Podcast 1026: Esophageal Balloon Tamponade Devices

Contributor: Jeffrey Olson, MD

Educational Pearls:

What are they?

• A flexible balloon and suction tube that we insert into the esophagus and into the stomach to stop bleeding.

When to use?

• Typically used for variceal bleeding. Use whenever the patient is too unstable to be transferred to more definitive therapy.

What are the different types?

• Linton - Nachlas Tube

• Single gastric balloon with a suction port for the stomach and sometimes a suction port for the esophagus.

• Sengstaken - Blakemore Tube

• Gastric balloon and esophageal balloon with only a gastric suction port

• Minnesota Tube

• Both gastric and esophageal balloon and both gastric and esophageal suction ports

How do you place one?

• Before placement

• Secure the airway first in a patient with massive ongoing hematemesis

• Insertion

• Fully lubricate the tube.

• Remove the white caps from the gastric and esophageal inflation ports.

• Test your balloons by placing them in the water and inflating them using your syringe.

• Place your three-way stopcocks on your esophageal and gastric inflation ports.

• Insert the tube similar to an OG tube until you have reached the 50 cm mark for the gastric balloon

• Use a slip syringe at the gastric aspiration site and auscultate to confirm that you are in the stomach. Then fill the gastric balloon with 50 cc of air.

• Verify the placement of the gastric balloon with a chest x-ray. (You can also pre-check with ultrasound)

• Fully inflate the gastric balloon

• Blakemore: 250ccs

• Minnesota: 450-500ccs

• Apply traction to the tube by tying a roller bandage to the end of it and then the other end to a 1L bag of IV fluids. Then hang the roller bandage over an IV pole.

• Place the nasogastric tube down to the pre-measured level above the gastric balloon and suction the esophageal space. If there is continued bleeding coming from the nasogastric tube then you will need to inflate the esophageal balloon.

• Note that Minnesota tubes already have their own esophageal suction port and will NOT need this NG tube placement to suction the esophagus.

• Use a "manometer" to inflate the esophageal balloon to 30mmHg. If bleeding persists, you can go to a maximum of 45mmHg

What are some tricks?

• Using silk ties to add an accessory NG tube to add an extra suction port to a Blakemore tube

• Using a bougie to help advance

• Put the tube on ice to increase stiffness and make it easier to pass

• Use Macgills to help advance

• Use a laryngoscope

• Use endoscopic biopsy forceps threaded down the gastric port

What does the data say?

• "The overall success rate of initial hemostasis with [Blakemore] tube was 75.8. Rebleeding rate after successful initial hemostasis with [Blakemore] tube was 22.0%, and esophageal rupture occurred in 6.1%. Mortality within 30 days was 42.4%" (Choi, 2017)

References

1. Choi JY, Jo YW, Lee SS, Kim WS, Oh HW, Kim CY, Yun EY, Kim JJ, Lee JM, Kim HJ, Kim HJ, Kim TH, Jung WT, Lee OJ, Kim RB. Outcomes of patients treated with Sengstaken-Blakemore tube for uncontrolled variceal hemorrhage. Korean J Intern Med. 2018 Jul;33(4):696-704. doi: 10.3904/kjim.2016.339. Epub 2017 Nov 10. PMID: 29117668; PMCID: PMC6030415.

2. https://www.aliem.com/trick-inflating-esophageal-balloon-blakemore-minnesota-tube-without-manometer/

3. https://www.tamingthesru.com/blog/air-care-series/balloon-tamponade-of-variceal-hemorrhage

4. https://radiopaedia.org/articles/esophageal-balloon-tamponade-device

5. https://simkit.co/blakemore-minnesota-and-linton-tube-tips-and-tricks/

6. https://www.bjaed.org/article/S2058-5349%2817%2930055-0/fulltext

Summarized by Jeffrey Olson MD | Edited by Jeffrey Olson MD

Special thanks to Dr. Travis Barlock, Dr. Evan Fisch, and the Corewell Health East - William Beaumont Emergency Medicine Residency Program for their contributions in researching for this episode.

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