| Patient Education |
|
Click here for patient education.
|
|
You are in: eMedicine Specialties >
Clinical Procedures > Gastrointestinal Procedures
Sengstaken-Blakemore Tube
Article Last Updated: Aug 26, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 13  
Author: Richard Treger, MD, Assistant Clinical Professor of Medicine, West Los Angeles Veterans Affairs Medical Center; Clinical Instructor, Department of Emergency Medicine, UCLA/Olive View–UCLA Medical Center
Coauthor(s):
Thomas P Graham, MD, FACEP, Associate Professor of Internal Medicine/Emergency Medicine University of California at Los Angeles School of Medicine/University of Los Angeles Medical Center;
Stanley K Dea, MD, Chief of Endoscopy, Acting Chief of Gastroenterology, Consulting Gastroenterologist Olive View-University of California at Los Angeles Medical Center; Director of Enteral Feeding, West Los Angeles Veterans Affairs Medical Center; Director of Endoscopic Training, University of California at Los Angeles Affiliated Training Program in Gastroenterology
Editors: Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine; Luis M Lovato, MD, Associate Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
esophageal tamponade tube, Sengstaken-Blakemore tube, sengstaken blakemore tube, sengstaken, sengstaken tube, blakemore, blakemore tube, Minnesota tube, Linton-Nachlas tube, balloon tamponade, esophageal varices, bleeding esophagus, gastric balloon, esophageal balloon, esophageal suction port, gastric varices, Y-tube connector, endotracheal intubation, balloon, tamponade, gastric balloon pressure, nasogastric tube, esophageal aspiration port, variceal bleeding
Balloon tamponade of bleeding esophageal varices was described as early as the 1930s. A double-balloon tamponade system originally developed by Sengstaken and Blakemore in 1950 has undergone relatively few changes to the current day.1, 2, 3 The 3 major components of a Sengstaken-Blakemore tube are a gastric balloon, an esophageal balloon, and a gastric suction port. 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.4 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
Sengstaken-Blakemore tube. Image courtesy of Richard Treger, MD.
Linton-Nachlas tube. Image courtesy of Richard Treger, MD.
- Acute life-threatening bleeding from esophageal or gastric varices that does not respond to medical therapy (including endoscopic hemostasis and vasoconstrictor therapy)9, 10, 11
- Acute life-threatening bleeding from esophageal or gastric varices when endoscopic hemostasis and vasoconstrictor therapy are unavailable
- Variceal bleeding stops or slows
- Recent surgery that involved the esophagogastric junction
- Known esophageal stricture (Click here to complete a Medscape CME activity on treatment for esophageal strictures.)
- Topical anesthetic (spray and jelly) for oropharynx (For more information, see Anesthesia, Topical.)
- Intubation and sedation for most patients
- Gastroesophageal balloon tamponade tube
- Y-tube connector or similar adapter (if not already part of the tamponade balloon ports)
Y-tube connector. Image courtesy of Richard Treger, MD.
Lopez valve. Image courtesy of Richard Treger, MD. - Traction device or setup
Pulley device for traction. Image courtesy of Richard Treger, MD and Stanley Dea, MD. - Manual manometer or sphygmomanometer
Sphygmomanometer. Image courtesy of Richard Treger, MD. - Vacuum suction device with suction tubing and connectors
Vacuum suction device. Image courtesy of Richard Treger, MD. - Tube clamps, 4
- Large (60 mL) irrigating syringe (catheter tip)
- Soft restraints
- Water-soluble lubricating jelly
- Scissors for emergency balloon decompression
- Elevate the head of the bed to 45° and position the patient on the bed.
- The left lateral decubitus position is an acceptable alternative position.
The following instructions pertain to the Sengstaken-Blakemore and Minnesota tubes. 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.
- The threshold to perform endotracheal intubation should be low, as the risk of regurgitation and aspiration is extremely high. To minimize this risk, perform nasogastric (NG) lavage and maximal stomach evacuation prior to the 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, test this while balloons are submerged under water).
- (Optional step) 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.
Setup for measuring gastric or esophageal balloon pressure. Image courtesy of Richard Treger, MD. - (Optional step) 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 has esophageal aspiration ports (ie, Minnesota tube).
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.
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).
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.
Illustration of placement of Sengstaken-Blakemore tube. Image courtesy of CR Bard, Inc. - Apply suction to the gastric and esophageal aspiration ports.
- (Optional step) 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, as it may be located in the esophagus.
- When the gastric balloon is correctly positioned in the stomach, inflate the balloon with the full recommended volume of air (usually 450-500 mL) and 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 0.45-0.91 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.
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 4-lumen tube), inflate the esophageal balloon to the lowest pressure needed to stop bleeding (usually 30-45 mm Hg), and then clamp the port for the esophageal balloon. Check the balloon pressure periodically.
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 (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 by 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 satisfactorily positioned, the tube 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, given the high mortality among patients who rebleed, consider alternatives such as sclerotherapy and transjugular intrahepatic portacaval shunt (TIPS).
- 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.
- Aspiration:10 This is probably the most frequent major complication. 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.12
- Asphyxiation:13, 14 This complication 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:15 This 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.
- 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
- Hiccups
Thanks to CR Bard, Inc. for their assistance.
The authors and editors of eMedicine gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.
| Media file 1:
Sengstaken-Blakemore tube. Image courtesy of Richard Treger, MD. |
|  View Full Size Image | |
Media type: Video
|
| Media file 2:
Linton-Nachlas tube. Image courtesy of Richard Treger, MD. |
| View Full Size Image | |
Media type: Photo
|
| Media file 3:
Lopez valve. Image courtesy of Richard Treger, MD. |
| View Full Size Image | |
Media type: Photo
|
| Media file 4:
Pulley device for traction. Image courtesy of Richard Treger, MD and Stanley Dea, MD. |
| View Full Size Image | |
Media type: Photo
|
| Media file 5:
Sphygmomanometer. Image courtesy of Richard Treger, MD. |
| View Full Size Image | |
Media type: Photo
|
| Media file 6:
Vacuum suction device. Image courtesy of Richard Treger, MD. |
| View Full Size Image | |
Media type: Photo
|
| Media file 7:
Setup for measuring gastric or esophageal balloon pressure. Image courtesy of Richard Treger, MD. |
| View Full Size Image | |
Media type: Photo
|
| Media file 8:
NG tube tied along Sengstaken-Blakemore tube. Image courtesy of Richard Treger, MD. |
| View Full Size Image | |
Media type: Photo
|
| Media file 9:
Air being suctioned from gastric balloon using 60-mL syringe. Image courtesy of Richard Treger, MD. |
| View Full Size Image | |
Media type: Photo
|
| Media file 10:
Plastic plug being inserted into lumen of balloon port. Image courtesy of Richard Treger, MD. |
| View Full Size Image | |
Media type: Photo
|
| Media file 11:
Illustration of placement of Sengstaken-Blakemore tube. Image courtesy of CR Bard, Inc. |
| View Full Size Image | |
Media type: Illustration
|
| Media file 12:
Illustration of setup for inflating and measuring pressure in esophageal balloon. Image courtesy of CR Bard, Inc. |
| View Full Size Image | |
Media type: Illustration
|
| Media file 13:
Y-tube connector. Image courtesy of Richard Treger, MD. |
| View Full Size Image | |
Media type: Photo
|
- Bauer JJ, Kreel I, Kark AE. The use of the Sengstaken-Blakemore tube for immediate control of bleeding esophageal varices. Ann Surg. Mar 1974;179(3):273-7. [Medline].
- Boyce HW Jr. Modification the Sengstaken-Blakemore balloon tube. Nord Hyg Tidskr. Jul 26 1962;267:195-6. [Medline].
- Sengstaken RW, Blakemore AH. Balloon tamponage for the control of hemorrhage from esophageal varices. Ann Surg. May 1950;131(5):781-9. [Medline].
- Chojkier M, Conn HO. Esophageal tamponade in the treatment of bleeding varices. A decadel progress report. Dig Dis Sci. Apr 1980;25(4):267-72. [Medline].
- Conn HO, Simpson JA. Excessive mortality associated with balloon tamponade of bleeding varices. A critical reappraisal. JAMA. Nov 13 1967;202(7):587-91. [Medline].
- Paquet KJ, Feussner H. Endoscopic sclerosis and esophageal balloon tamponade in acute hemorrhage from esophagogastric varices: a prospective controlled randomized trial. Hepatology. Jul-Aug 1985;5(4):580-3. [Medline].
- Yoshida H, Mamada Y, Taniai N, Tajiri T. New methods for the management of gastric varices. World J Gastroenterol. Oct 7 2006;12(37):5926-31. [Medline].
- Yan BM, Lee SS. Emergency management of bleeding esophageal varices: drugs, bands or sleep?. Can J Gastroenterol. Mar 2006;20(3):165-70. [Medline].
- Hunt PS, Korman MG, Hansky J, Parkin WG. An 8-year prospective experience with balloon tamponade in emergency control of bleeding esophageal varices. Dig Dis Sci. May 1982;27(5):413-6. [Medline].
- Panés J, Terés J, Bosch J, Rodés J. Efficacy of balloon tamponade in treatment of bleeding gastric and esophageal varices. Results in 151 consecutive episodes. Dig Dis Sci. Apr 1988;33(4):454-9. [Medline].
- D'Amico G, Pagliaro L, Bosch J. The treatment of portal hypertension: a meta-analytic review. Hepatology. Jul 1995;22(1):332-54. [Medline].
- Edlich RF, Landé AJ, Goodale RL, Wangensteen OH. Prevention of aspiration pneumonia by continuous esophageal aspiration during esophagogastric tamponade and gastric cooling. Surgery. Aug 1968;64(2):405-8. [Medline].
- Collyer TC, Dawson SE, Earl D. Acute upper airway obstruction due to displacement of a Sengstaken-Blakemore tube. Eur J Anaesthesiol. Apr 2008;25(4):341-2. [Medline].
- Agarwal R, Aggarwal AN, Gupta D. Endobronchial malposition of Sengstaken-Blakemore tube. J Emerg Med. Jan 2008;34(1):93-4. [Medline].
- Pinto-Marques P, Romãozinho JM, Ferreira M, Amaro P, Freitas D. Esophageal perforation--associated risk with balloon tamponade after endoscopic therapy. Myth or reality?. Hepatogastroenterology. Jul-Aug 2006;53(70):536-9. [Medline].
- Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. 4th. Philadelphia, PA: WB Saunders; 2003.
Sengstaken-Blakemore Tube excerpt Article Last Updated: Aug 26, 2008
Topic originally published: May 31, 2007
|
