A prospective single-center observational study to assess the efficacy of the second-generation supraglottic airway device I-gel in laparoscopic surgeries in children

Supraglottic airway device versus tracheal tube for pediatric laparoscopic surgery-A systematic review and meta-analysis

BACKGROUND

Conventionally, tracheal tubes have been used for general anesthesia in pediatric laparoscopic surgeries. Recently, supraglottic devices are being used for the same. The performance of supraglottic devices versus tracheal tubes in children undergoing laparoscopic surgery is uncertain.

METHODS

A systematic review and meta-analysis of randomized controlled trials that compared supraglottic devices versus tracheal tubes in patients ≤18 years undergoing laparoscopic surgery under general anesthesia was conducted. The outcomes were peak airway pressures (cm H2 O), end-tidal carbon dioxide during pneumoperitoneum (mm Hg), recovery time (min), postoperative sore throat and adverse events. Mean difference and odds ratio, with 95% confidence intervals were reported using a random effect model.

RESULTS

Eight trials (n = 591) were included in the final meta-analysis. There was no statistically significant difference in the peak airway pressures (MD 0.58, 95% CI: -0.65 to 1.8; p = .36) and end-tidal carbon dioxide (MD -0.60, 95% CI: -2.00 to 0.80; p = .40) during pneumoperitoneum in the supraglottic device and the tracheal tube group. The tracheal tube group had higher odds of sore throat (OR 3.30, 95% CI: 1.69-6.45; p = .0005) and the supraglottic airway group had faster recovery time (MD 4.21, 95% CI: 3.12-5.31; p < .0001), which were statistically significant. The certainty of evidence is graded low.

CONCLUSION

There is low quality evidence to suggest that for pediatric laparoscopic surgeries of short duration, supraglottic devices could provide comparable intraoperative ventilation in terms of peak airway pressures and end tidal carbon dioxide, with lower odds of postoperative sore throat and faster recovery time when compared to tracheal tubes.

[Update 2022: interdisciplinary statement on airway management with supraglottic airway devices in pediatric emergency medicine-The laryngeal mask is and remains state of the art : Joint statement of the Institute for Emergency Medicine and Medicine Management (INM), the University Clinic Munich, LMU Munich, Germany, the Working Group for Pediatric Critical Care and Emergency Medicine of the German Interdisciplinary Society for Critical Care and Emergency Medicine (DIVI), the Medical Directors of Emergency Medical Services in Bavaria (ÄLRD), the Scientific Working Group for Pediatric Anesthesia (WAKKA) of the German Society for Anesthesiology and Intensive Care Medicine (DGAI), the Scientific Working Group for Emergency Medicine of the German Society for Anesthesiology and Intensive Care Medicine (DGAI) and the Society of Neonatology and Pediatric Critical Care Medicine (GNPI)]

BACKGROUND

Airway management with supraglottic airway devices (SGA) in life-threatening emergencies in children is increasingly being used. Different specifications of laryngeal masks (LM) and the laryngeal tube (LT) are commonly used devices for this purpose. We present a literature review and interdisciplinary consensus statement of different societies on the use of SGA in pediatric emergency medicine.

MATERIAL AND METHODS

Literature review in the PubMed database and classification of studies according to the criteria of the Oxford Centre for Evidence-based Medicine. Levels and consensus finding within the group of authors.

RESULTS

The evidence for successful applications of the various types of LM is significantly higher than for LT application. Reported smaller series of successful applications of LT are currently limited to selected research groups and centers. Especially for children below 10 kg body weight there currently exists insufficient evidence for the successful application of the LT and therefore its routine use cannot be recommended. SGAs used for emergencies should have a gastric drainage possibility.

DISCUSSION

Considering the scientific data and the large clinical experience with the LM in medical routine and emergency situations in children currently only the LM can be recommended for alternative (i.e., non-intubation) emergency airway management in children. If alternative airway management is part of a local emergency strategy, the LM should be provided in all pediatric sizes (1, 1½, 2, 2½, 3) for out of hospital use and in hospital emergency use and all users should regularly be trained in its application.

Comparison of the oropharyngeal leak pressure between three second generation supraglottic airway devices during laparoscopic surgery in pediatric patients

BACKGROUND

Previous studies have shown Proseal LMA and I gel similar to endotracheal intubation in ventilatory ability in pediatric laparoscopic surgeries.

AIMS

The primary aim of this study was to assess whether there is a significant difference in the oropharyngeal leak pressure between Ambu Auragrain, I-gel, and Proseal LMA during pediatric laparoscopic surgery.

METHODS

In this randomized controlled trial, 90 male patients of American Society of Anesthesiologists physical status I aged between 6 months and 10 years who were scheduled for laparoscopic single-sided inguinal hernia repair were recruited and randomly allocated to three groups in which airway was secured with Ambu Auragain, I gel, or Proseal LMA. The primary outcome was oropharyngeal leak pressure. The secondary outcomes were peak pressures before and after pneumoperitoneum, fiberoptic view, insertion attempts, insertion time, manipulations, perioperative and postoperative anesthesia-related problems. Continuous variables were compared using the one-way analysis of variance or the Kruskal-Wallis test with post hoc Turkey analysis. Categorical and ordinal data were compared using the chi-square test or Fisher's exact test.

RESULTS

Oropharyngeal leak pressure before pneumoperitoneum was higher with I gel as compared to Ambu Auragain (27.36 ± 5.72 cm of H₂ O vs 23.56 ± 5.72 cm of H₂ O) (p = .021) and PLMA (27.36 ± 5.72 cm of H₂ O vs 23.24 ± 4.35 cm of H₂ O) (p = .011). Oropharyngeal leak pressure after pneumoperitoneum was also higher with I gel as compared to Ambu Auragain (31.58 ± 4.35 cm of H₂ O vs 26.83 ± 5.00 cm of H₂ O) (p = .001) and Proseal LMA (31.58 ± 4.35 cm of H₂ O vs 27.03 ± 3.80 cm of H₂ O) (p = .002). Oropharyngeal leak pressures of Ambu Auragain and Proseal LMA were comparable. Postoperative complications were similar in all the supraglottic airway devices. No regurgitation or aspiration-related problem was observed in our study.

CONCLUSION

I gel had a higher oropharyngeal leak pressure than the other two supraglottic airway devices and therefore may represent a better choice in situations where higher ventilatory pressures may be necessary, for example, in extremes of weight trendelenburg position, etc. CLINICAL TRIAL IDENTIFIER: Clinical trial registry of India (CTRI/2018/11/016445).