Unstable patients with gastroesophageal varices receiving maximal medical therapy

 Endoscopy is unavailable or unsuccessful

CONTRAINDICATIONS

 Esophageal strictures or recent gastroesophageal surgery

 Relative:

    No active bleeding

    Incomplete equipment

    Source of bleeding likely gastric

SUPPLIES

 Sengstaken–Blakemore (SB) tube (triple lumen tube) or Minnesota tube (quadruple lumen tube). The fourth port is for suctioning the proximal esophagus.

 Salem Sump (double-lumen nasogastric tube) and silk ties to create necessary fourth lumen (not needed if using a Minnesota tube)

 60-mL Luer lock syringe

 60-mL Piston syringe

 2 Christmas tree catheter adapters

 2 Three-way stopcocks

 2 Heplock caps

 Surgilube

 1 Sterile gauze bandage roll (Kerlix)

 1 L NS (normal saline)

 Kelly clamps (padded)

 2 wall-suction units

 Straight connector

 Manual sphygmomanometer

TECHNIQUE

 Preparation

 Secure the airway. The patient will be intubated in almost all scenarios. Raise the head of the bed to 45 degrees.

 Assemble attachments to gastric balloon and esophageal balloon ports

 Test for air leaks using 60-cc Luer lock syringe

    Gastric balloon—Inflate 250-cc air

    Esophageal balloon—Inflate 60-cc air

 Deflate the balloons completely

 If using an SB tube, create fourth lumen:

    Place the distal tip of Salem Sump 2 cm proximal to the esophageal balloon and secure with silk ties (FIGURE 29.1)

 Placement and Gastric Balloon Inflation

    Lubricate the gastroesophageal balloon tamponade (GEBT). Insert orogastrically so that the 50-cm mark aligns with the patient’s lip. Can insert nasally; however, the oral route is preferred (FIGURE 29.2).

    Confirm placement via air insufflation through gastric port and auscultation for gastric sounds

    Connect gastric port to 60 to 120 mm Hg intermittent suction. Inflate the gastric balloon with 50 cc of air.

    Confirm with chest x-ray that the inflated balloon is in the stomach

    Inflate additional 200 cc of air into gastric balloon, for a total of 250 cc of air

    Affix padded Kelly clamp to gastric balloon port

 Traction

    The proximal end of the GEBT needs to be secured with traction

    Attach Kerlix distal to SB tube ports by creating a slip knot. Secure the opposing end to 1-L NS bag (or similar weight).

    Hang Kerlix over the IV pole, allowing the 1-L NS bag to hang freely, applying traction to the SB tube

 Esophageal Balloon Inflation

    Connect sphygmomanometer to the three-way stopcock on esophageal balloon port

    Inflate the esophageal balloon to 30 to 45 mm Hg (typically 50–70 cc air), using lowest pressure necessary

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