Morning Report: 1/3/2014

Here’s Dr. Nordstrom presenting today’s Morning Report!

Case:

47 y.o male with history of EtOH abuse, presents with vomiting.

VS: 97/52, HR 123 RR 24, Os Sat 98%.

On exam the patient has a mildly distended abdomen with multiple dilated veins and spider angiomas.

During evalutation the patient vomits a large amount of dark red blood.

Initial plan:

– Large bore IVs, O2, Monitor, Labs

While doing this the patient vomits again- frank blood.

VS: BP 84/45, HR 130

What now?:

– IVF, Blood/FFP, Octreotide gtt

– Endoscopy

While GI is on their way the patient codes, is in PEA arrest.

How about now?:

– Resus, ABC’s

-*Blakemore Tube*

Indications for the use of a Blakemore Tube

– Acute life threatening bleed from esophageal or gastric varices that are not responsive to medical therapy. (i.e. endoscopic hemostasis or vasoconstrictors)

– Acute life threatening bleed from varices when endoscopy is not immediately available.

Contraindications:

– variceal bleeding stops or slows

– recent surgery at the GE junction

– known esophageal stricture

Preparation:

– Intubation and sedation for airway control (very high risk of aspiration)

Materials:

– Suction

– Manual manometer (optional)

– Traction set up (normal saline bags, IV pole, string)

– Clamps

– Blakemore tube

Procedure:

– inflate balloons (gastic and esophageal) to check for air leaks.

– optional step: inflate gastric balloon with attached manometer and 3 way valve checking pressure with each 100ml. To total 500 ml. make note of barometric pressure with each 100ml put into the gastric balloon

– optional step: consider adding esophageal suction if not present. This can be done by tying an NG tube using silk suture. Leave it to terminate 3cm proximal to the beginning of the esophageal balloon.

– Fully deflate the balloons and clamp or seal the ports.

– Apply lubricant to the tube

– Pass the tube to at least the 50 cm mark. Oral route is preferred.

– Inflate the gastric balloon to 450-500ml. If using manometer ensure that pressure is not >15 mmHg greater than as previously checked with each 100ml added to the balloon. Clamp the gastric balloon port.

– Apply gentle traction to the tube. Applying pressure to the diaphragm and GE junction with the inflated balloon.

– Attach the pulley device to apply 1-2 pounds of traction. (about 500ml to 1L NS)

– Attach gastric and esophageal suction ports to suction and check for persistent bleeding.

– If bleeding persists, THEN you can inflate the esophageal balloon to the minimum pressure required to tamponade bleeding. (about 30-40ml)

– If bleeding still persists, you can add an additional weight to the traction device (Max 2.5lbs).

– Confirm placement with portable chest Xray.

– Once bleeding is controlled reduce pressure in the esophageal balloon by 5ml every 3 hours until 25ml are in the esophageal balloon. Maintain this for 12-24 hours, then deflate esophageal balloon for 5 min every several hours to prevent necrosis.

– Do not leave in place for more than 48 hours.

– Arrange TIPS procedure or sclerotherapy.

Pearls:

– Do not inflate the esophageal balloon first.

– Keep scissors near by and cut balloon ports if airway compromise.

– High risk of pressure necrosis. (Less than 24hours of esophageal balloon)

Complications:

– Aspiration – low threshold for intubation

– Asphyxiation – secondary to proximal migration of the tube

– Esophageal rupture – secondary to gastric balloon inflated in the esophagus or prolonged use of esophageal balloon.

References:

http://emedicine.medscape.com/article/81020-overview
Conn HO, Simpson JA. Excessive mortality associated with balloon tamponade of bleeding varices. A critical reappraisal.JAMA. Nov 13 1967;202(7):587-91.