Unit IV Gastrointestinal System Section Sixteen Special Gastrointestinal Procedures PROCEDURE Esophagogastric 108 Tamponade Tube Rosemary Lee PURPOSE: Esophagogastric tamponade therapy is used to provide temporary control of bleeding from gastric or esophageal varices. • Contraindications include latex allergy, esophageal strictures, PREREQUISITE NURSING and recent esophageal surgery. Relative contraindications are KNOWLEDGE heart failure, respiratory failure, hiatal hernia, severe pulmo- nary hypertension, and cardiac dysrhythmias. 4,8,12 • Tamponade therapy exerts direct pressure against the • Because of the risk for aspiration, it is recommended the varices with the use of a gastric and/or esophageal balloon patient be endotracheally intubated for airway protection and may be used for patients who are unresponsive to before esophagogastric tamponade tube insertion. 13 medical therapy or are too hemodynamically unstable for • Sedation should be considered, but dosing should be indi- endoscopy or sclerotherapy. 1,3 vidualized on the assessment of each patient. Sedation • Esophagogastric tamponade tubes are used to control should be used with caution in the setting of liver injury bleeding from either gastric and/or esophageal varices. and/or failure due to these patients ’ impaired metabolism The suction lumens allow the evacuation of accumulated of sedating medications. The plan for sedation, if needed, blood from the stomach or esophagus. The suction lumens is individualized with the goal to achieve patient comfort. also allow for the intermittent instillation of saline solu- • Head of bed (HOB) should be at least 30 to 45 degrees at tion to assist with evacuation of blood or clots and provide all times to reduce the risk of aspiration. 6 a means of irrigation if indicated. • The use of esophageal tamponade is decreasing in clinical • Three types of tubes are available for esophagogastric practice because up to 50% of varices rebleed after the tamponade therapy. The two most common tubes are the balloons are defl ated. 12,13 Additionally, major complica- Sengstaken-Blakemore (Bard, Inc., Covington, Georgia) tions can occur with the use of esophageal balloon tam- tube ( Fig. 108-1 ) and the Minnesota esophagogastric tam- ponade therapy. 13 However, esophagogastric tubes are still ponade tube. The Sengstaken-Blakemore tube has a used in areas where esophagogastric duodenoscopy is not gastric and esophageal balloon and a gastric aspiration readily available. The use of esophageal tamponade is lumen. The four-lumen Minnesota tube ( Fig. 108-2 ) has designed to be a temporary intervention until more defi ni- gastric and esophageal balloons and separate gastric and tive therapy can be carried out. Balloon tamponade is esophageal aspiration lumens. The third, the Linton or recommended to be used for only 24 to 48 hours. 2,13 Linton-Nachlas tube, (Mallinckrodt Inc., Tyco Health Care Group, Hampshire, UK) has a gastric balloon and EQUIPMENT separate gastric and esophageal aspiration lumens and is used only for treatment of bleeding gastric varices. The • Tamponade tube (Sengstaken-Blakemore, Minnesota, or Minnesota tube is considered the preferred tube for esoph- Linton-Nachlas) agogastric tamponade therapy because it allows for aspi- • Irrigation kit (or catheter-tip, 60-mL syringe and basin) ration of drainage above the esophageal balloon and • Nasogastric (NG) tubes (one for Sengstaken-Blakemore below the gastric balloon. tube) • Esophagogastric tamponade tubes may be introduced via • Normal saline (NS) solution for irrigation either the nasogastric or the orogastric route. The tubes • Water-soluble lubricant are then advanced through the oropharynx and esophagus • Topical anesthetic agent and into the stomach. • Sphygmomanometer or pressure gauge 958 108 Esophagogastric Tamponade Tube 959 Esophageal balloon Gastric Esophageal aspiration balloon Gastric balloon Figure 108-3 Balanced suspension traction securing tamponade tube and placement. (From DeGroot KD, Damato M: Critical care skills, Norwalk, CT, 1987, Appleton & Lange.) Gastric balloon Football helmet Face guard Esophageal Figure 108-1 Sengstaken-Blakemore tube in place with both the balloon inflation port esophageal and gastric balloons infl ated. (From Carlson KK, editor: Philadelphia, 2009, Saunders.) AACN advanced critical care nursing, Gastric aspiration port Chin strap Gastric balloon inflation port Gastric aspirate Figure 108-4 Tamponade tube secured in position with helmet. Esophageal aspirate Gastric balloon Esophageal balloon • Four rubber-shod clamps or plastic plugs that may come with the balloon kit • Adhesive tape Esophageal balloon • Two suction setups and tubing • Cardiac monitor • Scissors, must be kept at bedside Gastric balloon Additional equipment, to have available as needed, includes the following: • Rubber cube sponge (used for nasal tamponade tube Figure 108-2 Minnesota four-lumen tube. (From Swearingen placement)—may be used for traction PL: Photo atlas of nursing procedures, Reading, MA, 1991, • Balanced suspension traction apparatus with 1 pound of Addison-Wesley.) weights, 500 mL of NS solution ( Fig. 108-3 ), or football helmet with face mask ( Fig. 108-4 ) 960 Unit IV Gastrointestinal System ❖ Decreased hematocrit and hemoglobin values ❖ Change in level of consciousness • Assess the baseline cardiac rhythm. Rationale: Passage of a large-bore tube into the esophagus may cause vagal stimulation and bradycardia. • Assess the baseline respiratory status (i.e., rate, depth, pattern, and characteristics of secretions). Rationale: Use of topical anesthetic agents in the nares or oropharynx may alter the gag or cough refl ex, increasing the risk for aspiration. Passage of a large-bore tube may impair the airway. Large amounts of blood in the stomach predispose a patient to vomiting and potential aspiration. Figure 108-5 Lopez valve. (Courtesy of ICU Medical, Inc,. San • Assess the patient ’ s ability to protect the airway. Ratio- Clemente, CA.) nale: Multiple factors can infl uence the patient ’ s ability to protect the airway, including the presence of vomiting and depressed mental status. Inserting an endotracheal • Lopez enteral valve ( Fig. 108-5 ) (ICU Medical, San Cle- tube before inserting the esophageal balloon is mente, CA), a three-way stopcock used to attach a 60-mL recommended. 13 catheter-tip syringe and the handheld manometer to the • Assess the patient ’ s level of consciousness. Rationale: If Minnesota tube the patient has an altered level of consciousness, he or she • Emergency medications and equipment, including trans- may need to be intubated and mechanically ventilated cutaneous pacemaker and intubation equipment prophylactically to prevent airway complications. • Endotracheal suction equipment • If anticipating a nasal esophageal tube placement: • Marker ❖ Assess for medical history of nasal deformity, surgery, • Cervical collar trauma, epistaxis, or coagulopathy. Rationale: The risk for complications and bleeding with nasal insertion is PATIENT AND FAMILY EDUCATION increased. ❖ Evaluate patency of nares. Occlude one naris at a time, • Explain the procedure and reason for the esophagogas- and ask the patient to breathe through the nose. Select tric tube insertion. Rationale: Patient anxiety may be the naris with the best airfl ow. Rationale: Choosing the decreased. most patent naris eases insertion and may improve • Explain the patient ’ s role (if applicable) in assisting with patient tolerance of the tube. the passage of the tube and maintenance of tamponade ❖ The nasal route is not recommended in patients with traction. Rationale: Patient cooperation is elicited during coagulopathy. Rationale: The risk for bleeding and the insertion and tamponade therapy. complications is increased. • Explain to the patient that the procedure may be uncom- • Assess for allergy to latex. Rationale: Balloon tamponade fortable because the gag refl ex may be stimulated, causing tubes contain natural latex and may cause anaphylaxis in the patient to be nauseated or to vomit. Rationale: This patients with a latex allergy. explanation prepares the patient for what to expect during the procedure. Patient Preparation • Ensure that the patient and family understand preproce- dural information. Answer questions as they arise, and PATIENT ASSESSMENT AND reinforce information as needed. Rationale: Understand- PREPARATION ing of previously taught information is evaluated and rein- forced. Typically this is an emergency procedure and the Patient Assessment patient and family will be under stress. • Assess signs and symptoms of major blood loss. Ratio- • The physician, advanced practice nurse, or other health- nale: Esophageal or gastric varices can cause signifi cant care professional measures the tube from the bridge of the blood loss: nose to the earlobe to the tip of the xiphoid process. Mark ❖ Tachycardia the length of tube to be inserted. Rationale: Estimating ❖ Tachypnea the length of tube to be inserted helps place the distal tip ❖ Hypotension in the stomach. ❖ Decreased urine output • If the patient is alert, elevate the patient ’ s HOB to 30 to ❖ Decreased fi lling pressures (pulmonary artery pressure, 45 degrees. If the patient is unconscious or obtunded, pulmonary artery wedge pressure, central venous pres- place the patient ’ s head down in the left lateral position. sure, stroke volume, stroke volume index) Rationale: Positioning facilitates the passage of the tube ❖ Decreased platelet counts into the stomach and reduces the risk for aspiration.