1 7/15/2013. Introduction Esophageal and gastric bleeds can be massive. Minnesota Tube Nursing Care Bundle There are many techniques to stabilize An intervention to enhance the patient. nursing comfort and patient safety. Medications Endoscopy IR. Minnesota Tube Pathophysiology Portal vein feeds the liver Used for life threatening bleeds not controlled by other Hepatic vein carries blood from the liver to the methods. inferior vena cava Outside hospitals stabilize ETOH damages the liver causing cirrhosis patients with these tubes The list of equipment Collateral circulation is formed to compensate necessary for the placement of for the liver disease the tube is long and time consuming to gather. Portal HTN causes varices Varices develop in esophagus, stomach, rectum and umbilical regions Hemorrhage of varices The big bleed Treatments When all else fails Pharmaceuticals Tamponade Octreotide Minnesota tube Vasopressin Sengstaken Blakemore tube Nexium Endoscopy Banding Injections Surgery IR.
2 TIPS procedure 1. 7/15/2013. Indications and Contraindications Minnesota vs Sengstaken Blakemore Indications Contra Indications Minnesota Esophageal varices Absolutes 4 lumens Gastric varices Bleeding has stopped Radiograph-opaque rubber Recent surgery of EG 41 inches long junction 18F. Known esophageal stricture Fairly stiff and strong Relatives material Inadequately prepared staff Improper equipment CHF. Hiatal hernia Unidentified source of bleeding Minnesota vs Sengstaken Blakemore Side by side comparison Sengstaken Blakemore Minnesota Sengstaken Blakemore Does not have esophageal suction port Must insert OGT to suction esophagus Not as stiff as MN tube More delicate for clamps Supplies needed Minnesota tube GRAB BAG.
3 Minnesota Tube Intubation tray (if not already intubated). All supplies needed 2 wall suction setups Laminated card with diagrams Yankauer Manometer Laminated copy of P&P. 60cc cath tip syringe Laminated card with supplies 4 way stopcock 2-4 hemostats padded needed to replenish bag Topical anesthetic Water soluble lubricant Football helmet or over bed traction Tape Permanent Marker Scissors Catheter Adapter for manometer set up Sedation Ice bath (basin or graduated cylinder full of ice and water). 2. 7/15/2013. Tube Placement Prior to insertion performed by GI MD or skilled Internist assisted by RN. Pass tube through nare or mouth to 50cm mark Gather and prepare all supplies Inflated gastric balloon with 50-100ml air Check X-ray to confirm placement Record pressure of inflated balloons Apply suction to gastric and esophageal ports Ensure suction is adequate Inflate to 300-500ml air once placement is confirmed Tape scissors to head of bed Secure tube to football helmet or traction Consider a second X-ray if placement is Prepare football helmet or over bed traction uncertain RN Role Assist with preparation and insertion Record all pressures and position Monitor patient Assess skin.
4 Insertion site and around football helmet Monitor suction Correctly label ports Irrigate often to maintain patency Watch for signs of migration Monitor for continued bleeding Continued bleeding despite gastric RN role balloon inflation what next? Consider filling esophageal balloon Monitor for bleeding Balloon can increase risk of esophageal rupture Monitor esophageal balloon pressure every 2 hrs Oral care Inflate to lowest pressure needed to stop bleeding to Keep HOB>30 degrees max of 45mmHg Monitor mucous membranes for necrosis Confirm placement again with X-ray Titrate down pressure once hemostasis occurs Maintain 25mmHg for 12-24hrs 3. 7/15/2013. Documentation Complications Aspiration PNA. Pressures of gastric balloon from 100ml air to Airway obstruction 500ml air in 100ml increments prior to insertion Esophageal ulceration or rupture Date and time of tube insertion Mucosal membrane breakdown Amount of air used to fill gastric balloon Inflation of balloon outside of stomach Pressure of esophageal balloon and any titration of pressure Placement marking of tube In case of emergency When to discontinue tube?
5 Gastric balloon deflated 24-48hrs after Tube migration is considered hemostasis an emergency It is imperative that tube is Monitor for signs of rebleed then discontinue removed immediately if it tube has migrated Grasp tube at mouth and Ensure balloons are completely deflated prior to cut below ports this will discontinuation deflate all balloons MD to consider endoscopy after tube removal immediately so tube can be removed This is the reason we keep scissors at the HOB. What are your resources? Bibliography Christensen, T. (2004). The treatment of oesophageal varices using a Policy and Procedure Sengstaken-Blakemore tube: considerations for nursing practice. British GI MD Association of Critical Care Nurses, Nursing in Critical Care, 9(2), 58-63.
6 Grab Bag Christensen, T. C. (2007). The implementation of a guideline of care for Education Material in the Charge Nurse Book patients with a Sengstaken-Blakemore tube in situ in a general intensive care unit using transitional change theory. Intensive and Critical Care Nursing, 23, 234-242. Criner, G., D'Alonzo, G. (2002). Critical Care Study Guide: Text and Review. New York: Springer-Verlag. Greenwald, B. (2004). The Minnesota Tube: Is Use and Care in Bleeding Esophageal and Gastric Varices. Gastroenterology Nursing, 5, 212 - 217. 4. 7/15/2013. Bibliography of Images and videos ( ). Retrieved April 28, 2013, from UMDNJ: ( ). Retrieved April 28, 2013, from Intensive-Care: Gastric Varices. ( ). Retrieved April 28, 2013, from El Salvadore Atlas of Gastrointestinal Video Endoscopy: Minnesota Four-Lumen Tube.
7 ( ). Retrieved April 28, 2013, from Cardinal Health: Portal Hypertension. ( ). Retrieved April 28, 2013, from Narayana Institute of Vascular Science;. Advanced Vascular and Endovascular Surgery, Bangalore: :portal- hypertension&catid=39:conditions-we-trea t&Itemid=151. Portal Hypertension. ( ). Retrieved April 28, 2013, from Narayana Institute of Vascular Science;. Advanced Vascular and Endovascular Surgery, Bangalore: :portal- hypertension&catid=39:conditions-we-trea t&Itemid=151. 5.