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

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

Sengstaken-Blakemore Tube

Intubate patient
Fully inflate and deflate each balloon using its respective port to check for leaks
If using Sengstaken-Blakemore tube, secure NG tube to tamponade device with distal end of NG tube 3 cm proximal to esophageal balloon
Use NG tube to measure 50 cm from top of gastric balloon on Sengstaken-Blakemore tube, and mark 'G'
Use NG tube to measure 50 cm from top of esophageal balloon on Sengstaken-Blakemore tube, and mark 'E'
Attach 3-way stopcocks to esophageal and gastric ports
Insert tube orally (may need to use lubrication and Magill forceps) to > 50 cm
Test for location in stomach by injecting air through the tube and auscultating at the epigastrium
Inflate gastric balloon (port marked 'G') with 50 mL of air
Confirm location of gastric balloon in the stomach using portable XR
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
Tie tube to casting sleeve/Kerlex attached to a 1L bag of normal saline, and hang bag over IV pole to provide 1 kg traction
Attach esophageal and gastric aspiration ports to suction
If bleeding continues, inflate the esophageal balloon
- Inflate to 20-40 mm Hg (use manometer to test pressure)
- Do not inflate more than 45 mm Hg

Get the kit, 4 Kelly clamps, 50 mL syringe, lube
Take out nasogastric tube, if present
- Nasogastric tube depth can be used to estimate how far to place Minnesota
Clamp all ports on Minnesota EXCEPT gastric inflation and suction with Kelly clamps
- Take out the little white stoppers in all the ports
- If this takes a long time you can just leave in and clamp below if there is space
- Put gastric suction to suction
Test the gastric tube with air to see that they inflate in water bath
Insert lubed tube to 50-60 cm mark (estimate bridge of nose to xiphoid process) and test pump 50 mL air then get a KUB to verify position
Then count carefully to 9 more pumps of 50 mL (Minnesota gastric tube holds 500cc, you need 9 more pumps after the initial 50 mL.
- have someone count with you)
Unclamp the gastric inflation port, pump 50 mL, then re-clamp, then pump again, repeat until you hit 10 total times

PEARLS

No need to use 3 way stopcocks/ Christmas tree adaptors, just Kelly clamp all ports other than gastric inflation site
- We initially tried to find all the adaptors etc., but ended up having air leaks because they were not connected correctly or the right kind and the gastric balloon did not stay inflated. Don't use anything other than Kelly clamps
- Can connect suction to gastric suction but in general, ignore all ports other than gastric inflation.
No need to use esophageal tube or manometer as MOST of the time the gastric tamponade will be sufficient and you don’t want to risk over inflating the esophagus
- Have someone count with you to not lose count of how much air you’ve inserted!

Due to misplaced balloon, migration, over-inflation, prolonged use
- Mucosal ulceration
- Aspiration
- Airway or large vessel obstruction
- Esophageal rupture

Authors: