Sengstaken-type tube: Insertion techniques and Nursing management

Sengstaken-type tube

Used to manage oesophageal variceal haemorrhage that continues despite pharmacological ± per-endoscopic therapy. The device (sengstaken-Blakemore or similar ) is a large-bore rubber tube, usually containing two balloons ( oesophageal and gastric ) and two further lumens ( oesophagal and gastric ) that open above and below the balloons. This device works usually by the gastric balloon alone compressing the varices at the cardia. Inflation of the oesophageal balloon is rarely necessary. 

Insertion techniques 

The tubes are usually kept in the fridge to provide added stiffener for easier insertion. 

• The patient often requires judicious sedation or mechanical ventilation ( as warranted by conscious state /level of agitation ) prior to insertion. 
• Check balloons inflate properly beforehand. Lubricate the end of the tube. 
• Insert via mouth. Place to depth of 55-60cm, i. e.  to ensure gastric balloon is in stomach prior to inflation. 
• Inflate gastric balloon with water to volume instructed by manufacturer (usually 200mL). A small amount of radio-opaque contrast may be added. Negligible resistance to inflation should be felt. Clamp gastric balloon lumen. 
• Pull tube back until resistance is felt, i.e. gastric balloon is at cardia. Fix tube in place by applying countertraction at the mouth. Old fashioned methods, such as attaching the tube to a free-hanging litre bag of saline, have been superseded by more manageable techniques. For example, two wooden tongue depressors, 'thickened' by having Elastoplast wound around them, are placed on either side of the tube at the mouth and then attached to each other at both ends by more Elastoplast. The tube remains gripped at the mouth/cheek by the attached tongue depressors, but can be retracted until adequate but not excessive traction is being applied. 
• Perform X-ray to check satisfactory position of gastric balloon. 
• If bleeding continues ( continued large aspirates from gastric or oesophageal lumens )  inflate oesophageal balloon (approximately 50mL)

Subsequent Management 

• The gastric balloon is usually kept inflated for 12-24h and deflated prior to endoscopy ± sclerotherapy. The traction on the tube should be tested hourly by the nursing staff. The oesophageal lumen should be placed on continuous drainage while enteral nutrition and administration of drugs can be given via the gastric lumen. 
• If the oesophageal balloon is used, deflate for 15-10 min every 1-2h to reduce the risk of oesophageal pressure necrosis. Do not leave oesophageal balloon inflated for >12h after sclerotherapy. 
• The tube may need to stay in situ for 2-3d through periods of deflation should they be allowed. 

Complications 

• Aspiration 
• Perforation 
• Ulceration 
• Oesophagel necrosis