Balloon tamponade for massive GI bleeding

Indications

• Unstable patient with massive upper GI bleed and any of the following:
  • Inability to perform endoscopy
  • Endoscopy failed (e.g., cannot visualize source due to heavy bleeding)
  • Delay in endoscopy or GI consultation
  • Need to stabilize prior to transfer

Contraindications

• Esophageal stricture
• Recent esophageal or gastric surgery

Equipment Needed

• Balloon device
  • Sengstaken-Blakemore Tube
  • Minnesota Tube
• 60 cc syringe
• Padded(tape) kelly clamps
  • Used to clamp gastric and esophageal balloon ports to maintain precise pressure/volume
• Manometer
• 3-way connector device
• NG tube (only for Sengstaken-Blakemore)
• Kerlex
• IV pole
• 1 L bag IVF
• May need Magill forceps for manoeuvring tube into the esophagus

Procedure

1. Patient should be intubated prior to placement to decrease aspiration risk
2. Test tubes for leaks and inflate in 100 mL increments while measuring the pressure each time
3. If using Sengstaken-Blakemore tube, secure NG tube to tamponade device with distal end of NG tube 3 cm proximal to esophageal balloon
   • This will function as esophageal aspiration port
4. Insert tube orally to at least 50 cm mark
   • Use lubrication and laryngoscope to aid in placement
5. Inject air into gastric port and listen over the stomach
   • If air is auscultated, inject 50 cc into gastric balloon and shoot CXR to confirm placement in stomach
6. Gastric aspiration port to continuous suction
7. Completely fill gastric balloon
   • Sengstaken-Blakemore: 250-300cc
   • Minnesota: 450-500cc
   • Measure the pressure at each 100 mL increment
     • If pressure is >15mm Hg more than corresponding pre-insertion pressure deflate the balloon and advance further prior to filling gastric balloon
8. Place 1 kg traction on tamponade device and mark device at the lips
   • Tie one end of kerlex around the distal portion of tamponade device (proximal to port insertion sites) and attach other end to 1 L bag IVF
   • Hang 1 L bag over IV pole
9. Esophageal and gastric aspiration ports to suction
10. If bleeding continues inflate the esophageal balloon
    • Inflate to 20-40 mm Hg
    • Do not inflate more than 45 mm Hg

Complications

• Due to misplaced balloon, migration, overinflation, prolonged use
  • Mucosal ulceration
  • Aspiration
  • Airway or large vessel obstruction
  • Esophageal rupture

See Also

• Upper gastrointestinal bleeding

External Links

• LITFL: Sengstaken-Blackmore and Minnesota Tubes
• EMCRIT: Blakemore Tube Placement for Massive Upper GI Hemorrhage