Unstable patients with gastroesophageal varices receiving maximal medical therapy
Endoscopy is unavailable or unsuccessful
Esophageal strictures or recent gastroesophageal surgery
No active bleeding
Source of bleeding likely gastric
General Basic Steps
Placement and gastric balloon inflation
Esophageal balloon inflation
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
1 Sterile gauze bandage roll (Kerlix)
1 L NS (normal saline)
Kelly clamps (padded)
2 wall-suction units
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
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