see: [Robert Hedges - Balloon Tamponade of gastroesophageal varices](x-devonthink-item://31ACDC98-D2CC-48C5-BE69-E9B37E53FA8C?page=985), [Dunn - Upper GI haemorrhage](x-devonthink-item://8042AAFB-59BB-4F27-9FDB-FD9D064666CC) section on Tamponade of varices see also: [[Upper GI Bleed|UGIB]] > [!key points] > - there are a variety of oesophageal balloon tamponade devices; Sengstaken-blackmore is one well-known version > - balloon compression of varices at the gastro-oesophageal junction > - **requires intubation first** to prevent aspiration and for comfort > - can be inserted orally or nasally > - initially controls haemorrhage in 90% of cases; persistent control in only 505 of cases ## Indications Unstable patients with massive variceal bleeding where: - endoscopy is not available - endoscopy is unsuccessful at controlling bleeding - physicians are unavailable and vasoactive agents have failed to stop the bleeding - severe variceal bleeding uncontrolled by other measures (sclerotherapy or vasopressin) - \> 2000mL transfusion in 24 hours - mallory weiss tear with ongoing bleeding ## Equipment ![[Pasted image 20250210145244.png]] - gastric port has introducer wire inserted which should be lubricated to assist removal - *gastric balloon* inflates to 200-300mL - *oesophageal balloon* inflates to maximal of 30 mmhg (use manometer to measure pressure) - there is a radiolucent mark located just above gastric balloon - aspiration ports above and below the balloons ![[Pasted image 20250210144925.png]] **Minnesota tube** - four lumens: gastric, gastric balloon, oesophageal balloon, drainage above oesophageal balloon ## Insertion technique - intubated patient - co-phenylcaine to nasal passage if nasal insertion - check balloon integrity by inflating gastric balloon with 100mL aliquots of air and record pressures up to 300mL, then remove all air from balloons while gently twisting them - measure length from *bridge of noste to xiphisternum* - apply oesophageal spigot and clamp two deflation ports and put caps on - lubricate tube - insert tube to 50cm depth - *remove guide wire* from gastric suction port ; if difficult to remove may be kinked and need to be re-sited - place gastric port on free drainage - inflate gastric balloon with 50mL of air - *X-ray to confirm correct position* - inflate gastric balloon to increments of 100mL to max of 300mL and chekc pressure with pre-recorded pressures - apply gentle traction on tube ot lodge in the upper stomach - tie tube to 500mL bag of saline for traction and mark the oral depth - aspirate oesophageal port to determine if bleeding is continuing - *if bleeding is continuing, inflate oesophageal balloon up to max 30 mmHg* **post procedure:** - sit patient up to 30-45 deg - leave gastric port on free drainage - suction oesophageal port hourly - leave tube in situ no longer than 24 hours - aim for urgent endoscopy or selective angiography for erosion not controlled by endoscopy ## Complications - pulm aspiration in 10% / pneumonitis - oesophageal perforation / rupture - sinusitis - necrosis of alar cartilage - airway obstruction - dislodgement of previous variceal bands - esophageal and gastric mucosal erosions