a) What is the tube in the image above used for? (10% marks)
b) Describe the steps for insertion of this tube. (40% marks)
c) What are the contraindications for its insertion? (20% marks)
d) What are the complications of its use? (30% marks)
a)
Minnesota tube (Sengstaken-Blakemore or gastro-oesophageal balloon tamponade device acceptable) for balloon tamponade of bleeding oesophageal varices.
b)
Intubate patient to protect airway and simplify insertion. Check balloon for leaks & lubricate tube.
Pass via nares (or mouth if severe coagulopathy present) and guide under laryngoscopic control into oesophagus, until 50cm inserted.
Slowly inflate gastric balloon: 250ml air.
Gently withdraw tube until resistance felt (~30-35cm) as balloon engages with gastro-oesophageal junction.
Aspirate both ports. Check volume of fresh blood: reducing?
If bleeding has ceased (~80%) then leave oesophageal balloon deflated. Apply traction to tubing (as below)
If bleeding from mouth or oesophageal aspiration port continues, then inflate oesophageal balloon with air to 25-30mmHg (max 40).
Deflate oesophageal balloon for 10 min every 2-hrs.
Apply traction to tubing by tying 500ml bag of fluid over pulley.
Check position on CXR: identify gastric balloon below diaphragm & radio-opaque marker along course.
Or any acceptable technique
c)
Oesophageal stricture
Recent oesophageal surgery
Hiatus hernia
Unknown cause of GI bleed
d)
Trauma to nose, pharynx, oesophagus
Incorrect placement or dislodgement of gastric balloon in pharynx or oesophagus (may result in acute upper airway obstruction if airway not secured)
Oesophageal tear or rupture Failure to control bleeding. Aspiration pneumonitis.
Secondary infection: pneumonia, sinus
Nasal or oral mucosal ulceration & necrosis from traction.
In order to be specific: that image above is of a Minnesota tube, not an SB tube (see the number of ports?). This question is essentially identical to Question 30 from the first paper of 2013 and Question 18.3 from the first paper of 2008.
b)
The sequence of insertion should be as follows:
Contraindications to SB tube insertion include the following:
Complications of SB tube insertion and measures to prevent them:
Preventative measure |
|
Aspiration |
|
Oesophageal rupture |
|
Gastric balloon migration; upper airway obstruction |
|
Oesophageal necrosis |
|
Nepean ICU - A McLean, V McCartan - Insertion, care and removal of the Sengstaken Blakemore or Linton tube (2005)
Bennett, Hugh D., Lester Baker, and Lyle A. Baker. "Complications in the use of esophageal compression balloons (Sengstaken tube)." AMA archives of internal medicine 90.2 (1952): 196-200.
Bauer, JOEL J., I. S. A. D. O. R. E. Kreel, and ALLAN E. Kark. "The use of the Sengstaken-Blakemore tube for immediate control of bleeding esophageal varices." Annals of surgery 179.3 (1974): 273.
Seror, J., C. Allouche, and S. Elhaik. "Use of Sengstaken–Blakemore tube in massive postpartum hemorrhage: a series of 17 cases." Acta Obstetricia et Gynecologica Scandinavica 84.7 (2005): 660-664.
Sengstaken, Robert W., and Arthur H. Blakemore. "Balloon tamponage for the control of hemorrhage from esophageal varices." Annals of surgery 131.5 (1950): 781.
Puyana, Juan Carlos. "Gastroesophageal Balloon Tamponade for Acute Variceal Hemorrhage" - from Irwin and Rippe's Intensive Care Medicine, 7th Edition
Seet, E., et al. "The Sengstaken-Blakemore tube: uses and abuses." Singapore medical journal 49.8 (2008): e195-7.
Roy, M. K., et al. "Sengstaken tube for bleeding rectal angiodysplasia." British journal of surgery 83.8 (1996): 1111-1111.
Hughes, J. Preston, Harvey P. Marice, and J. Byron Gathright. "Method of removing a hollow object from the rectum." Diseases of the Colon & Rectum 19.1 (1976): 44-45.
Morita, Seiji, et al. "Successful hemostasis of intractable nasal bleeding with a Sengstaken-Blakemore tube." Otolaryngology--Head and Neck Surgery 134.6 (2006): 1053-1054.
Isaacs, K. L., and S. L. Levinson. "Insertion of the Minnesota tube." Manual of gastroenterologic procedures 3 (1993): 27-35.
Bauer, JOEL J., I. S. A. D. O. R. E. Kreel, and ALLAN E. Kark. "The use of the Sengstaken-Blakemore tube for immediate control of bleeding esophageal varices." Annals of surgery 179.3 (1974): 273.