Novel Use of Glidescope Indirect Laryngoscopy for Insertion of a Minnesota Tube for Variceal Bleeding

Adam B. Schlichting, MD, MPH; Jayna M. Gardner-Gray, MD; Gina Hurst, MD

Disclosures

J Emerg Med. 2015;49(1):40-42. 

In This Article

Abstract and Introduction

Abstract

Background: With improvements in endoscopic and interventional radiologic therapies, insertion of gastroesophageal balloon tamponade catheters, commonly known as Sengstaken-Blakemore or Minnesota tubes, is a rarely performed procedure for esophageal or gastric variceal bleeding. In small hospitals or freestanding emergency departments, endoscopic or interventional radiology (IR) therapies might not be available, so patients with exsanguinating variceal bleeding must be stabilized or temporized for transport to larger hospitals. Occasionally, tamponade devices are necessary as a rescue therapy for failed endoscopic or IR therapies or can be used as definitive therapy in select cases. In addition to being rarely performed, there are multiple technical complications associated with blind insertion of tamponade catheters.

Discussion: We describe a novel use of indirect laryngoscopy using a Glidescope for assisting in placement of a Minnesota tube in 4 patients with exsanguinating esophageal bleeding. Conclusions: Insertion of a Minnesota tube for bleeding esophageal or gastric varices is an uncommon, technically challenging procedure that can be lifesaving, and is something emergency physicians, intensivists, and gastroenterologists should be capable of performing. Addition of indirect laryngoscopy may help to improve rapid, safe, and successful placement of these devices.

Introduction

Since the initial description of using a balloon tamponade device for esophageal varices by Sengstaken and Blakemore in 1950, this seldom-performed procedure has proven to be lifesaving.[1] In the setting of acute exsanguination secondary to gastrointestinal hemorrhage, placement of a balloon tamponade device can be used as a temporizing measure to control bleeding until more definitive therapy can be arranged, or, in select cases, as a definitive therapy. At most hospitals, definitive therapy for variceal bleeding begins with endoscopic evaluation and therapy, including banding, sclerotherapy, or stenting of varices. Additional therapies may include interventional radiology for embolization or transjugular intrahepatic portosystemic shunting, or surgical interventions, such as esophagectomy or gastrectomy. These definitive therapies are often not immediately available 24 hours per day.

With the improved mortality afforded by rapid endoscopic therapy, balloon tamponade catheters are rarely utilized as an index therapy. A 2003 multicenter study of 725 patients with variceal bleeding reported index therapy of balloon tamponade was employed in only 5.5% of patients, while in a more recent case series of 1308 patients with gastric variceal bleeding, balloon tamponade was used as the index, nonpharmacologic therapy in only 1.9% of patients.[2,3] Despite the low utilization of tamponade therapy, a 2006 case series of 100 patients with variceal bleeding in which balloon tamponade was employed, 48% had a balloon catheter placed after failed attempts at endoscopic therapy. Overall, tamponade was effective in achieving hemostasis in 61% of patients.[4]

Given the infrequent nature at which this blind technique is performed, it is often associated with serious complications, particularly if the device is malpositioned in the airway or not advanced far enough into the stomach, such that the gastric balloon is inflated in the esophagus.[5–7] Many of these complications are associated with operator inexperience and difficult pharyngoesophageal anatomy. In an attempt to improve proper placement of a Minnesota tube, we employed the use of indirect visualization via Glidescope video laryngoscopy, and report our experience with 4 patients in whom we used this technique.

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