005332 – Sengstaken-Blakemore Tube Management in ICU

Caboolture Hospital Intensive Care Unit

Guideline 

Effective from: January 2020

Review date: January 2023

Sengstaken-Blakemore Tube Management in ICU – 005332

 

Balloon tamponade with a Sengstaken-Blakemore Tube is a resuscitative intervention in attempt to achieve haemostasis in oesophageal variceal haemorrhage. The tube is used to temporarily stabilise the patient while more definitive treatment is organised. This intervention carries risk of oesophageal necrosis and or rupture, and aspiration of gastric contents.

Purpose and intent

This guideline outlines equipment and procedures necessary for insertion, ongoing management, removal and troubleshooting of the Sengstaken-Blakemore Tube. The information in this document is also applicable to the Minnesota oesophageal-gastric tube, a substitute option. 

Scope and target audience

This Guideline applies to all Caboolture ICU medical and nursing clinical staff (permanent, temporary and casual) and all organisations and individuals acting as its agents (including Visiting Medical Officers and other partners), involved in providing care and management of patients admitted to the Intensive Care Unit

Competency and education

All clinicians involved in the insertion and management of a Sengstaken-Blakemore tube must ensure that this is within their scope of clinical practice, determined by the individual’s credentials, education, training, competence and maintenance of performance at an expected level of safety and quality. The clinician’s scope of practice is also dependent upon the capacity and capability of the service area in which they are working. Education is provided to nursing and medical staff through their unit induction process and formal education programs such as in-service and ICU transition to nursing practice program, this includes supervised practice and/or simulation.

Procedure / process

The core principles of Sengstaken-Blakemore tube management follows Aseptic Non-Touch Technique (ANTT) and Personal Protective Equipment (PPE) including eye-protection must be worn for all procedures with risk of exposure to bodily fluids. Observe the five moments of hand hygiene throughout all clinical patient contact.

Roles and responsibilities

Staff Role

Documentation Responsibilities

Medical Officer

  • Determining the indications for insertion of Sengstaken-Blakemore tube.
  • Checking tube lumens and balloons prior to insertion.
  • Insertion procedure and review of outcomes of resuscitative interventions.
  • Determining frequency of gastric aspirates.
  • Ordering X-ray to confirm tube placement.
  • Order blood products as indicated by haemorrhagic loss.
  • Documentation of the procedure including consent and any complications.

Registered Nurse

  • Setting up and assisting the Medical Officer during insertion procedure.
  • Post-insertion management and care of the patient and the traction system.
  • Patient with Sengstaken-Blakemore tube in situ requires constant observation and 1:1 nurse-to-patient allocation
  • Observations, oropharyngeal care management and continued securement of the tube.
  • Escalation of deterioration or patient compromise and continued haemorrhagic losses.
  • Assisting medical officer in removal of tube as directed/clinically indicated.

Multi-disciplinary team

  • Continual review of ongoing necessity for tube.
  • Sengstaken-Blakemore tube should be removed as soon as possible; indicated for less than 24hrs in situ.
  • Logistical arrangement for definitive treatment.

Documentation requirements

The following must be documented in the approved ICU clinical information system (CIS):

  • Tube added to drains tab in system with date, time and position of insertion and ceased in system when removed from patient.
  • Pressures in gastric and oesophageal balloons recorded at checking, insertion and at a minimum of hourly while in situ.
  • Recording tube position at incisors on commencement of shift and at a minimum of hourly to monitor for dislodgement or migration.
  • Recording drainage outputs and aspirated volumes in the drains tab of CIS.

Components of Sengstaken-Blakemore (and Minnesota) tube

  • gastric balloon
  • gastric aspiration lumen
  • oesophageal balloon
  • oesophageal aspiration lumen (Minnesota tube only)
  • Minnesota tube – The only difference is the addition of the oesophageal aspiration port; insertion, balloon management, traction and general care are as per Sengstaken-Blakemore tube.

 

Figure 2.  Diagram of Sengstaken Blakemore tube insitu

Initial Sengstaken-Blakemore tube management

The following outlines the procedure and equipment required for insertion, maintenance and removal of Sengstaken-Blakemore tube. Intubation and sedation are recommended prior to insertion.

Equipment for insertion:

The medical team may require endoscopy for assistance in placement under direct visualisation.

  • Magill’s forceps
  • Yankauer suction tip
  • Sengstaken-Blakemore tube (kept in ICU storeroom with airway equipment – Compactor C)
  • water-soluble lubricant
  • laryngoscope (with light checked)
  • local anaesthetic spray
  • 50 mL syringe
  • drainage bag
  • suction equipment x 2
  • one suction unit on low pressure, another suction unit connected to Yankauer sucker
  • if traction is required seek from alternative source (from another hospital may be required)
  • alternatively use an IV pole with a 500mL bag fluid as the weight
  • cuff manometer

Sengstaken-Blakemore tube insertion process

Preparation for insertion:

Medical officer must check all the components of the tube before insertion. 

Gastric balloon:

  • Use the 50 mL syringe to inflate the gastric balloon with 50 mL of air
  • Connect gastric balloon to the sphygmomanometer, check & record the pressure
  • Continue inflating gastric balloon to 300 mL of air and record the pressure, then deflate

Oesophageal balloon:

  • Use the 50 mL syringe to inflate the oesophageal balloon with air until the balloon just begins to stretch
  • This normally occurs after inserting between 80 -100 mL of air

connect oesophageal balloon to the sphygmomanometer, check & record the pressure

  • Deflate both balloons completely and lubricate the tube.
  • Assist the patient into a left lateral position if they are not intubated, otherwise position patient in supine.

Insertion of the Sengstaken-Blakemore tube:

  1. Insert tube via oral cavity into the oesophagus as per standard gastric tube insertion proceedure.
  1. potential use of a laryngoscope may aid visualisation of the proximal opening of the oesophagus
  2. potential requirement for endoscopic assisted placement of tube
  1. Pass the tube to the 50 cm mark.
  2. Preliminary check of tube placement by auscultated air injection into stomach or aspiration of stomach contents.

  1. Inflate gastric balloon with 50 mL of air.
  2. Check balloon pressure against pre-insertion recording.
  1. if pressure exceeds the pre-insertion pressure by 15 mmHg or greater, the gastric balloon is incorrectly sited and should be collapsed
  2. otherwise, progress to next steps
  1. Inflate gastric balloon with 300 mL of air, then check the pressure in the gastric balloon.
  1. this should not exceed the pre-insertion pressure by greater than 15 mm Hg
  1. Pull back tube until resistance is felt – when the inflated gastric balloon rests in gastric fundus and against the oesophageal gastric junction.
  2. Document the level or measurement of tube at patient’s incisors.
  1. Document balloon pressure and volume of air inserted in patient’s record on ICU CIS.

Immediate post-insertion process:

  1. Recheck the position of the tube with an X-ray
  2. Apply traction rope to the tube and thread through pulley (if required)
  3. Hang traction weight or 500 mL/ 1L bag of IV fluids to the distal end of the traction rope (if required)

Ongoing Sengstaken-Blakemore tube management

Gastric balloon /port:

  • maintain the pressure in the balloon with the cuff-manometer, otherwise apply a clamp
  • check and record balloon pressures hourly
  • adjust volume of air to maintain required amount of pressure
  • pressure should not vary from baseline > 5 mm Hg

Oesophageal balloon /port:

  • if oesophageal balloon is inflated, check pressure in oesophageal balloon hourly
  • ensure the pressure does not exceed 40 mm Hg
  • never inject fluids in the oesophageal port
  • oesophageal balloon should be deflated periodically to reduce the risk ofoesophageal necrosis
  • generally deflate balloon for 15 minutes every 4 hr

General system management and patient care

  • Keep scissors at bedside to cut balloon ports in case of airway obstruction from upward migration of tube.
  • If the patient is not intubated, nurse in left lateral position as much as practicable.
  • Elevate head of bed 25 degrees to provide counter-traction for the weights.
  • Ensure traction weights hang freely from the foot of bed at all times.
  • Avoid rolling patient side to side whilst traction in use, instead lift patient in direction of pulley for bed-making, X-ray positioning, bed-pan etc.
  • If it is absolutely necessary to roll patient side to side, one nurse to hold tube in place whilst traction weight released.
  • Recheck tube position and balloon pressures immediately post procedure.
  • Ensure all ports of the tube clearly labelled if the product is not labelled.
  • Apply drainage bag to the Gastric aspiration port.
  • Measure and record volume of drainage as often as required by medical officer.
  • Spigot any lumen not connected to continuous suction or drainage bag.
  • Check tube position hourly and PRN (after moving patient).
  • Balloons should not be inflated for > 24 hours.

Patient monitoring:

Closely observe the patient for: 
  • bleeding – check haemoglobin every 2nd – 4th hourly, or as ordered by Medical Officer
  • acute onset of abdominal or back pain (as may be indicative of oesophageal rupture)
  • signs of respiratory distress
  • complaints of ear or neck pain
  • increased abdominal distension.
  • monitor fluid and electrolyte status for imbalances related to prolonged gastric suctioning and /or blood loss
  • pressure areas on the lower lip
    • for pressure area prevention, apply rest-on foam between lower lip and underside of Sengstaken-Blakemore tube and reposition hourly

Troubleshooting

If bleeding continues, the possible causes are:

  • falling balloon pressures; check and re-inflate accordingly
  • movement of the tube; check it is still in the correct position

Process for removal of Sengstaken-Blakemore tube

Ensure medical order exists for removal of the Sengstaken-Blakemore tube.

  1. If using both balloons, deflate sequentially.
    1. Oesophageal balloon must be deflated first followed by gastric balloon.
  2. Slowly deflate oesophageal balloon.
  3. Ensure traction weights /fluid bag are removed beforedeflating gastric balloon and relax traction on the gastric balloon lumen.
  4. Monitor gastric aspirate for recurrence of bleeding.
    1. The MO may choose to monitor the patient for several hours before proceeding further.
  5. Recheck all air from the oesophageal and gastric balloons is aspirated before tube removed.
  6. If no bleeding recurrence, tube is removed – smoothly and gently with consistent force.
  7. Dispose tube in clinical waste.
  8. Document removal and cease ‘drain’ in CIS.

Partnering with consumers

The Patient and their carer/next of kinare to be encouraged and given the opportunity to ask questions, clarify information and identify goals of care during communication processes.  Staff are responsible for providing information in a way that is understandable and that meets patient’s needs and are to use perception checking techniques to ensure patient and family’s understanding of discussions. 

Aboriginal and Torres Strait Islander considerations

Specific cultural implications exist for the provision of healthcare for Aboriginal and Torres Strait Islander patients and their families.

  • As a matter of best practice to provide culturally capable patient care, seek cultural guidance from the local Aboriginal and Torres Strait Islander Hospital Liaison Officer, the Aboriginal and Torres Strait Islander Cultural Practice Coordinator, Health Worker, the family group or the wider community.
  • Refer to the Metro North Hospital and Health Service Intranet page on Cultural Resources and Queensland Health Publication: “Aboriginal and Torres Strait Islander:  Patient Care Guidelines Published by the State of Queensland (Queensland Health), May 2014.

Legislation and other authority

  • Health Act 1937
  • Health Practitioner Regulation National Law Act 2009

References

Christensen, T, & Christensen, M 2007, ‘The implementation of a guideline of care for patients with a Sengstaken-Blakemore tube in situ in a general intensive care unit using transitional change theory’, Intensive And Critical Care Nursing, 23, 4, p. 234-242

Christensen, T 2004, ‘The treatment of oesophageal varices using a Sengstaken-Blakemore tube: considerations for nursing practice’, Nursing In Critical Care, 9, 2, pp. 58-63

Treger, R, & Kate, V 2016, Sengstaken-Blakemore tube placement, emedicine Medscape [Online] Accessed 7 November 2016, http://emedicine.medscape.com/article/81020-overview

Weingart, S 2016, Blakemore tube placement for massive upper GI haemorrhage, EMcrit [Online] Accessed 7 November 2016, http://emcrit.org/procedures/blakemore-tube-placement/

Related Documents


Document history

Author

Clinical Nurse Consultant, Caboolture Hospital ICU

Custodian

Clinical Nurse Consultant, Caboolture Hospital ICU

Compliance evaluation
and audit 

Adverse events relating to Sengstaken Blakemore tubes will be documented in the patient’s medical record. All clinical incidents, near-miss events and procedural noncompliance of Sengstaken Blakemore tube management are to be recorded via RiskMan and addressed by the Caboolture ICU Safety and Quality Committee. This information will be used to review practice and identify areas for future quality improvement initiatives as per MNHHS Quality Improvement Procedure (PROC089). In the absence of clinical incidents, proactive annual audit from CIS data of IAL documentation will be conducted and presented within the schedule of Caboolture ICU Safety and Quality Committee. 

Replaces Document/s

CRICU 003713/WUG Sengstaken-Blakemore Tube Management in ICU

Consultation

Key stakeholders

Director, Caboolture Hospital ICU

Clinical Nurse Consultant, Caboolture ICU

Staff Specialist and Consultants, Caboolture ICU

Broad Consultation

Members of Caboolture ICU Safety and Quality Committee

CNC, Caboolture Wound and Stoma Care

ICU Clinical Nurses NSQHS Portfolios Standard 5 and Standard 8

Marketing Strategy

A Policy, Procedure and Protocol Staff Update will be published online each month to update staff of all new and updated policies, procedures and protocols.  This update will be emailed to all Safety and Quality Units in each clinical directorate and a broadcast email sent to all Metro North staff with a link to the published update.

Key words

Oesophageal varices; bleeding; haemorrhage; gastric; Sengstaken Blakemore; 005332

 

 

 

Custodian Signature

Date

Clinical Nurse Consultant, Caboolture Intensive Care Unit, Metro North Hospital and Health Service

AUTHORISATION

 

 

 

Authorising Officer Signature

Date

Director, Intensive Care, Caboolture Hospital, Metro North Hospital and Health Service 

 

The original signed version is kept in file at Service Improvement Unit, Caboolture Hospital, Metro North.