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Dysphagia Coeliac diagnosis pathway (Adults) Sengstaken/Minnesota Tube for Bleeding Varices Eradication of Helicobacter pylori Acute Severe Ulcerative Colitis Acute Upper GI Bleeding (AUGIB) Iron Deficiency Anaemia Dyspepsia Nutritional Support in Adults Refeeding Syndrome Parenteral Nutrition Crohn’s Disease Acute Pancreatitis Suspected Variceal Bleeding Lower Gastrointestinal Bleeding
Home | Articles | Gastrointestinal | Sengstaken/Minnesota Tube for Bleeding Varices

Sengstaken/Minnesota Tube for Bleeding Varices

Last updated 24th January 2022

Indication

  1. For uncontrolled upper GI bleeding due to varices
  2. Not controlled by endoscopy and banding / injection
  3. Temporary only to allow control and stabilisation prior to definitive treatment locally or transfer to tertiary centre (typically 24hrs)

Where

  1. Ideally in theatre (but could be in ED/CCU if circumstances dictate)
  2. Patient intubated to prevent loss of airway/ aspiration (have 2 suctions available)
  3. With Radiographer support with Fluoroscopy (or CXR as second choice)

Organise Equipment

  1. Minnesota tube 4 lumens ideally from fridge (Sengstaken only has 3 lumens- precursor of Minnesota)
  2. Laryngoscope/ videoscope/ Magills to aid insertion
  3. Manufacturer of Minnesota may change so taps / bungs /connectors may vary
  4. Take note of manufactures maximum volumes and pressures.
  5. Gather 2 clamps, manometer, Christmas tree connector (chest drain bottle will usually have one), 3 way taps, 3 bladder syringes.
  6. Bowl with water – test connectors and check for leaks of both balloons under water

Insertion

  1. Measure tube from mouth to ear to xiphisternum and add 10cm
  2. Lubricate liberally distally and insert to this distance ORALLY (usually 50-60cm)
  3. Check tube position with Fluoroscopy then inject 50ml AIR into gastric balloon
  4. If fluoroscopy not available then inject 50ml AIR into gastric balloon and check CXR
  5. If position OK then continue to inflate to 300ml (check pressure with manometer during inflation if possible – should not rise above 15mmHg). Gentle traction to take up slack as balloon comes up against gastro-oesophageal junction.
  6. Click link for video

Control of Bleeding

  1. Apply traction with 500ml bag fluid attached to ETT tube tie hung over drip stand attached to bed (± pulley). Position of stand can vary to suit best avoidance of pressure necrosis in mouth. Mark tube with marker pen at lips.
  2. Aspirate both gastric and oesophageal lumens every 10 mins and watch for blood at mouth.
  3. If bleeding not controlled increase to 1000ml fluid bag on traction
  4. If blood still appearing at mouth and on aspirating oesophageal lumen the oesophageal balloon will need inflated (a minority of patients)
  5. Inflate oesophageal balloon with manometer attached to 30mmHg. If not able to watch pressure continuously measure after every 25ml to manufacturer’s maximum or 30mmHg reached.
  6. Increase to maximum 40 mmHg if still bleeding
  7. Do final CXR /screen and transfer to CCU

Aftercare in CCU

  1. Minnesota tube should be on continuous traction for max 24 hrs – can briefly be released for adjustments to prevent pressure necrosis at mouth
  2. Hourly:  Gastric and oesophageal aspirates (can also both be attached to bags for free drainage).  Check for oral / lip pressure necrosis and adjust angle of traction.  Oesophageal balloon manometer pressure (if inflated) – record on ICCA
  3. 3 Hourly:  If bleeding controlled reduce oesophageal balloon pressure by 5 mmHg every 3 hours until 25mmHg reached.  Keep at 25mmHg for 12-24 hours (as agreed by clinical Team)
  4. 6 Hourly:  Deflate oesophageal balloon completely for 5 mins and reinflate to previous pressure that stopped the bleeding

Removal

  1. Deflate oesophageal balloon FIRST after 12-24 hours
  2. Then after 1-2 hours take off traction
  3. Then after 1-2 hours deflate gastric balloon (Traction MUST come off first or tube will come out) Removal will happen in theatre prior to repeat endoscopy

Traction Method

  1. Ideally pulley should be used to reduce friction
  2. Drip stand could be moved to suit but should ALWAYS be attached to BED
  3. Alternative method of traction may be required for transfer to another centre if endoscopy not available in DGRI (See Below)

Supportive Management in CCU Specific to Varices:

  1. 30 degrees Head up
  2. Terlipressin and broad spectrum antbiotics

Minnesota Tube

Golden Rules

  1. Always INFLATE the GASTRIC balloon first
  2. Always DEFLATE the OESOPHAGEAL balloon first
  3. If in doubt about position do CXR
  4. Never exceed 15mmHg with GASTRIC balloon
  5. Never exceed 45mmHg with OESOPHAGEAL balloon
  6. Never irrigate OESOPHAGEAL port
  7. Deflate OESOPHAGEAL balloon every 6 hours
  8. Last thing to happen is release of traction on GASTRIC balloon

Set up of Alternative Method of Traction for Patients Being Transferred

  1. Step 1: Secure a thin rolled up 10×10 cm gauze to the longitudinal surface of each tongue depressor. A sleek tape may be used to secure the gauze
  2. Step 2: Wrap the tape around the cranial end of the SB tube using two twists, do not cut it from the roll. The SB tube should be cleaned with a swab prior to ensure it is dry before
  3. Step 3: Wrap the sleek tape around both sides of the tongue depressor construct and then finish by wrapping a layer circumferentially around the SB tube
  4. Step 4: Apply a foam wrap to the surface which is in contact with the mouth and lips. (Ideally use the same foam that is used in casts as this has been designed to withstand considerable friction)
  5. Step 5: Take note of the marking and educate staff on the construct. This may be repositioned by the nursing staff by twisting/altering the direction.