Sengstaken-Blakemore Tube???

[Orange Julius]

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I've never seen one of these used myself. Given a situation of a cirrotic with bleeding varices, when if at all would you use one of these things?

Does anyone use them anymore? Are they a last resort? At what point do you call for an SB tube?

 

[xpert787]

In my reading it's more or less a temporizing measure to buy time for TIPS in a person with very bad bleeding. It works I think about 80% of the time, but can't be in longer then 24hrs due to risk of esophageal perf.

 

[SLUser11]

In my reading it's more or less a temporizing measure to buy time for TIPS in a person with very bad bleeding. It works I think about 80% of the time, but can't be in longer then 24hrs due to risk of esophageal perf.

Agree with Xpert. They are rare, and I've never used one. The only time it's come up in recent memory was a pediatric liver failure patient.

The indication is for variceal bleeding that is not controlled with endoscopic banding or sclerotherapy. It is pretty neat-looking, having an irrigation and suction port....can only really be used to temporize a patient. TIPS is more definitive.

The role would be to temporize an exsanguinating patient until you can do TIPS or a surgical shunt.....if none of those work, you can staple off the esophagus as a last resort. You can imagine how morbid all of this is....I quote the med students a 25% mortality for a variceal bleed, and higher mortality for recurrent bleeds....

 

[Smurfette]

Never seen one used either, always sent for a TIPS.

I did read up on how to use them before the boards, but I don't know if they still expect people to know this or not given TIPS is now preferable. I think they want you to know they exist, in case you need to do it temporarily in order to get the patient to TIPS (i.e. transfer out if unavailable in your hospital). No one in my Osler course (took right before boards) had ever used one either. In truth, I don't know if our residency hospital even had them available---probably buried in a supply closet somewhere for years, and not likely to be found quickly.

 

[SLUser11]

I've never seen one of these used myself. Given a situation of a cirrotic with bleeding varices, when if at all would you use one of these things?

Does anyone use them anymore? Are they a last resort? At what point do you call for an SB tube?

Two intellectual topics in 1 day.....i am so pleasantly surprised I don't know what to do. Quick, someone post about cute scrub tops or something mindless so my equilibrium can be restored....

 

[GregsAnatomy]

I put one in when I was an intern. Pt with massive variceal hemorrhage they couldn't stop endoscopically. We don't have IR available at night so we got called to put in the SB tube as a temporizing measure.

Its relatively simple to use. You just insert it like an NGT (preferably after intubating the patient). Then inflate the gastric balloon to the pressure indicated on the box (you can use the BP manometer to check the pressure). Pull back until the gastric balloon is snug at the GE junction, then inflate the esophageal balloon to the specified pressure. Then the best part....put a football helmet on the patient and secure the tube to it.

Pretty sure that patient died....

 

[SLUser11]

.....given TIPS is now preferable. I think they want you to know they exist, in case you need to do it temporarily in order to get the patient to TIPS....

TIPS is preferable, obviously, but TIPS isn't always an option. Even if there's an IR guy in house, not all patients have anatomy amenable to the procedure, and a lot of these patients have portal vein thrombosis, which I believe makes TIPS much more difficult (but not impossible).

I think TIPS and the SB tube are syngergistic in theory, and one does not eliminate the utility of the other.

 

[Mr Cookie Pants]

I put one in when I was an intern. Pt with massive variceal hemorrhage they couldn't stop endoscopically. We don't have IR available at night so we got called to put in the SB tube as a temporizing measure.

Its relatively simple to use. You just insert it like an NGT (preferably after intubating the patient). Then inflate the gastric balloon to the pressure indicated on the box (you can use the BP manometer to check the pressure). Pull back until the gastric balloon is snug at the GE junction, then inflate the esophageal balloon to the specified pressure. Then the best part....put a football helmet on the patient and secure the tube to it.

Pretty sure that patient died....

This always had me interested...where does the football helmet come from? Is it in the kit? Always a fun piece of trivia, I got pimped about it on GI during IM.

 

[opr8n]

ive had the opportunity to see tubes used twice in my residency, but both times it was a minessota tube instead (this tube has an esophageal suction port above the balloon so an ngt doesent have to usedud in conj with the SSB tube. Both times it was a childs C cirrhotic who came in with uncontrollable hematemesis in the middle of the night. TIPS was attempted in the next 24-48 hrs is usually not available immediatly. The other option i would try before transecting the esophagus is an emergent portocaval shunt and im pretty sure this is the board answer before esophageal transection

 

[Smurfette]

TIPS is preferable, obviously, but TIPS isn't always an option. Even if there's an IR guy in house, not all patients have anatomy amenable to the procedure, and a lot of these patients have portal vein thrombosis, which I believe makes TIPS much more difficult (but not impossible).

I think TIPS and the SB tube are syngergistic in theory, and one does not eliminate the utility of the other.

I realize my view is also a bit skewed by the fact that our transplant attendings didn't really use the SSB tubes....our IR guys were good, and if that failed, the transplant guys were willing to do shunts.

In my current environment, we'd have to send the patient elsewhere, and truthfully, I don't know if we have any SSB tubes here, either. I'll have to ask my partners about that....

 

[ESU_MD]

The football helmet is always the most theatrical part of the situation. Often has local team insignia and a larger than life story behind it

 

[dr.evil]

Used it once in med school and once in practice. I took the guy in my private practice and did the Segura procedure which was unbelievably awesome to do something I've only read about. Actually stopped the bleeding and then the guy coded as we rolled him out of the O.R. I've never even heard of an adult living after a SB or Minnesota tube.

It may be something we do just to have something to do instead of throwing our hands up and giving up.

 

[dpmd]

Got to use one once as a junior resident. Was called to the ER for a stat GIB consult. Chief was in the OR or somewhere else not immediately available. Get there and the guy is exsanguinating and hemodynamically unstable despite the attempt at massive transfusion. Had to hunt down the tube (felt cool because no one had thought to do it before I got there) and read the directions to put the thing in. Was not a candidate for anything else really (wasn't going to survive a trip down the hall even if we had TIPS capabilities, or a trip to the OR). He died anyway (didn't even get a chance to grab the helmet from the ICU and put it on).

I think it is one of those things you need to have in your toolbox just in case, but doesn't require actually doing it to be a well trained surgeon (like the ED thoracotomy). And I think you have to get the helmet separately if you want one. Otherwise you have to have someone sit there and hold it, or maybe use an IV pole or something.

We have done emergency portacaval shunts before, but no segura's.

 

[ESU_MD]

Used it once in med school and once in practice. I took the guy in my private practice and did the Segura procedure which was unbelievably awesome to do something I've only read about. Actually stopped the bleeding and then the guy coded as we rolled him out of the O.R. I've never even heard of an adult living after a SB or Minnesota tube.

It may be something we do just to have something to do instead of throwing our hands up and giving up.

Nice jib, Not too many can claim a survivor in an emergent segura.

Sewing in a shunt is much less technically demanding.. And quicker?

 

[hanky1982]

And I think you have to get the helmet separately if you want one. Otherwise you have to have someone sit there and hold it, or maybe use an IV pole or something.

Don't flame me here, but why is a helmet needed. I mean I understand the reasoning for holding it in place, but why couldn't you just tape it to their face much like securing an ET tube?

 

[tkim]

Don't flame me here, but why is a helmet needed. I mean I understand the reasoning for holding it in place, but why couldn't you just tape it to their face much like securing an ET tube?

If you secure to one place on the face it will cause tissue necrosis. Tying to a helmet allows you to move it around and avoid this.

I almost had the chance to drop a SB tube for a massive GIB. Called central supply, they brought up this old thing that both balloons wouldn't hold air during testing. Only one in the hospital. GI said nevermind.

 

[hanky1982]

If you secure to one place on the face it will cause tissue necrosis. Tying to a helmet allows you to move it around and avoid this.

Agreed that any substantial length of time could jeopardize the skin. However, aren't these only used as a temporary measure (couple hours to a day) so that a more definitive action (TIPS) could be performed?

 

[GreatSaphenous]

Don't flame me here, but why is a helmet needed. I mean I understand the reasoning for holding it in place, but why couldn't you just tape it to their face much like securing an ET tube?

I have placed a few, all as either bridges to TIPS or post TIPS failure. The thing that struck me the first time is how much bigger it is than a standard NG. I stopped for a beat wondering how on earth I was going to fit this thing into the guy's nostril. Then a remembered the 6th law of the House of God and pushed that baby home.

One key point that has always helped me is to remember that there are 2 balloons and two suction ports. The danger of these tubes is making the esophagus ischemic which is why they can't be used for long stretched of time. Once I have the tube in place, I inflate the gastric balloon and pull it back to the EG junction till it sticks in place and the tie it to the helmet (the reason for the helmet is to prevent the tube from retracting distally). Once it's in place I put both ports to suction. If the distal port shows fresh bleeding the tube is not seated properly. If the proximal port aspirated fresh blood then I inflate the esophageal balloon. Believe it or not, a well placed balloon at the EG junction will control most varices and keep you from having to inflate the other balloon.

One side note, at Shock Trauma we used a catcher's mask instead of a football helmet.

All for now, go back to your frosted mini wheats,
I remain the Great Saphenous!!!!

 

[dpmd]

One side note, at Shock Trauma we used a catcher's mask instead of a football helmet.

Seems like it might be easier to fit a variety of head sizes.

For the other person, you want to pull a little tension on the tube, so tape won'cut it. That is why I mentioned IV pole, or you could rig up a traction bar I guess.

 

[JackADeli]

It seemed like we spent an exhorbant amount of time discussing this.... Heck, this dang tube seemed to be one of those standard "fall backs" for the chief led conferences... when the chief "forgot" to prepare a topic to discuss. The topic of "what is the difference between a stanky and a minisota tube/device, how often to lower pressure, what do you secure with, pounds, etc......

In my anecdotal experience, it is a less used modality then the historic varieties of gastrectomies, vagotomies, etc.... that also seem to be emphasized (for ?historic knowledge). Honestly, you need to ask how relavent something is if the only way to assure someone can find the device is for the chiefs to "hand-down" the device to the next years chiefs. Our hospital had like only one device.... If the chief in "possession" was not around and left no clues to where he/she kept the "resident secured" device, it took at least as long for the hospital supply/etc... department to find their only one as it took for IR to get all their gear and staff ready!

But, when it came to the boards, the questions asked were not what is the difference between stanky and Mini or what port does what.... The questions were splean thrombose to varices, liver failure varices, perf gastric ulcer, perf Duo ulcer, refract ulcer disease.... what kind of gastrectomy and what kind of vagotomy, etc......

 

[core0]

Seems like it might be easier to fit a variety of head sizes.

For the other person, you want to pull a little tension on the tube, so tape won'cut it. That is why I mentioned IV pole, or you could rig up a traction bar I guess.

We actually have a tube holder for this. It looks like a Hannibal Lecter Mask with feet that go on the face and a slot for the Blakemore and ET tube. The Blakemore goes in first and there is a metal plate that prevents it from slipping. Then the ET tube compresses the blakemore into the holder. Works pretty well without all the drama of the football helmet.

 

[ESU_MD]

, you need to ask how relavent something is if the only way to assure someone can find the device is for the chiefs to "hand-down" the device to the next years chiefs. Our hospital had like only one device.... If the chief in "possession" was not around and left no clues to where he/she kept the "resident secured" device, it took at least as long for the hospital supply/etc... department to find their only one as it took for IR to get all their gear and etc......

resident secured devices would be a great thread.
My favorites in the call room-
Pigtail drains WITH adapters for pleurovacs stolen from ir

 

[JackADeli]

resident secured devices would be a great thread.
My favorites in the call room-
Pigtail drains WITH adapters for pleurovacs stolen from ir

Yep, that would be interesting thread of listed items. I was fortunate thaat my hospital had congenital heart babies... so, the pedi-heart patients stock room always had them cause you know the weren't getting 36Fr CTubes

I kept hold of "banding gun" for the tie-bands for tubing, i.e. pleuravac.
The OR kept the stryker gauge for measuring compart syndrome... in big ugly briefcase.

 

[Buzz Me]

I've used the SBT a couple times before (while on ICU rotations). We also have the Minnesota tube, which has four lumens (esophageal balloon, gastric balloon, and a suction port for both the esophagus and stomach).

 

[aashiq]

I've never seen one of these used myself. Given a situation of a cirrotic with bleeding varices, when if at all would you use one of these things?

Does anyone use them anymore? Are they a last resort? At what point do you call for an SB tube?

When Medical therapy, sclerotherapy and EVL fails, the patient continues to bleed, We use the SB tube to try and arrest the bleeding before TIPS/Surgery

 

[NJA61479]

Whenever I have seen them it's usually in the ER put in by some resident or attending freaking out because the patient comes in seemingly exsanguinating. I once got a consult from the ER and the reason was "needs crash gastrectomy."
I walked in and the patient as intubated and had the S-B tube in, football helmet and all, there was blood everywhere. It was a sight, but we certainly didn't do any sort of "crash gastrectomy."
laughable

the only other place where I have seen them is in some of the pre-liver transplant patients who have failed every other measure to control the portal HTN and are awaiting livers, most don't fare so well