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■ All balloons are collapsed and balloon ports clamped. Tube is then passed

through mouth/nose into stomach. Suction is applied to gastric and

esophageal aspiration lumens and position confirmed by X-ray. Incre-

ments of 100 mL of air are introduced through the gastric balloon infla-

tion lumen until the recommended total volume (usually 500 mL) fills

the gastric balloon. The intragastric balloon pressure is monitored. If high,

balloon is likely in the esophagus and should be deflated and replaced into

stomach. Once the gastric balloon is inflated, the tube is pulled back until

the resistance of the diaphragm is firmly felt and the proximal end is

secured using a traction device.

■ If blood is still detected in the gastric aspiration port (or in the esophageal

aspiration port on a four-lumen tube) after lavage, the esophageal balloon

should be inflated to the pressure recommended in the accompanying

instructions (generally 30 to 45 mm Hg).

■ After bleeding has been controlled by the tamponade, the pressure in the

esophageal balloon is generally reduced by 5 mm Hg every 3 hours until

an intraesophageal balloon pressure of 25 mm Hg is achieved without

ongoing bleeding.

COMPLICATIONS

■ Ulceration of mucosal surfaces, mucosal ischemia inducing esophageal

necrosis, aspiration pneumonia, asphyxiation, duodenal rupture

INTERPRETATION OFRESULTS

■ Pressure should be maintained at the lowest level that will stop bleeding

from each of the aspiration suction ports.

NEUROLOGIC PROCEDURES

Lumbar Puncture

INDICATIONS

■ Evaluate for: Infection, SAH, demyelinating CNS process, or carcinoma-

tous/metastatic disease.

■ Therapy for: Pseudotumor cerebri (idiopathic intracranial HTN), normal

pressure hydrocephalus.

CONTRAINDICATIONS

■ Absolute: Infection near the puncture site

■ Relative: Increased ICP due to space occupying lesion

■ Relative: Lateralizing signs (hemiparesis), uncal herniation (unilateral third

nerve palsy with AMS)

■ Relative: Bleeding diathesis

TECHNIQUE

■ Patient positioning: Lateral decubitus or seated position

■ Needle placement: L2–3 to L5–S1 interspaces in adults, L4–L5 or L5–S1

in infants (cord ends at L3 level at birth)

COMPLICATIONS

■ Bleeding: Spinal epidural/subdural hematoma

■ Herniation

PROCEDURES AND SKILLS

Opening pressures are only

useful when the LP is done on

a recumbent patient. On

seated patients, the pressure

will usually be higher than

normal and does not reflect

the ICP.