health services code e.15 nursing procedure title

Approved: September 3, 2021 of 14

HEALTH SERVICES

CODE: E.15

NURSING PROCEDURE

TITLE - ESOPHAGOGASTRIC TAMPONADE

A. Preparation of Equipment and Patient

I. Obtaining Stomach Balloon Baseline Pressures

II. Testing Balloon for Leaks

B. Assisting With Insertion

I. Inflation of Stomach Balloon

II. Inflation of Esophageal Balloon

III. Connecting to Traction

C. Maintenance

I. Assessing Esophageal Hourly Cuff

Pressure

II. General Tube and Patient Management

D. Assisting With Non Emergent Removal and Balloon Deflation

E. Emergency Removal

CATEGORY: RN – Special Nursing Procedure

EDUCATION

Learning Module

Online E-quiz

PURPOSE

To assist the physician with nasal or oral insertion of a Four Lumen Esophagogastric Tamponade Tube (Minnesota Tube). This tube is placed, when other hemostasis techniques have not worked, to control acute haemorrhage in esophageal and/or gastric variceal rupture by providing temporary compression to the ruptured vessels.

To safely maintain Minnesota tube while it is in situ.

To assist the physician with removal of Minnesota tube.

NURSING ALERT:

Insertion, removal and/or adjusting of Minnesota tube® are the responsibility of a physician.

Inflation and deflation of stomach and/or esophageal balloon(s) are the responsibility of a physician.

Critical care bed required pre or post insertion as patient requires continuous vital sign monitoring during insertion and while Minnesota® Tube is in place.

HEALTH SERVICES

CODE: E.15


NURSING ALERT (Continued)

If planning on utilizing oral route for Minnesota insertion, ensure patient is intubated prior to attempting insertion.

If utilizing nasal route and patient is not intubated, ensure intubation supplies are kept at the bedside at all times. If any signs of airway obstruction are assessed the Minnesota tube must be removed as in section E - Emergency Removal.

Sedation should be considered for procedure.

Head of bed should be at least 30-45 degrees at all times to reduce the risk of aspiration.

Recommend two 18 gauge intravenous lines for fluid resuscitation and blood replacement.

Ensure scissors remain at bedside at all times, for emergency tube removal.

Esophageal and stomach balloons must be deflated prior to initiation of CPR. Physician will provide further direction regarding possible tube removal.

ALLERGY ALERT: This product contains natural rubber; allergic reaction may occur in those with latex allergies.

EQUIPMENT Esophagogastric Tamponade Kit

NOTE: Esophagogastric Tamponade Kits are housed in the following locations:

o Pasqua – ICU and GI Unit o RGH – MICU and Endoscopy Unit

1. PPE - Facemask with visor/face shield, clean gloves, impervious gown 2. Minnesota® Four Lumen Esophagogastric Tamponade Tube - special order 3. Plastic catheter tip plug (4) - with Minnesota® Tube 4. Foam nose guard - with Minnesota® Tube 5. Suction tubing 10 ft (2) - #319771 6. Suction regulator x2 7. 60 mL catheter tip syringe (2) - #311118 8. Equipment to measure balloon pressures:

8.1 Pressure manometer “cufflator” - special order 8.2 Filter for manometer - obtain from RT Department 8.3 Pressure tubing extension for manometer - obtain from RT Department 8.4 3 way stopcock (2) - #310905 8.5 Catheter adapter - #311653 8.6 Lopez Valve - Special order 500 mL bag of IV solution - #310004

9. Water soluble lubricant (large tube) - #313128 10. Kelley clamps with rubber-tips added (2) - unit stock 11. Twill tape - #310627 12. Waterproof tape - #319309 13. Black marker - unit stock 14. Scissors - unit stock 15. Irrigation Tray - #310820 16. Normal Saline 500 mL container for irrigation #310342 17. Local anaesthetic spray

HEALTH SERVICES

CODE: E.15


18. Incontinent pad 19. Single IV pole

A. Preparation of Equipment and Patient

PROCEDURE:

1. Explain procedure to patient and family. Physician to obtain consent. 2. Wash hands and apply personal protective equipment.

I. Obtaining Stomach Balloon Baseline Pressures

NURSING ALERT:

The physician performing the procedure may elect to omit this step in the case of a medical emergency.

1. Put together cufflator set up as follows: (See Figure 1.1)

a. Connect cufflator to the female end of the 3 way stopcock. b. Place catheter adapter on the male end of stopcock. c. Leave the stopcock lever off to the middle port.

Figure 1.1

HEALTH SERVICES

CODE: E.15


2. Attach cufflator set up to the upper arm of the stomach balloon pressure monitoring port. (See Figure 1.2)

Figure 1.2

3. Insert the tapered end of the Lopez valve into the stomach balloon inflation port. (See Figure 1.2)

4. Insert the 60 mL catheter tip syringe into the red universal adaptor port of the Lopez valve. 5. Leave the plug of the medication port open. 6. Turn off valve to stomach balloon inflation port and draw up 50 mL of air in syringe. 7. Turn off valve to side medication port and push 50 mL of air into balloon inflation port.

8. Repeat step 7 with another 50 mL of air. This will total 100 mL of air. Document

reading on Cufflator. 9. Repeat steps 6-8 with each 100 mL air increment until 500 mL of air has been

inflated into the stomach balloon. The pressures documented at each stage prior to insertion are known as the baseline stomach balloon pressure readings.

HEALTH SERVICES

CODE: E.15


NOTE: As balloon pressure increases, the pressure reading on the Cufflator will

decrease.

II. Testing Balloons for Leaks

1. Leave stomach balloon inflated. 2. Inflate the esophageal balloon with 50 mL of air. 3. Clamp the esophageal lumen with rubber tipped forceps to maintain inflated esophageal

balloon. 4. Submerge inflated balloons in water to test for leaks.

5. Release clamp on esophageal balloon and remove Lopez valve from stomach balloon

inflation port and remove all air. 6. Reinsert all plugs. 7. Assist physician in lubricating the tube, including both balloons with water soluble

lubricant.

NOTE: Physician may request the tube to be chilled in a basin of ice to assist with insertion.

B. Assisting with Insertion and Tube Placement Confirmation 1. Pre-medicate as ordered by physician. 2. Position patient in high fowlers or semi fowlers if conscious. If patient unconscious, the patient

may need to be positioned in left lateral position with head down. 3. Remove NG tube if present prior to inserting the Minnesota® tube. 4. Physician will insert tube - either nasally or orally to the 50 cm mark. The 50 cm mark

indicates tip of tube is in the stomach. 5. Lavage the stomach via gastric aspiration port with NS until clear of large blood clots.

NOTE: Gently aspirate fluid instilled and assess the amount and quality of fluid

withdrawn. If unable to withdraw the instilled amount notify the physician.

HEALTH SERVICES

CODE: E.15


6. Connect stomach aspiration port (labelled on Minnesota® Tube) to intermittent suction at 60-120 mmHg or as directed by physician (2). (see figure 1.3)

7. Connect esophageal aspiration port (labelled on Minnesota® Tube) to intermittent

suction at 120-200 mmHg or as directed by physician (2). (see figure 1.3) 8. Assist physician to inflate gastric balloon with 50 mL of air and obtain portable x-ray to confirm

placement.

NOTE: Auscultation is not a reliable assessment of placement.

Figure 1.3

I. Inflation of Stomach Balloon

NURSING ALERT:

In the case of a medical emergency the physician may inflate the gastric balloon with 100 mL of air and then verify the position with a portable x-ray. Once verified the balloon may be completely inflated.

NURSING ALERT:

Following tube placement, suction is applied immediately to the stomach and esophageal aspiration lumens to avoid regurgitation of stomach contents, blood, and saliva during inflation of stomach balloon.

Also known as Upper Arm of Stomach Balloon Port

Also known as Upper Arm of Esophageal Balloon Port

HEALTH SERVICES

CODE: E.15


NOTE: Once correct tube placement is confirmed, stomach balloon may be fully inflated by physician.

NURSING ALERT:

Stomach balloon must be inflated prior to esophageal balloon inflation.

Use only air to inflate balloon.

Maximum inflation is not to exceed 500 mL of air.

Stomach balloon pressure reading must be within 20 cm H2O from baseline stomach balloon pressure readings. (Reading > 20 cm H2O indicates balloon is located within esophagus which could result in esophageal rupture)

PROCEDURE

1. Connect the cufflator set up to the Minnesota® tube by connecting the catheter

adapter to the upper arm of the stomach balloon port. (See Figure 1.2)

2. Insert the tapered end of the Lopez valve into the stomach balloon inflation port. (See Figure 1.2)

3. Insert the 60 mL catheter tip syringe into the red universal adaptor port of the Lopez valve. 4. Leave the plug of the medication port open.

5. Turn off valve to stomach balloon inflation port and draw up 50 mL of air in syringe. 6. Turn off valve to side medication port and assist physician to push 50 mL of air into

balloon inflation port. 7. Assist physician to slowly inflate stomach balloon with increments of 50 mL of air until a

total of 450-500 mL of air is reached.

8. Inform physician of stomach pressure reading with each 100 mL increment of air inflation. NOTE: The stomach balloon pressure during inflation should be no more than

20 cm H20 higher than the baseline pressure that was measured prior to insertion of tube.

9. Clamp stomach balloon inflation port with rubber tipped clamps, remove Lopez valve with

60 mL catheter tipped syringe and cufflator set up. Reinsert both plugs.

10. Assist physician as they gently pull back tube to assess resistance.

11. Reconfirm tube placement, as ordered by physician (x-ray or by endoscopic procedure).

12. Mark placement of tube with a black marker as it emerges from nose or mouth.

HEALTH SERVICES

CODE: E.15


13. Attach the foam nose guard to the tube as it emerges from the nostril if tube was inserted nasally. Secure tube to nose/cheek using waterproof tape while maintaining resistance. (Foam guard provided with Minnesota® tube.)

NOTE: After inflation of the stomach balloon, the stomach balloon does not

require continuous pressure monitoring.

NURSING ALERT:

If bleeding is not controlled with stomach tamponade, inflation of the esophageal balloon may be considered by the physician.

II. Inflation of Esophageal Balloon

PROCEDURE 1. Connect the cufflator set up to the Minnesota® tube by connecting the catheter adapter to

the upper arm of the esophageal balloon port. 2. Insert the tapered end of the Lopez valve into the esophageal balloon inflation port.

(See Figure 1.2) 3. Insert the 60 mL catheter tip syringe into the red universal adaptor port of the Lopez

valve. 4. Leave the plug of the medication port open.

5. Turn off valve to esophageal balloon inflation port and draw up 50 mL of air in syringe for

the physician to instill into esophageal balloon inflation port (See figure 1.3).

6. Turn off valve to side medication port and assist physician to push 50 mL of air into balloon inflation port.

7. Assist physician to slowly inflate the esophageal balloon with 50 mL increments of air to the

lowest pressure that will stop bleeding. (Generally haemostasis is achieved at 40-61 cm H2O).

NURSING ALERT:

Pressure not to exceed 61 cm H20.

8. Clamp esophageal balloon inflation port, remove 60 mL catheter tipped syringe and

cufflator set up. Reinsert both plugs.

HEALTH SERVICES

CODE: E.15


9. Ensure the esophageal aspiration port is maintained between 120-200 mmHg intermittent suction or as directed by physician.

NURSING ALERT:

Hourly esophageal pressure monitoring is mandatory when esophageal balloon is inflated to ensure pressure is maintained at level that achieved haemostasis.

It is recommended to decrease the esophageal balloon pressure by 7 cm H2O every 3 hours as prescribed until pressure is 34 cm H2O, without evidence of bleeding. This is the responsibility of the physician.

III. Connecting to Traction

PROCEDURE

NOTE: If bleeding has not stopped, physician may consider applying gentle traction to the Minnesota tube.

1. Ensure head of bed is 30-45 degrees unless contraindicated. 2. Remove waterproof tape holding tube in place. 3. Tie one end of twill tape (approx. 2 meter in length) around Minnesota tube approx. 2

inches from insertion site.

Figure 1.4

4. Tie the other end to a 500 mL (500 gram/1 pound weight) or 1,000 mL (1kg / 2 pound weight) bag of IV fluid as directed by the physician.

Figure 1.5

HEALTH SERVICES

CODE: E.15


5. Place IV pole at the foot of patient’s bed. 6. Allow the bag to hang freely over the IV pole. Ensure twill tape is positioned to reduce

risk of nasal necrosis and ensure patient comfort.

NOTE: When you reposition the patient, make sure that the IV bag is hanging freely and observe the patient for discomfort. Use caution not to pull too hard on the traction.

Figure 1.7

NURSING ALERT:

Ensure scissors are always available at the head of the bed in the event the balloons need to be deflated immediately.

C. Maintenance of Tube I. Assessing Esophageal Hourly Cuff Pressures

PROCEDURE

NOTE: Use minimal pressure capable of maintaining tamponade to a maximum of 61 cm H20.

1. Remove plug from upper arm of esophageal balloon port and insert cufflator setup.

2. Remove rubber tipped clamps.

3. Assess and document esophageal balloon pressure reading at end of expiration.

4. Clamp lumen with rubber tipped forceps, remove cufflator set up and insert plug.

HEALTH SERVICES

CODE: E.15


II. General Tube and Patient Management

NURSING ALERT:

Maximum recommended tamponade therapy: o Esophageal balloon - 24-48 hours o Stomach balloon - 48-72 hours

Since continual pressure of 40-61 cm H2O on esophagus for long time intervals may induce necrosis, periodic deflation of esophageal balloon is recommended for 30 minutes every 8 hours. This is the responsibility of the physician.

If bleeding reoccurs, contact physician immediately.

PROCEDURE

1. Continuous monitoring of airway patency and respiratory status.

2. Continuous monitoring for signs of rebleeding. 3. Monitor esophageal balloon pressure every hour or as directed by the physician.

NOTE: If esophageal balloon pressure falls outside ordered parameters, notify physician immediately.

4. Monitor stomach and esophageal output every hour. 5. Irrigate stomach/esophageal aspiration ports as follows to maintain lumen patency,

unless physician prescribes otherwise.

5.1. Irrigate stomach port with 50 mL normal saline solution every 30 mins or as needed.

5.2. Irrigate esophageal port with 5-10 mL normal saline every 2-4 hours or as needed. 6. Ensure head of bed is maintained at least 30-45 degrees at all times to reduce risk of

aspiration. 7. Inspect traction set up hourly if traction is applied.

8. Maintain scissors at the bedside at all times for emergency tube removal.

9. Inspect tube placement and insertion site every hour.

NOTE: Notify physician if tube has migrated out 3 cm or greater.

10. Provide care to nares every 2 hours when tube is inserted nasally.

11. Provide oral care every 2 hours and as needed.

HEALTH SERVICES

CODE: E.15


D. Assisting with Removal

NURSING ALERT:

Removal of the tube is the responsibility of the physician.

Removal of the tube is performed in stages.

Never deflate stomach balloon while esophageal balloon is still inflated. A deflated stomach balloon may allow an inflated esophageal balloon to migrate into the airway.

1. Assist physician with deflation of esophageal balloon as follows:

1.1 Unclamp esophageal balloon port. 1.2 Aspirate all air from esophageal balloon port using syringe. 1.3 Observe for signs of re-bleeding for 12-24 hours, or as directed by physician. 1.4 If re-bleeding occurs, notify physician immediately and prepare to assist physician

with re-inflation of the esophageal balloon. 2. Assist physician with deflation of the stomach balloon as follows:

2.1 Remove traction from Minnesota® tube. 2.2 Secure Minnesota® tube to patients’ nose/cheek using tape. 2.3 Unclamp stomach balloon of Minnesota® tube. 2.4 Aspirate all air from stomach balloon port using syringe. 2.5 Observe for signs of re-bleeding for 12-24 hours, or as directed by physician. 2.6 If re-bleeding occurs, notify physician immediately and prepare to assist with re-inflation of

stomach balloon.

3. Assist physician with removal of Minnesota® tube 3.1 Remove intermittent suction from Minnesota® tube. 3.2 Actively aspirate any remaining air in esophageal and stomach balloons using syringe.

Clamp balloon ports prior to removing syringe. 3.3 If unable to aspirate from balloon ports, cut Minnesota® tube ensuring to sever both

balloon ports. 3.4 Remove Minnesota® tube.

E. Emergency Removal

NURSING ALERT:

Emergency deflation of both balloons may be needed in case of life threatening complications such as airway occlusion due to balloon migration or esophageal rupture (sudden loss pressure may indicate rupture of the balloon or esophagus).

Notify physician immediately if any signs of airway obstruction are assessed, verbal order required for emergency removal of Minnesota® tube.

HEALTH SERVICES

CODE: E.15


PROCEDURE

1. Cut twill tape with scissors to remove the applied traction. 2. Hold Minnesota® tube close to patient’s nose or mouth. 3. Cut Minnesota® tube between hand and bifurcation of the tube. Ensure to sever both balloon

ports to allow for complete deflation. 4. Remove Minnesota® tube.

HEALTH SERVICES

CODE: E.15


REFERENCES

Bard. (2012). Bard® Minnesota four lumen Esophagogastric tamponade tube for the control of bleeding from esophageal varices: User manual. West Sussex, UK: Bard Limited.

EM:Rap Productions. (2016, April, 15). Placement of a Minnesota tube for bleeding varices

(video file). Retrieved from https://youtu.be/4FHIiA_doWU Saskatoon Health Region. (2017). Esophageal tamponade tube (Minnesota tube) – Assisting

with insertion, care of a patient, assisting with removal: Policies & procedures. Saskatoon, SK: Saskatchewan Health Authority.

Society of Gastroenterology Nurses and Associates, Inc. (2013). Gastroenterology nursing: A

core curriculum (5th ed.). USA: Author. Wiegand, D., 2017. AACN procedure manual for high-acuity, progressive, and critical care. 7th

ed. St. Louis: Elsevier, pp.958-969. Winnipeg Health Authority. (2017). Esophagogastric Tamponade Tube (EGTT): Assisting with

insertion, care and removal. Practice Guideline. Winnipeg, MB: Author. Written by: Stephen Selinger, CNE, ICU, RQHR Jennifer Taylor, Unit Coordinator, GI Unit, RQHR Date: July 6, 2011 Revised by: Teresa Vall, CNE – ICU, Pasqua Hospital Jennifer Taylor, Unit Coordinator, GI Unit, Pasqua Hospital Date: July 23, 2014 Revised by: Kendra Cole, CNE – ICU, Pasqua Hospital Shayleen Middlekoop, CNE – SICU, Regina General Hospital Elana Straub, CNE – MICU, Regina General Hospital Date: July 13, 2021

Approved by RQHR Procedure Committee: Date:

Regina Qu’Appelle Health Region

Health Services Nursing Procedure

Committee

3Sep21

Keyword(s): Minnesota Tube, esophagogastric tamponade, variceal bleed, GI bleed

https://youtu.be/4FHIiA_doWU

health services code e.15 nursing procedure title

Documents