRIPTION

Sengstaken-Blakemore tube (has ports for gastric and esophageal balloons and a gastric aspiration port)

Minnesota tube (has an esophageal aspiration port in addition to the gastric aspiration port)

METHOD OF INSERTION

• patient is often endotracheally intubated first
• local anaesthetic jelly to nostril
• supine with 45 degrees head up
• estimate length by bridge of nose to xiphoid process
• check both balloons for leaks
• evaluate compliance curve of gastric balloon pre-insertion by inflating the  balloon with incremental 100ml aliquots of air to maximal recommended volume (usually 250 -300ml for SBT, 450-500ml for Minnesota) and note the corresponding balloon pressure at each step
• lubricate balloons
• insert via mouth via laryngoscopy into the oesophagus
• confirm position on CXR (gastric balloon in stomach)
• inflate gastric balloon using 50mL increments up to 250 -300ml for SBT or 450-500ml for Minnesota tube
  • If, post-insertion, balloon pressure on inflation with a given volume is >15 mmHg than the pre-insertion pressure, the balloon may be in the oesophagus and should  be deflated and position checked
  • pull balloon back until against gastric fundus
  • note measurement at lips and fix securely with traction and rope pulley system with 500mL bag of fluid
• inflation of oesophageal balloon usually is not required (if required inflate to 40mmHg)
  • never use on its own
  • use only if continuing bleeding despite an adequately inflated gastric balloon correctly placed and with appropriate tension

OTHER INFORMATION

• avoid inflation of gastric balloon in oesophagus as this is almost always fatal!
• CXR prior to balloon inflation and after inflation or fluoroscopic insertion

COMPLICATIONS

• haemorrhage (note that re-bleeding on balloon deflation occurs in ~50% of cases)
  (check position, ensure balloon inflated, correct coagulopathy)
• painful or uncomfortable
  (check position; provide sedation and analgesia)
• aspiration
  (use only in intubated patient and position patient head-up 30-45 degrees)
• pressure necrosis
  (do not leave SBT in situ for more than 24-36 h, avoid prolonged inflation of gastric balloon – deflate after 12 hr and reinflate if ongoing bleeding)
• oesophageal perforation
  (ensure both balloons completely deflated prior to insertion, avoid inflation of oesophageal balloon, and ensure gastric balloon is correctly positioned during inflation)
• acute upper airway obstruction due to balloon migration
  (avoid use in unintubated patient — if SBT in unintubated patient and develops  respiratory distress, immediately cut lumens for oesophageal and gastric balloons  and remove tube)
• cardiac arrhythmias
  (check position; correct electrolytes; cardioversion)

VIDEO

References and Links

FOAM and web resources

• EMCrit — Blakemore Tube Placement for Massive Upper GI Hemorrhage (2013)
• EMCrit — PulmCrit Wee: Ultrasound-guided blakemore tube placement (2016)