Author(s): Ben Warner and Mark Wilkinson
Indications, contraindications and potential complications of insertion of a Sengstaken-Blakemore tube are given in Table 125.1.
- Sengstaken-Blakemore tubes should only be inserted by those who are competent at placing them because of the risks of oesophageal perforation. They are usually inserted at the time of the endoscopy, if variceal bleeding cannot be controlled.
- See Table 125.2 for equipment needed for placement.
Technique
Preparation
- If the patient has a reduced conscious level (grade 2 encephalopathy or more), endotracheal intubation should be done by an anaesthetist before insertion of the tube to prevent misplacement of the tube in the trachea or inhalation of blood.
- If the patient has a normal conscious level, explain the procedure and obtain consent. Give supplemental oxygen via nasal cannulae, with monitoring of oxygen saturation by oximetry. Attach an ECG monitor. Sedation with midazolam can be given but only if an anaesthetist is available in case endotracheal intubation becomes necessary.
- Put on apron, mask and gloves. Check the suction equipment works. Anaesthetize the patient's throat with lidocaine spray.
Placement of the tube
- Ideally, the tube should be kept in the fridge beforehand so as to stiffen the tubing ready for easier insertion. Lubricate the end of the tube with KY jelly and pass it through the gap between your index and middle fingers placed on the tongue: this reduces the chance of the tube curling. Ask the patient to breathe quietly through his or her mouth throughout the procedure. Steadily advance the tube until it is inserted to the hilt. An assistant should aspirate blood from the mouth and from all lumens while you insert the tube.
- If at any stage of the procedure the patient becomes dyspnoeic, withdraw the tube immediately and start again after endotracheal intubation.
- Inflate the gastric balloon with the water/contrast mixture (310 mL). Insert a bung or clamp the tube. If there is resistance to inflation, deflate the balloon and check the position of the tube with X-ray screening. Pull the tube back gently until resistance is felt.
- Never inflate the oesophageal balloon unless trained in the reasons to do so.
- Firm traction on the gastric balloon is usually sufficient to stop the bleeding since this occurs at the filling point of the varices in the lower few centimetres of the oesophagus.
- Place a sponge pad (as used to support endotracheal tubes in ventilated patients) over the side of the patient's mouth to prevent the tube rubbing. Strap the tube to the cheek. Fixation with weights over the end of the bed is less effective, and may lead to displacement, especially in agitated patients. Mark the tube in relation to the teeth so that movement can be detected more easily.
- Obtain a chest X-ray to check the position of the tube. Write a note of the procedure in the patient's record, documenting: monitoring/sedation if given/any complications/post-procedure chest X-ray findings/plan of management.
Aftercare
- Continue terlipressin infusion and other supportive therapy (Chapter 77). If facilities for variceal injection/banding are available, the tube should be removed in the endoscopy suite immediately before this, which can be done as soon as the patient is haemodynamically stable (and usually within 12h). If endoscopic therapy is not possible, discuss the case with the regional liver unit and arrange transfer if appropriate. Alternatively, start planning for oesophageal transection within 24h if bleeding recurs when the balloon is deflated.
- Do not leave the tube in for longer than 24h because of the risk of mucosal ulceration. Changing the side of the attachment to the cheek every 2h reduces the risk of skin ulceration, but should be done carefully because of the risk of displacement.