三腔二囊管Chapter 1 Sengstaken-Blakemore tube
学习目标
1.了解三腔二囊管的作用
2.掌握三腔二囊管的使用方法及注意事项
3.了解三腔二囊管止血的优势
4.掌握以下词汇
liver cirrhosis 肝硬化
Sengstaken-Blakemore tube 三腔二囊管
esophageal and gastric varices 食管胃底静脉曲张
portal hypertension 门脉高压
estimate 估算
paraffin oil 石蜡油
pylorus 幽门
hemorrhage and necrosis 出血和坏死
Li Ming is a patient diagnosed with liver cirrhosis.He is conscious with poor spirit and vomits around 500 mL ofblood within a shortperiod oftime.He is using Sengstaken-Blakemore tube.
Xiao Ran is a gastroenterology nurse and Lin Yun is a newly graduated intern nurse.
Lin Yun: Miss Xiao Ran, how does the Sengstaken-Blakemore tube achieve hemostasis?
Xiao Ran: Sengstaken-Blakemore tube is used for patients with esophageal and gastric varices bleeding caused by portal hypertension.Hemostasis is achieved through the compression of Sengstaken-Blakemore tube.
Lin Yun: How to use a Sengstaken-Blakemore tube?
Xiao Ran: First, patient cooperation is required for the purpose of rapid hemostasis.Second, check the tube before intubation.Make sure there is no leak, and the sizes and shapes of the inflated balloons are equal.After exhausting the air in the two balloons, mark stomach balloon, esophagus balloon and stomach lumen.Third, measure the distance from the patient's nose to the subxiphoid process, and estimate the insertion length.Generally,the insertion length is 55 to 65 cm.Apply paraffin oil to the anterior segment of the tube, the double balloon portion and the patient's nasal cavity.Have the patient take 20 to 30 mL paraffin oil orally.Insert the tube gently from the nostril.When it reaches the pharynx, instruct the patient to swallow.When the estimated distance is reached, if the gastric contents can be extracted from the gastric tube cavity, it indicates that the tip has reached the pylorus.Inject 200 mL air into the gastric sac, seal the open end of the gastric balloon tube by a vascular clamp, and then pull outward the tube.If hemostasis cannot be achieved, inject 80 to 100 mL air into the esophageal sac, seal the open end of the esophageal balloon tube with a vascular clamp, and continuously pull the outer end of the tube with a weight of 0.5 kg through a pulley device.The pulling direction is at a 45 degrees to the patient's supine position, so as to achieve hemostasis through air bag compression.Make a clear mark on the exposed part of the tube entering the nostril for observation.Connect the gastric tube opening to the gastrointestinal decompression device to observe hemorrhage.
Generally, Sengstaken-Blakemore tube is put in place for 12 hours.If there is no sign of second bleeding, traction may be relaxed.If bleeding continues, traction can be sustained up to 24 hours.After 24 hours, traction must be relaxed to reduce the risk of erosive hemorrhage and necrosis caused by long-time stress of esophageal and gastric fundus mucosa.Before deflation, have the patient take 20 to 30 mL of paraffin oil orally.Slowly draw out the air in the esophageal balloon.Keep monitoring the possible bleeding before exhausting air in gastric balloon.If bleeding continues, maintain the traction and compression to stop bleeding.If bleeding stops, relax the traction and keep them in place for another 24 to 48 hours.If there is no sign of second bleeding, pull out the tube and observe for at least 24 hours.If no bleeding is observed afterwards, regular diet can be restarted.
Lin Yun: Well, why not choose other quick hemostasis methods?
Xiao Ran: The vision is poor due to large amount of blood in esophageal and stomach cavity during acute hemorrhage.The success rate of emergency endoscopic hemostasis is low.However,emergency surgery is hampered by poor liver function and limited effective circulating volume.Therefore, compression hemostasis using Sengstaken-Blakemore tube is the preferred emergency treatment for patients with cirrhosis and gastrointestinal bleeding.
Lin Yun: I see.Thank you, Xiao Ran.
Xiao Ran: You're welcome.
译文
李明是一位肝硬化患者，神志清、精神不振，短时间内呕吐出鲜血量约500 mL，正在使用三腔二囊管止血。
小冉是一名消化科护士，林允是一名刚毕业的实习护士。
林允：小冉老师，三腔二囊管是怎么达到止血目的？
小冉：三腔二囊管适用于门脉高压所致的食管胃底静脉曲张破裂出血的患者，通过三腔二囊管压迫达到止血的目的。
林允：怎么使用三腔二囊管呢？
小冉：首先，取得患者配合以达到迅速止血的目的。第二，插管前先检查双气囊及三腔管是否漏气，充气后气囊大小形状是否均匀，并抽净双气囊内气体，并对胃气囊、食管气囊和胃腔进行标记。第三，测量患者鼻部至剑突下距离，估算插入长度，一般在55～65 cm，将三腔管前段、双气囊部及患者鼻腔涂石蜡油，并让患者口服20～30 mL石蜡油，将三腔二囊管从鼻孔轻轻插入，到达咽部时嘱患者做吞咽动作，到达估算距离时，若能由胃管腔抽出胃内容物，表示头端已至幽门。向胃囊内注入200 mL空气，用血管钳封闭胃气囊管的开口端，再向外牵拉三腔二囊管；如不能有效止血，食管囊内注气80～100 mL，用血管钳封闭食管气囊管的开口端，用0.5 kg重物通过滑车装置持续牵拉三腔二囊管外端，牵拉方向与患者平卧体位成45°，以达到气囊压迫止血的目的。三腔二囊管露出鼻腔部分做一醒目标志，以便观察，将胃管开口连接胃肠道减压装置，观察出血情况。
三腔二囊管一般放置12小时后观察无再次出血情况，可放松牵引，若仍有出血迹象，可适当延长至24小时，24小时后必须放松牵引，防止食管胃底黏膜压迫时间过长引起糜烂性出血、坏死，放气前让患者口服石蜡油20～30 mL，缓慢抽出食管囊内气体，继续观察有无出血，再放胃囊气体。若仍有出血迹象，继续牵引压迫止血，若出血已停止，可放松牵引后继续放置24～48小时，若无继续出血迹象，可拔出三腔二囊管，拔管后至少观察24小时，仍无出血迹象，可适当恢复饮食。
林允：嗯，为什么不选择其他快速止血方式呢？
小冉：肝硬化患者因短时间量大出血，食管胃腔内充满血液使视野模糊不清，急诊内镜止血成功率不高。而急诊外科手术受肝功能分级分佳及有效循环血容量有限的影响，因此，三腔二囊管压迫止血是肝硬化消化道出血患者首选的紧急止血措施。
林允：明白了，谢谢小冉。
小冉：不客气！