Blakemore

[Jabbed]

First Blakemore attempt, couldn't get past the GE junction. I'd actually been researching this a bunch lately and tried all the tricks that I can think of. Lubed everything up really well, tried MacGills, tried using a bougie through the gastric side port for some rigidity. I advanced it up to 50 cm mark but the tip was still just above the diaphragm. GI wasn't able to advance it any further though.

Any other thoughts? Feels bad man.

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[WilcoWorld]

All I can offer is: don't sweat not being able to do a useless procedure.

IMO: Blakemores are simply torture devices for perimorbid patients.

 

[alpinism]

Meh I’m 50% survival with blakemores.

Not sure how they’re considered torture devices since patients should be tubed and sedated before attempting placement.

 

[alpinism]

Honestly it’s hard to say without being there in person. It’s definitely more difficult than a normal gastric tube and often takes a little extra force with lots of extra lube applied to the ballon.

It’s could also be that your tube was just too large for the actual gastric junction opening depending on the size of the patient.

 

[WilcoWorld]

patients should be tubed and sedated before attempting placement.

"Mortality within 30 days was 42.4%, and the related independent factors with mortality ... endotracheal intubation before SB tube (hazard ratio, 2.81; p = 0.018)."

 

[Groove]

I guess you could try a Frova or something more stiff but honestly...if you force it too much you're more apt to perforate the esophagus or stomach or rip up existing varices and make them bleed even more. I've never even put in a Blakemore and the one time I took care of someone in the ICU who got a Blakemore from one of my attendings in residency, we pulled the plug on them within 24 hours. Mortality is ridiculous. It's a gigantic Hail Mary. I haven't worked at a single hospital since residency where we even had them available.

 

[The Knife & Gun Club]

First Blakemore attempt, couldn't get past the GE junction. I'd actually been researching this a bunch lately and tried all the tricks that I can think of. Lubed everything up really well, tried MacGills, tried using a bougie through the gastric side port for some rigidity. I advanced it up to 50 cm mark but the tip was still just above the diaphragm. GI wasn't able to advance it any further though.

Any other thoughts? Feels bad man.

Did the person have known varices?

My first blakemore had the same problem, and eventually we figured out from collateral that they had a big lower esophageal tumor that was probably the source of the bleed. Really not much you can do IMO, since trying to force it any harder could’ve perfed the esophagus/tumor.

 

[Radetzky]

"Mortality within 30 days was 42.4%, and the related independent factors with mortality ... endotracheal intubation before SB tube (hazard ratio, 2.81; p = 0.018)."

Almost certainly an epiphenomenon

 

[WilcoWorld]

Almost certainly an epiphenomenon

I'm not proposing causation, probably correlation.

But I stand by my claim. If you're thinking of putting a SB tube in me, please just start a morphine drip instead.

 

[Radetzky]

I'm not proposing causation, probably correlation.

But I stand by my claim. If you're thinking of putting a SB tube in me, please just start a morphine drip instead.

Agreed

 

[Tipsy McStagger]

I think that study has some issues with confounding. They're stating that lower CP score and no intubation were associated with better outcomes. Why aren't they making an argument that patients with lower CP scores and patients who's UGIB are obviously not bad enough to warrant intubation are less sick and thus more likely to survive?

I think they may have made the erroneous jump from: intubation = mortality in UGIB, when they could have easily have said: "if you aren't as sick you're more likely to survive regardless of intubation."

Has anyone here honestly seen a UGIB that was so bad that you thought to yourself "oh sure, this guy's airway is protected, I'll just put in a Blakemore without securing their airway?" Seems farfetched to me. When I put in blakemores, they're usually on deaths doorstep. They are basically blood volcanoes out of their mouths and GI often has nothing to offer. no way I could ever do it safely without securing the airway first.

 

[Jabbed]

Yes they were definitely varices and yes I actually did try the Frova trick.

But, we ended up passing it anyway. We procured endoscopy biopsy forceps from the endo suite and passed it through the gastric lumen. You're essentially using it as a stylet and it makes the tube much stiffer and easier to advance. The Frova by comparison was way more rigid and cumbersome to advance. After it was in place and inflated, you just pull the forceps straight out.

Pretty neat.

 

[WilcoWorld]

When I put in blakemores, they're usually on deaths doorstep.

That's my actual point. I'm certainly not arguing against airway protection for unstable UGI bleeds.

 

[Tipsy McStagger]

That's my actual point. I'm certainly not arguing against airway protection for unstable UGI bleeds.

I must have misunderstood your position. Apologies.

 

[WilcoWorld]

I must have misunderstood your position. Apologies.

It's all good, when I post a quote without context I'm setting myself up to be misunderstood.

 

[Apollyon]

It's all good, when I post a quote without context I'm setting myself up to be misunderstood.

Well, that is a completely unreasonable statement, but, you are known for being unreasonable!

/sarcasm

 

[norski]

N=2, but still, anything soft, like a blakemore (sengenstaken in yurp) can be a lot easier to place if you use an esophageally placed ett as a conduit. After tubing the trachea, that is.

 

[The Knife & Gun Club]

N=2, but still, anything soft, like a blakemore (sengenstaken in yurp) can be a lot easier to place if you use an esophageally placed ett as a conduit. After tubing the trachea, that is.

This is a really interesting idea, so what they just have 2 ETTs in their mouth? Make sure RT doesn’t accidentally unhook the vent and connect it to the wrong tube 😬

 

[norski]

Yup, pretty much. Remove the connector from the esophageal tube to be safe. That and a red hose coming out of the tube might hopefully let the RT know that would be the wrong one.

This is a really interesting idea, so what they just have 2 ETTs in their mouth? Make sure RT doesn’t accidentally unhook the vent and connect it to the wrong tube

 

[Mount Asclepius]

In a really bad upper GI bleeder you can also intentionally intubate the esophagus with an ETT and then hook it up to a suction canister. Can sometimes make visualizing the airway and tracheal intubation a little easier.

 

[Angry Birds]

In a really bad upper GI bleeder you can also intentionally intubate the esophagus with an ETT and then hook it up to a suction canister. Can sometimes make visualizing the airway and tracheal intubation a little easier.

Just have your RT intubate the patient