Esophageal Tube Insertion and Removal
Used to control hemorrhage from esophageal or gastric varices, an esophageal tube is inserted nasally or orally and advanced into the esophagus and stomach. Ordinarily, a doctor inserts and removes the tube. However, in an emergency situation, a nurse may remove it.
Once the tube is in place, a gastric balloon secured at the end of the tube can be inflated and drawn tightly against the cardia of the stomach. The inflated balloon secures the tube and exerts pressure on the cardia. The pressure, in turn, controls the bleeding varices.
Most tubes also contain an esophageal balloon to control esophageal bleeding. The esophageal balloon should be used to control bleeding for no longer than 36 hours; the gastric balloon, for no longer than 72 hours. Pressure necrosis may develop and cause further hemorrhage or perforation.
Other procedures to control bleeding include irrigation with tepid or iced saline solution, drug therapy with a vasopressor, variceal banding, and transjugular intrahepatic portosystemic shunts. Used with the esophageal tube, these procedures provide effective, temporary control of acute variceal hemorrhage.
Equipment
For Insertion
Esophageal tube ▪ nasogastric (NG) tube (if using a Sengstaken-Blakemore tube) ▪ two suction sources ▪ irrigation set ▪ 2 L of normal saline solution ▪ two 60-mL syringes ▪ water-soluble lubricant ▪ ½″ or 1″ adhesive tape ▪ stethoscope ▪ foam nose guard ▪ four rubber-shod clamps (two clamps and two plastic plugs for a Minnesota tube) ▪ traction equipment (football helmet or a basic frame with traction rope, pulleys, and a 1-lb [0.5-kg] weight) ▪ manometer ▪ Y-connector tube (for Sengstaken-Blakemore or Linton tube) ▪ basin of water ▪ cup of water with straw ▪ scissors
▪ gloves ▪ gown ▪ waterproof marking pen ▪ goggles ▪ sphygmomanometer ▪ anesthetic spray.
▪ gloves ▪ gown ▪ waterproof marking pen ▪ goggles ▪ sphygmomanometer ▪ anesthetic spray.
For Removal
60-mL syringe ▪ gloves ▪ gown ▪ goggles ▪ sphygmomanometer.
Preparation of Equipment
For Insertion
Keep the football helmet at the bedside or attach traction equipment to the bed so that either is readily available after tube insertion. Place the suction machines nearby and plug them in. Open the irrigation set and fill the container with normal saline solution. Place all equipment within reach.
Test the balloons on the esophageal tube for air leaks by inflating them and submerging them in the basin of water. If no bubbles appear in the water, the balloons are intact. Remove them from the water and deflate them. Clamp the tube lumens so that the balloons stay deflated during insertion.
To prepare the Minnesota tube, connect the manometer to the gastric pressure monitoring port. Note the pressure when the balloon fills with 100, 200, 300, 400, and 500 mL of air.
Check the aspiration lumens for patency, and make sure they’re labeled according to their purpose. If they aren’t identified, label them carefully with the waterproof marking pen.
Implementation
Verify the doctor’s order.
Confirm the patient’s identity using at least two patient identifiers according to your facility’s policy.1
Explain the procedure and its purpose to the patient, and provide privacy. Answer all questions to decrease anxiety and increase cooperation.
Perform hand hygiene, and put on gloves, gown, and goggles to protect yourself from splashing blood.2,3,4
Assist the patient into semi-Fowler’s position, and turn him slightly toward his left side. This position promotes stomach emptying and helps prevent aspiration.
For Insertion
Explain that the doctor will inspect the patient’s nostrils for patency.
To determine the length of tubing needed, hold the balloon at the patient’s xiphoid process and then extend the tube to the patient’s ear and forward to his nose. Using a waterproof pen, mark this point on the tubing.
Inform the patient that the doctor will spray his throat (posterior pharynx) and nostril with an anesthetic to minimize discomfort and gagging during intubation.
After lubricating the tip of the tube with water-soluble lubricant to reduce friction and facilitate insertion, the doctor will pass the tube through the more patent nostril. As he does this, he’ll direct the patient to tilt his chin toward his chest and to swallow when he senses the tip of the tube in the back of his throat. Swallowing helps to advance the tube into the esophagus and prevents intubation of the trachea. (If the doctor introduces the tube orally, he’ll direct the patient to swallow immediately.) As the patient swallows, the doctor quickly advances the tube at least ½″(1.3 cm) beyond the previously marked point on the tube.
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