Minnesota esophagogastric tamponade tube

Introduction

A four lumen device for tamponade of gastric & esophageal bleeding. The four lumens provide access for:

• gastric access
• esophageal aspirate
• esophageal balloon (manometer port)
• gastric balloon (manometer port)

               ------  gastric aspirate
              |
              |------  esophageal aspirate
--< >< >-------
  ^  ^        |--------<   esophageal balloon & manometer port
  |  |        |
               --------<   gastric balloon & manometer port
gastric &
esophageal
balloons

Both the gastric & esophageal balloons must be blown up, tested for air leaks prior to intubation. The gastric balloon should be standardized for pressures at 100, 200, 300, 400 & 500 mL of inflation.

The patient is placed on a fluoroscopic table with the head elevated to 45 degrees. The posterior pharynx & nostrils are anesthetized with a topical anesthetic. A lubricated* 18 French Levin tube (included) is passed into the patient's stomach. The stomach is lavaged with normal saline to remove blood clots. Complete removal of blood from the stomach reduces the risk of aspiration of blood reduces the risk of blood into the trachea during intubation. Following gastric lavage, the Levin tube is withdrawn.

After suctioning the air from the gastric & esophageal balloons, the two pressure monitor outlets are clamped & plugs inserted into the lumens for inflation of the gastric & esophageal balloons. This maintains deflation of the balloons during intubation. The tube is introduced through the nostrils into the posterior oropharynx & advanced to the 50 cm mark indicating that the tip of the tube is well below the diaphragm. Suction is applied immediately to the gastric & esophageal aspiration lumens to avoid regurgitation of gastric juice, blood & saliva during the inflation of the gastric balloon. Aspiration of gastric juice from the gastric aspiration lumen provides evidence for proper location of the tube.

The clamps & plugs are removed from the gastric balloon ports. The pressure monitoring port is connected to a Hg manometer (included). Increments of 100 mL of air are introduced through the gastric balloon inflation lumen until a total of 450-500 mL of air fill the gastric balloon. If the intragastric balloon pressure recorded is 15 mm Hg > than the pressure recorded at the same volume prior to intubation, the gastric balloon is in the esophagus & further inflation may cause esophageal rupture. If the gastric balloon is in the esophagus, it must be deflated & introduced into the stomach.

When the gastric balloon has been inflated with 450-500 mL of air, the air inlet & pressure monitoring outlets of the gastric balloon are clamped. The tube is pulled back gently until the resistance of the diaphragm is firmly felt against the gastroesophageal junction. The tube emerging from the nostril is fixed with a rubber sponge nasal guard (included). Saline lavage of gastric contents through the gastric aspiration port should be attempted until the aspirate is clear.

If the gastric aspirate does not clear, the esophageal balloon should be inflated to a pressure of 35-45 mm of Hg recorded continuously during inflation through the manometer port of the esophageal balloon. If bleeding continues during esophageal tamponade, it usually arises from a gastric varix. In this case, external traction on the tube should be initiated. The tube is kept taut by fixing it to the nasal guard. External traction should be employed cautiously for short time intervals because it causes ulceration of the mucosa within a few hours.

The gastric aspiration lumen is connected to intermittent suction 60-129 mm Hg. Continuous suction 120-200 mm Hg of the esophagus removes swallowed saliva & regurgitated blood.

The esophageal balloon pressure should be maintained at the lowest level that stops the bleeding. It should not exceed 45 mm Hg. After bleeding has been terminated by tamponade, the pressure in the balloon is reduced by 5 mm Hg every 3 hours until an intra- esophageal balloon pressure of 25 mm Hg is achieved without bleeding. Since continuous pressure of 24-30 mm Hg on the esophagus for long periods of time may induce esophageal necrosis, periodic underinflation of the esophageal balloon for 5 min every 6 hours is recommended. If intraesophageal balloon pressure of 25 mm Hg can be maintained without bleeding, this pressure should be maintained for at least 12 hours. After 12 hours, the balloon may be deflated, but should be left in place for another 4 hours.

If bleeding fails to reoccur, the Minnesota tube is withdrawn. To insure deflation of the balloons, transect the protruding end of the balloon before withdrawal. After extubation, the mouth & posterior oropharynx are suction to remove regurgitated secretions.

The tube may be sterilized by ethylene oxide or autoclave.

*Caution: Use with water-soluble lubricants, Do not use lubricants with mineral oil or petrolatum as they damage the rubber in the tube

More general terms

• balloon tamponade

Additional terms

• esophageal varices