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)

sengstaken-blakemore tube

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

Minnesota-tube

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

SMACC EVO winner from Hennepin County Medical Center:

References and Links

FOAM and web resources

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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