A prospective randomised comparison of two insertion methods for i-gel placement in anaesthetised paralysed patients: standard vs. rotational technique

Comparison between head rotation and standard techniques for i-gel™ insertion: a randomized controlled trial

BACKGROUND

This study evaluated the effect of head rotation on the first-attempt success rate of i-gel insertion, aiming to alleviate the effect of gravity on the tongue and reduce resistance between the device and the tongue.

METHODS

Adult surgical patients were randomized to standard and head rotation technique groups. In the head rotation technique group, patients' heads were maximally rotated to the left before i-gel insertion. The primary endpoint was the first-attempt success rate. Secondary endpoints included the success rate within two attempts (using the allocated technique), time required for successful i-gel placement within two attempts, and success rate at the third attempt (using the opposite technique).

RESULTS

Among 158 patients, the head rotation technique group showed a significantly higher first-attempt success rate (60/80, 75.0%) compared to the standard technique group (45/78, 57.7%; P = 0.021). The success rate within two attempts was similar between the groups (95.0% vs. 91.0%, P = 0.326). The time required for successful i-gel placement was significantly shorter in the head rotation technique (mean [SD], 13.4 [3.7] s vs. 16.3 [7.8] s; P = 0.030). When the head rotation technique failed, the standard technique also failed in all cases (n = 4), whereas the head rotation technique succeeded in five out of the seven patients where the standard technique failed.

CONCLUSIONS

The head rotation technique significantly improved the first-attempt success rate and reduced the time required for successful i-gel insertion. It was effective when the standard technique failed. The head rotation technique may be an effective primary or alternative method for i-gel insertion.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (NCT05201339).

Conventional versus reverse insertion of i-gel® in overweight and obese patients - Interventional randomised controlled trial

Background and Aims

The supraglottic airway device, i-gel, is used in obese patients for short- to medium-duration surgical procedures. Insertion techniques have contributed to the successful and proper placement of i-gel in the first attempt. This study aims to compare two techniques for successfully inserting i-gel in the first attempt in overweight and obese patients as measured by oropharyngeal leak pressure (OLP).

Methods

This interventional, randomised, controlled study was conducted after ethical approval, and trial registration in overweight and obese patients. Patients were randomised into two groups: In Group C, the conventional technique was used, while in Group R, the reverse technique was used to insert i-gel. OLP, successful placement, required manipulations, time taken for insertion, number of attempts, and intraoperative and postoperative complications were studied. The collected data were analysed statistically.

Results

The mean OLP (30.46 ± 3.76 vs. 32.12 ± 3.10 mmHg, P = 0.018) and the mean time of insertion (16.42 ± 1.86 vs. 13.98 ± 1.97 s, P = 0.001) for conventional and reverse techniques, respectively, were statistically significant and favourable for Group R compared to Group C. Successful placement of i-gel at the first attempt, ease of insertion, number of attempts and all the manipulations except withdrawal and advancement were comparable in both the groups. No postoperative complications were noted.

Conclusion

The reverse technique significantly favoured the actual OLP values and the mean insertion time. Successful placement of i-gel at the first attempt was observed with both conventional and reverse techniques.

Comparison of rotational and standard methods of i-gel® insertion in patients of advanced age undergoing general anesthesia: a randomized clinical trial

OBJECTIVE

This study was performed to compare the performance of rotational versus standard insertion of the i-gel® (Intersurgical, Wokingham, Berkshire, England) in patients of advanced age.

METHODS

This single-center, randomized, double-blind trial involved 140 patients of advanced age undergoing general anesthesia. The patients were randomized into the standard group and rotational group. The primary objective of this study was to compare the success rate of the first attempt. The secondary outcome indicators were the insertion time and postoperative complications.

RESULTS

The placement success rate on the first attempt was significantly higher in the rotational group than in the standard group (92% vs. 73%, respectively). The overall success rate was 100% for the rotational method and 95% for the standard method. The mean ± standard deviation insertion times were similar (15 ± 7.34 vs. 14 ± 7.26 s, respectively). The incidence rates of blood staining of the i-gel®, hoarseness, and sore throat did not increase with the rotational technique and were not significantly different from those of the standard method.

CONCLUSION

Compared with the standard method, the rotational method of i-gel® insertion had a higher success rate and did not increase the insertion time and complications in patients of advanced age.Trial registration: This trial was registered at the Chinese Clinical Trial Registry (ChiCTR2000038763, Date of registration: 30/09/2020).

Standard digit-based versus 90° rotation technique for supraglottic airway device insertion: a meta-analysis of randomized controlled trials

BACKGROUND

Prompt insertion and placement of supraglottic airway (SGA) devices in the correct position are required to secure the airway. This meta-analysis was performed to validate the usefulness of the 90° rotation technique as compared with the standard digit-based technique for the insertion of SGA devices in anesthetized patients in terms of insertion success rate, insertion time, and postoperative complications.

METHODS

A literature search of PubMed, EMBASE, CENTRAL, CINAHL, Scopus, and Web of Science was conducted. Randomized controlled trials, without limitations on publication period, language, journal, or region, until July 2021, that compared the 90° rotation and the standard digit-based techniques for insertion of SGA devices in anesthetized patients were included.

RESULTS

The first-attempt (risk ratio [RR]: 1.16, 95% CI [1.09, 1.25], P < 0.001) and overall success rates (RR: 1.06, 95% CI [1.03, 1.09], P < 0.001) were significantly higher in the 90° rotation group. The insertion time was shorter in the 90° rotation group (mean difference: -4.42 s, 95% CI [-6.70, -2.15 s], P < 0.001). The incidences of postoperative sore throat (RR: 0.63, 95% CI [0.49, 0.83], P < 0.001) and blood staining (RR: 0.28, 95% CI [0.20, 0.39], P < 0.001) were lower in the 90° rotation group.

CONCLUSIONS

The use of the 90° rotation technique increases the success rate of SGA device insertion and decreases postoperative complications as compared with that of the standard digit-based technique in anesthetized patients.

The effects of two-handed jaw thrust on i-gel™ placement in anesthetized non-paralyzed patients

BACKGROUND

I-gel^TM is a second-generation supraglottic airway device with a non-inflatable cuff. In this prospective randomized investigation, we evaluated the effects of two-handed jaw thrust technique on i-gel insertion in anesthetized non-paralyzed patients.

METHODS

Seventy-four adult patients were allocated to two groups (N.=37 each). In the jaw thrust group, two-handed jaw thrust technique was applied to facilitate i-gel insertion. In the control group, conventional i-gel insertion was performed. The success rate at the first attempt, air leakage pressure, insertion time, and postoperative sore throat incidence were recorded.

RESULTS

The success rate at the first attempt was higher in the jaw thrust group (37 [100%] vs. 31 [84%], difference of 16%, 95% confidence interval for the difference: 1 to 33%, P=0.03). The median air leakage pressure was higher in the jaw thrust group than in the control group (20 [interquartile range 13] vs. 17 [interquartile range 3] cmH<inf>2</inf>O, difference: 6, 95% confidence interval of the difference: 3 to 8, P<0.01). The mean insertion time was shorter in the jaw thrust group (27±14 vs. 41±29 seconds, difference: 14 seconds, 95% confidence interval of the difference: 3 to 24, P=0.01). The incidence of postoperative sore throat at the postoperative one hour was lower in the jaw thrust group (seven [20%] vs. 15 [41%], difference 22%, 95% confidence interval for the difference: -1 to 42%, P=0.04).

CONCLUSIONS

The two-handed jaw thrust technique facilitated i-gel insertion compared to the conventional technique in anesthetized non-paralyzed patients.

Influence of two-handed jaw thrust during tracheal intubation on postoperative sore throat: a prospective randomised study

Objective

General anaesthesia with tracheal intubation results in sore throat. We evaluated the influence of the two-handed jaw thrust on postoperative sore throat in patients who require tracheal intubation.

Methods

In this prospective, double-blind, single-centre, parallel-arm, and randomised trial, 92 patients who were scheduled for general anaesthesia for total hip arthroplasty were allocated to one of two groups. In the jaw thrust group (n = 46), the two-handed jaw thrust manoeuvre was applied at intubation. In the control group (n = 46), conventional intubation with sham jaw thrust was performed. Incidences of airway morbidities including sore throat, hoarseness, and cough at 2, 4, and 24 hours postoperatively were compared.

Results

During the postoperative 24 hours, the incidence of sore throat (8 [17%] vs. 20 [44%]) and hoarseness were lower in the jaw thrust group (8 [17%] vs. 18 [39%]) compared with the control group. The incidence of cough during the postoperative 24 hours was similar between the groups.

Conclusions

The jaw thrust manoeuvre significantly reduced sore throat and hoarseness in patients after general anaesthesia using tracheal intubation.

Clinical trial registration: NCT 03568279.

A prospective randomised trial to compare three insertion techniques for i-gel™ placement: Standard, reverse, and rotation

Background and Aims:

This prospective randomised study was done to compare standard, reverse, and rotation techniques of i-gel™ placement in terms of insertion characteristics and success rate.

Material and Methods:

After institutional ethics committee approval, 135 patients aged 18-50 years, ASA I and II undergoing elective surgery under general anesthesia were included. After induction of anesthesia, i-gel™ was inserted by standard, reverse, and rotation technique in Groups I, II, and III, respectively. The primary objective was mean time of insertion. Secondary variables included ease of insertion, first attempt success rate, manoeuvres required, fiberoptic view of placement, oropharyngeal leak pressure, ease of placement of nasogastric tube, and complications if any.

Results:

Mean time of insertion was 18.04 ± 5.65 s, 15.00 ± 5.72 s and 16.12 ± 5.84 s for groups I, II, and III, respectively. Time taken for insertion was shortest and significantly lower (P = 0.048) for group II compared to group I. Insertion time was comparable between rest of groups. The overall success rate in groups I, II, and III were 91.1%, 95.6%, and 93.3% respectively (P = 0.7). The first attempt success rate was 82.2%, 89%, and 84.4% in groups I, II and III, respectively (P = 0.07). Manoeuvres were required in five (12.19%) patients in group I, four (9.30%) patients in group II, and three (7.14%) patients in group III (P = 0.602). Complications occurred in eight, three, and three patients in groups I, II, and III, respectively.

Conclusion:

All techniques of i-gel insertion are equally good and choice of technique depends upon the experience and comfort of the investigator with the particular technique.

Comparison of the standard and triple airway maneuvering techniques for i-gel™ placement in patients undergoing elective surgery: a randomized controlled study

PURPOSE

The i-gel is a supraglottic airway device with non-inflatable cuff which can suffer insertion failure if its standard placement technique is implemented. The aim of this study was to compare the placement technique proposed by the manufacturer of i-gel with the triple airway maneuver in terms of successful device insertion time and first-attempt success.

METHODS

After ethics committee approval, 103 ASA I-III patients were randomly allocated to the standard or triple airway maneuver groups. In the standard Group, the i-gel was inserted in the sniffing position while, in the triple group, it was inserted using the triple airway maneuver consisting of head tilt, jaw thrust, and open mouth. The time taken for successful insertion, first-attempt success rate, i-gel position, airway complications, and hemodynamic responses were assessed.

RESULTS

Between the two groups patient characteristics were similar. Time for successful insertion was significantly shorter in the triple group (20 ± 7 s) than with the standard technique (32 ± 11 s; p < 0.001). Successful insertion at the first attempt was 78% and 92% for the standard and triple group, respectively (p = 0.092). The i-gel position, airway complications, and hemodynamic responses were similar in both groups.

CONCLUSION

The triple airway maneuver required less i-gel insertion time as compared with the standard placement technique. First-attempt success rates were similar with both techniques, although the triple airway maneuver was superior to the standard method as a rescue technique in failed insertions. We therefore recommend use of the triple airway maneuver in i-gel insertion.

A prospective, randomized comparison of the LMA-protector™ and i-gel™ in paralyzed, anesthetized patients

Background

In the present study, we compare the LMA-Protector™ and the i-gel™ in terms of adequacy of the airway seal, insertion time, ease and accuracy of insertion, and the incidence of postoperative sore throat.

Methods

In 110 anesthetized and paralyzed adult patients, the i-gel™ (n = 55) or the LMA-Protector™ (n = 55) was inserted. The primary outcome was airway leak pressure. The secondary outcomes included the first-attempt success rate, insertion time, ease and accuracy of the device insertion, ease of gastric tube placement, blood staining on the device after removal, and incidence and severity of postoperative sore throat.

Results

The airway leak pressure was higher with the LMA-Protector™ than with the i-gel™ (31 [7] cmH₂O vs. 27 [6] cmH₂O, respectively; P = 0.016). Insertion time was longer with the LMA-Protector™ than with the i-gel™ (27 [16] sec vs. 19 [16] sec, respectively, P < 0.001), but ease of insertion and the first-attempt success rate were not different between the two groups. The LMA-Protector™ provided a worse fiberoptic view of the vocal cords and more difficult gastric tube insertion than the i-gel™ (both P < 0.001). Blood staining on the device was more frequent with the LMA-Protector™ than with the i-gel™ (P = 0.033). The incidence and severity of postoperative sore throat were not different between the two groups.

Conclusion

The LMA-Protector™ provided a better airway sealing effect than the i-gel™. However, it required a longer insertion time, provided a worse fiberoptic view of the vocal cords, and caused more mucosal injury compared to the i-gel™.

Trial registration

ClinicalTrials.gov (NCT03078517). Registered prior to patient enrollment, Date of registration: Mar 13, 2017.

Comparison of standard versus 90° rotation technique for LMA Flexible™ insertion: a randomized controlled trial

Background

Insertion of a flexible laryngeal mask airway (LMA Flexible) is known to be more difficult than that of a conventional laryngeal mask airway. The 90° rotation technique can improve the success rate with a conventional laryngeal mask airway but its effect with the LMA Flexible remains unknown. We assessed whether the 90° rotation technique increased the first-attempt success rate of LMA Flexible insertion versus the standard technique.

Methods

In total, 129 female patients undergoing breast surgery were analyzed. The primary endpoint was success at the first attempt. The insertion time, number of trials, number of manipulations required, and oropharyngeal leak pressure were also evaluated. Heart rate and mean blood pressure were recorded 1 min before and 1 min after insertion. Blood staining on the LMA Flexible after removal and postoperative sore throat were checked.

Results

The first-attempt success rates were comparable between the groups (93% vs. 98.3%, P = .20). The insertion time, number of trials and manipulations, hemodynamic variables, and complications, such as blood staining and sore throat, did not differ between the groups.

Conclusions

The 90° rotation technique is a good alternative to the standard technique for insertion of the LMA Flexible.

Trial registration

ClinicalTrials.gov (NCT03028896). It was registered retrospectively at Jan 19th, 2017.

Male requires a higher median target effect-site concentration of propofol for I-gel placement when combined with dexmedetomidine

OBJECTIVE

The supraglottic airway device (SAD) can be used for airway management of spontaneous breathing patients, and propofol is commonly applied for the SAD placement. This study was designed to assess the effect of gender on median target effect-site concentration (Ce₅₀) of propofol for I-gel placement when combined with dexmedetomidine.

MATERIAL AND METHOD

19 males and 18 females, aged 18 to 59 and undergoing elective surgery, were enrolled. After intravenous infusion of dexmedetomidine 1.0μg/kg over 10min followed by continuous infusion of 0.4μg/kg/h, target-controlled infusion of propofol under Marsh model was started and the initial Ce of propofol was set at 4.79μg/mL and 4.35μg/mL in the male and female patients, respectively. The I-gel was inserted when the Ce of propofol reached the pre-set concentration and bispectral index value was less than 60. The Ce of propofol required for I-gel placement was determined by the Dixon up-and-down method.

RESULTS

The Ce₅₀ (95% confidence interval) of propofol required for I-gel placement were 4.082μg/mL (3.798-4.332μg/mL) and 3.509μg/mL (3.266-3.749μg/mL) in male and female patients, respectively, with a significantly higher Ce₅₀ in males.

CONCLUSION

When combined with dexmedetomidine, males require a higher Ce₅₀ of propofol for I-gel placement compared to females.

Standard versus Rotation Technique for Insertion of Supraglottic Airway Devices: Systematic Review and Meta-Analysis

PURPOSE

Supraglottic airway devices have been widely utilized as an alternative to tracheal intubation in various clinical situations. The rotation technique has been proposed to improve the insertion success rate of supraglottic airways. However, the clinical efficacy of this technique remains uncertain as previous results have been inconsistent, depending on the variable evaluated.

MATERIALS AND METHODS

We systematically searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials in April 2015 for randomized controlled trials that compared the rotation and standard techniques for inserting supraglottic airways.

RESULTS

Thirteen randomized controlled trials (1505 patients, 753 with the rotation technique) were included. The success rate at the first attempt was significantly higher with the rotation technique than with the standard technique [relative risk (RR): 1.13; 95% confidence interval (CI): 1.05 to 1.23; p=0.002]. The rotation technique provided significantly higher overall success rates (RR: 1.06; 95% CI: 1.04 to 1.09; p<0.001). Device insertion was completed faster with the rotation technique (mean difference: -4.6 seconds; 95% CI: -7.37 to -1.74; p=0.002). The incidence of blood staining on the removed device (RR: 0.36; 95% CI: 0.27 to 0.47; p<0.001) was significantly lower with the rotation technique.

CONCLUSION

The rotation technique provided higher first-attempt and overall success rates, faster insertion, and a lower incidence of blood on the removed device, reflecting less mucosal trauma. Thus, it may be considered as an alternative to the standard technique when predicting or encountering difficulty in inserting supraglottic airways.

Laryngoscopy facilitates successful i-gel insertion by novice doctors: a prospective randomized controlled trial

BACKGROUND

This study investigated the hypothesis that the efficacy of insertion of the supraglottic device i-gel(®) (i-gel) can be improved by laryngoscopy and can provide better sealing pressure in anesthetized patients by novice doctors.

METHODS

Eighty-four adult patients were assigned to the laryngoscopy group (L group, 42 patients) or control group (i.e., conventional blind insertion; C group, 42 patients). Anesthesia was induced with propofol and remifentanil, and rocuronium 0.6-0.9 mg/kg was administered. The number of attempts until successful insertion, sealing pressure, vital sign changes upon insertion, and subjective difficulty of insertion by novice doctors were compared between the groups.

RESULTS

The total number of insertion attempts was one (L group 36 cases, C group 23 cases), two (L group 6 cases, C group 18 cases), and three (L group 0 case, C group 1 case), with significant differences between groups (P = 0.007). The sealing pressure was significantly higher in the L group than in the C group (L group 22.3 ± 2.6 cmH2O, C group 19.5 ± 2.7 cmH2O, P < 0.001). Vital sign changes (heart rate and blood pressure) did not differ between the two groups. The subjective difficulty of insertion was significantly lower in the L group than in the C group (L group 26.8 ± 11.8 mm, C group 47.0 ± 15.1 mm, P < 0.001). The incidence of postoperative pharyngeal pain was significantly lower in the L group than in the C group (P < 0.001), while the incidence of hoarseness did not differ between the two groups (P = 1.00).

CONCLUSION

Our results suggest that laryngoscopy facilitates i-gel insertion by novice doctors, as reflected in the rate of successful insertions, higher sealing pressure, and lower subjective difficulty of insertion in anesthetized patients.