Procedure of the Month: Gastrointestinal Balloon Tamponade Placement

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August 17, 2017 by Casey Carr

By: Casey Carr


Rarely used today due to the widespread availability of endoscopy and significant complications.

Balloon tamponade should be considered in acute esophageal hemorrhage when medical therapy and emergent endoscopy are not available or unsuccessful.

Balloon tamponade should not be performed if a patient has a history of esophageal stricture, hiatal hernia, esophageal ulcerations, recent gastric or esophageal surgery.

Significant medical problems may also preclude the use of balloon tamponade, depending on the stability of the patient.

Balloon tamponade is not helpful if a variceal source of bleeding cannot be demonstrated.


Equipment needed:

  1. Sengstaken-Blakmore (SB) tube or Minnesota tube
  2. Topical anesthetic spray
  3. Tongue blade
  4. Lidocaine
  5. 60 cc syringe (slip tip)
  6. Two wall suction set ups
  7. Tape
  8. Hemostat
  9. Scissors
  10. Three way stopcock (two)
  11. Manometer (hand held or mercury)
  12. Bite block
  13. Nasogastric tube
  14. ETT holder

 


Technique:

  1. Elevate the head of the bed at least 45 degrees (if patient intubated, can be performed supine)
  2. Apply topical anesthetic to nostrils and pharynx.
  3. Flush aspiration ports, check balloons for leaks
  4. Lubricate tube
  5. Place bite block
  6. Insert deflated tube to at least the 50 cm mark – preferably to the maximum depth allowed by the length of the tube. This is done as if placing an OG tube.
  7. Apply continuous suction to the gastric and esophageal aspiration port – if using a Blakemore, a concurrent nasogastric tube will need to be placed, and this will take the place of the esophageal aspiration port
  8. Inflate the gastric balloon with approximately 50 mL of air
  9. Confirm location of balloon below diaphragm with CXR
  10. Inflate the gastric balloon to the recommended total volume of air – this is usually 200-250 mL
  11. Monitor gastric balloon pressure using manometer – if pressure is 15 mm Hg higher than at testing pressure of an equivalent volume, balloon had likely migrated to the esophagus
  12. Pull back until resistance is met; apply continuous traction traction
  13. If blood returns from either aspiration port, inflate esophagus balloon – target pressure 35 – 45 mm Hg. Maximum of 45 mm Hg

Complications:

  • Esophageal perforation – almost universally fatal. Occurs from misplaced gastric balloon, over-inflated esophageal balloon, or prolonged inflation of the esophageal balloon.
  • Aspiration pneumonitis – incidence can be decreased by evacuating the stomach and intubating the patient before placement

Aftercare:

  • Examine tube, nares, mouth, and tongue frequently – mucosal ulcerataion can occur within hours
  • Regularly monitor the esophageal balloon pressure
  • Once bleeding controlled, decrease pressure in the esophageal balloon by 5 mm Hg every 3 hours until a pressure of 25 mm Hg.
  • Regardless of pressure, periodically deflate esophageal balloon for 2-4 minutes every 5-6 hours to decrease incidence of mucosal ischemia and necrosis
  • Esophageal balloon should not remain inflated for more than 24 hours

Pearls:

SB tubes are a triple lumen (gastric balloon, esophageal balloon, gastric aspiration) and double-balloon system (gastric and esophageal); as opposed to a Minnesota tube which is a quadruple lumen (esophageal balloon, esophageal aspiration, gastric aspiration, gastric balloon) and double-balloon system.

SB tubes require a concomitant nasogastric tube to be placed; Minnesota tubes do not.

The maximum volume to inflate into each balloon is manufacturer and size specific.


References:

  1. Reichman EF. Balloon Tamponade of Gastrointestinal Bleeding. In: Emergency Medicine Procedures. 2nd Edition. 2013.
  2. Winters ME. Balloon Tamponade of Gastroesophageal Varices. In: Roberts and Hedges’ Clinical Procedures in Emergency Medicine. 6th Edition. 2014

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