Use and Efficacy of I-Gel in Complicated Intubations in Newborn Infants: A Review of Case Reports in the Literature

INTRODUCTION

Current guidelines for neonatal resuscitation suggest the use of a laryngeal mask when ventilation with both facemask and endotracheal tube has failed in newborns weighing >2000 g or delivered ≥ 34 weeks of gestation age. Paediatric I-gel® is one of the latest supraglottic airway management devices suitable for children and newborns. I-gel® use was effective in guaranteeing adequate ventilation in patients with anatomic abnormalities in case of respiratory impairment or during surgical procedures after the induction of anaesthesia.

OBJECTIVE

The purpose of our review was to evaluate the use and efficacy of I-gel® in case of complicated intubations.

METHODS

In July 2023, two authors of this paper independently conducted searches of the MEDLINE, Web of Science, and Scopus databases without imposing any time constraints or other restrictions. Three case reports were included, each describing the use of I-gel® device in difficult intubations in newborns with anatomical abnormalities.

RESULTS

No difficulties were reported in the insertion of the device, which was placed even by inexperienced clinicians.

CONCLUSION

The data collected highlighted the possibility of using I-gel® not only as a rescue device after attempted and failed endotracheal placement but also as a first choice in selected patients. Studies on larger cohorts would be needed. Further research involving larger patient cohorts of multicentre NICUs is necessary to confirm the use of laryngeal masks in neonates weighing less than 2000 grams.

Predicted effect-site concentrations of remimazolam for i-gel insertion: a prospective randomized controlled study

This study is the first to report 50% and 95% effect-site concentrations (EC50 and EC95, respectively) of the new short-acting benzodiazepine, remimazolam, for the successful insertion of i-gels with co-administration of fentanyl. Thirty patients (38 ± 5 years old, male/female = 4/26) were randomly assigned into five groups to receive one of five different remimazolam doses (0.1, 0.15, 0.2, 0.25, and 0.3 mg/kg bolus followed by infusion of 1, 1.5, 2, 2.5, and 3 mg/kg/h, respectively, for 10 min), which were designed to maintain a constant effect-site concentration of remimazolam at the time of i-gel insertion. At 6 min after the start of remimazolam infusion, all patients received 2 µg/kg fentanyl. i-gel insertion was attempted at 10 min and the success or failure of insertion were assessed by the patient response. Probit analysis was used to estimate the EC50 and EC95 values of remimazolam with 95% confidence intervals (CIs). In the five remimazolam dose groups, two, two, four, five, and six of the six patients in each group had an i-gel successfully inserted. Two patients in the lowest remimazolam dose group were conscious at the time of i-gel insertion and were counted as failures. The EC50 and EC95 values of remimazolam were 0.88 (95% CI, 0.65-1.11) and 1.57 (95% CI, 1.09-2.05) µg/ml, respectively. An effect-site concentration of ≥ 1.57 µg/ml was needed to insert an i-gel using remimazolam anesthesia, even with 2 µg/kg fentanyl. Trial registration: The study was registered in Japan Registry of Clinical Trials on 19 April 2021, Code jRCTs041210009.

Negative pressure pulmonary edema after general anesthesia using the i-gel

Negative pressure pulmonary edema (NPPE) is a rare complication that occurs mainly after tracheal extubation. We report a case of postoperative NPPE associated with the use of the i-gel. A 28-year-old woman was scheduled for an emergency right axillary sentinel lymph node excision. During emergence, the patient experienced a sudden onset of airway obstruction, and spontaneous ventilation through the i-gel was impossible. Pink and frothy secretions were noted in the i-gel and the patient's oral cavity. Positive airway pressure with 100% oxygen was applied using a facemask, and the patient was subsequently treated with high-flow oxygen therapy. In this case, laryngospasm or displacement of the i-gel was believed to be the cause of airway obstruction. We recognized that NPPE is likely to occur regardless of the airway device, and the use of the i-gel cannot completely eliminate the possibility of NPPE occurrence.

Comparison of four different techniques of i-gel insertion by anaesthesia trainees in children undergoing daycare surgery: A single-blind, randomised, comparative study

Background and Aims

Different techniques of i-gel insertion have been described with variable success rates. This study aimed to assess the incidence of malposition of i-gel in children with 90° rotation, 180° rotation, jaw thrust-assisted and standard insertion techniques.

Methods

The study included 132 children undergoing elective surgery under general anaesthesia without neuromuscular blockade after approval from the Institutional Ethics Committee. The i-gel was inserted using one of the four randomised techniques (90° rotation, 180° rotation, jaw thrust-assisted insertion or standard insertion technique) by anaesthesia trainees. The primary objective of this study was to assess device malposition using three alternative techniques compared to the standard insertion technique by flexible video bronchoscopy.

Results

The incidence of malposition was the least in the 180° rotation technique group (27%) versus 39% in the standard and 90° rotation technique groups and 70% in the jaw thrust technique group (P = 0.004). Oropharyngeal leak pressure (OLP) was highest in the 180° rotation technique group, that is, 27.1 (5.3) cm H2O in the 180° rotation technique group versus 23 (4.3), 25.8 (4.1) and 24.7 (5.6) cm H2O in the standard, 90° rotation and assisted jaw thrust groups, respectively (P = 0.006). The time to i-gel insertion was the least with the standard insertion technique, that is, 16.9 (3.3) s, compared to 18.4 (3.1) s in the 90° rotation group, 19.5 (3.2) s in the180° rotation group and 20.1 (3.4) s in the assisted jaw thrust technique group (P < 0.001).

Conclusion

The 180° rotation technique for i-gel placement in children by anaesthesia trainees has the lowest incidence of malposition and the best OLP versus other techniques but lacks any clear advantage in clinical performance and ventilation.

Effect of superior laryngeal nerve block in alleviating sore throat after application of i-gel supraglottic airway: a randomized controlled trial

BACKGROUND

Postoperative sore throat (POST) is a common complaint after supraglottic airway device (SAD) application. Internal branch of the superior laryngeal nerve (iSLN) block has the potential to alleviate POST. The aim of this trial was to explore the effect of iSLN block in alleviating sore throat, as well as to identify the potential risk factors for POST after SAD insertion.

METHODS

One hundred thirty-four patients scheduled for elective gynecological surgery were randomized to either group T: tetracaine syrup (1%) for local lubrication on i-gel supraglottic device (n = 67) or group B: i-gel insertion with water based lubricant on it and followed by bilateral iSLN block (ropivacaine, 0.375%, 2 ml for each side) (n = 67). Under ultrasound guidance, iSLN was exposed below thyrohyoid membrane. The primary outcome was the intensity of sore throat at 6 h after surgery. In addition, POST score at 0.5 h and 24 h, the severity of postoperative swallowing discomfort, acoustic analysis and complications were measured.

RESULTS

Compared with tetracaine syrup for local lubrication, iSLN block resulted in a reduced intensity of POST at 0.5 h (P = 0.044, OR = 1.99, 95%CI 1.02 to 3.88) and 6 h (P < 0.001, OR = 5.07, 95%CI 2.53 to 10.14) after surgery, as well as less severity of swallowing discomfort (P < 0.001, OR = 2.21, 95%CI 1.63 to 2.99) and cough (P = 0.039, OR = 1.97, 95%CI 1.04 to 3.73). The patients after iSLN block presented lower jitter and shimmer value in acoustic analysis at 6 h after surgery (P < 0.001).

CONCLUSIONS

iSLN block was effective in alleviating POST, improving voice function, as well as reducing postoperative swallowing discomfort and coughing.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2000037974) on 8th Sept 2020.

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.

Effect of Intermediate Airway Management on Ventilation Parameters in Simulated Pediatric Out-of-Hospital Cardiac Arrest: Protocol for a Multicenter, Randomized, Crossover Trial

Most pediatric out-of-hospital cardiac arrests (OHCAs) are caused by hypoxia, which is generally consecutive to respiratory failure. To restore oxygenation, prehospital providers usually first use basic airway management techniques, i.e., bag-valve-mask (BVM) devices. These devices present several drawbacks, most of which could be avoided using supraglottic airway devices. These intermediate airway management (IAM) devices also present significant advantages over tracheal intubation: they are associated with higher success and lower complication rates in the prehospital setting. There are, however, few data regarding the effect of early IAM in pediatric OHCA. This paper details the protocol of a trial designed to evaluate the impact of this airway management strategy on ventilation parameters through a simulated, multicenter, randomized, crossover trial. The hypothesis underlying this study protocol is that early IAM without prior BVM ventilations could improve the ventilation parameters in comparison with the standard approach, which consists in BVM ventilations only.

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).

Difficult Airway Management in a Patient With Post-burn Contracture Neck

During reconstructive interventions in patients presenting with severe post-burn mento-sternal scar contracture, securing the airway forms a critical part of management. Extreme contracture is more likely to develop in patients who have had thoracic burns with ascending involvement of the neck and mandibular region. When cervical hyperextension and elevation of the mandible are impeded, post-burn contracture of the neck might render endotracheal intubation difficult. The development of rigid scar tissue that distorts the laryngeal and mandibular anatomy, or the development of microstomia following scar tissue retraction in facial burns, may make alternative approaches to direct laryngoscopy challenging. In patients with healed neck burns, intubation difficulties should be anticipated, and equipment for aiding intubation should be kept ready. Furthermore, a surgeon must be present throughout anesthesia induction in case an emergency neck release is required. Although the role of awake fiberoptic intubation has been well established in the general population, it is yet to be assessed in patients with burns. In this report, we present a case of successfully managed post-burn contracture that was planned for awake fiberoptic intubation.

Comparison of SaCoVLM™ video laryngeal mask-guided intubation and i-gel combined with flexible bronchoscopy-guided intubation in airway management during general anesthesia: a non-inferiority study

BACKGROUND

When a difficult airway is unanticipatedly encountered and the initial laryngoscopic intubation fails, a supraglottic airway device (SAD) may be placed to aid ventilation and oxygenation, and act as a conduit for intubation. SaCoVLM™, as new SAD, can offer a direct vision to guide intubation. However, no study has evaluated the performance of SaCoVLM™ video laryngeal mask (VLM) intubation and i-gel combined with flexible bronchoscopy (FB)-guided intubation in airway management during general anesthesia.

METHODS

A total of 120 adult patients were randomly allocated into the SaCoVLM™ group (Group S) and i-gel group (Group I). After induction of general anesthesia, guided tracheal intubation under direct vision of the SaCoVLM™ was conducted in Group S, while Group I received FB-guided tracheal intubation using the i-gel. The success rate of SAD placement, first-pass success rate of guided tracheal tube placement, and total success rate in both groups were recorded. The time for SAD placement, time for guided tracheal intubation, total intubation time (time for SAD placement and intubation), glottic exposure grading and postoperative intubation complications (i.e., dysphagia, hoarseness, pharyngalgia, etc.) of both groups were also compared.

RESULTS

The first-time success rate of SAD placement was 98% in two groups. The first-pass success rate of guided endotracheal intubation was 92% in Group S and 93% in Group I (P = 0.74 > 0.05). The total intubation time was 30.8(± 9.7) s and 57.4(± 16.6) s (95% CI = -31.5 to -21.7) in Group S and Group I, respectively (P < 0.01). The total complication rate was 8% in Group S and 22% in Group I (P < 0.05). The laryngeal inlet could be observed in the S group through the visual system of SaCoVLM™. No dysphagia or hoarseness was reported.

CONCLUSION

SaCoVLM™ can reveal the position of laryngeal inlet, thus providing direct vision for tracheal intubation. SaCoVLM™ -guided intubation is faster, and does not rely on FB, compared to i-gel combined with FB-guided intubation. Besides, SaCoVLM™ has a lower post-intubation complication rate.

TRIAL REGISTRATION

Chinese Clinical Trials Registry (ChiCTR2100043443); Date of registration: 18/02/2021.

The i-gel supraglottic airway device improves airway management during endobronchial ablative therapy under general anesthesia: a case report

Endobronchial ablative therapy (EAT) in patients with preexisting obstructive airway disease can cause hypoxemia because bronchoscope insertion interferes with ventilation and a low fraction of inspired oxygen (FiO₂) is essential to avoid airway fire. A man in his early 50s with moderately severe obstructive airway disease was scheduled for EAT for treatment of tracheal papillomatosis. Ventilation and oxygenation would have been difficult because of narrowing of the endotracheal tube by bronchoscopic insertion and a low FiO₂; therefore, an i-gel supraglottic airway device with a larger inner diameter was inserted. All visible intratracheal papillomas were ablated by a potassium titanyl phosphate laser through the bronchoscopic port that passed through the lumen of the i-gel at an FiO₂ of 0.3. During anesthesia for EAT, the i-gel supraglottic airway device provided a wider lumen for ventilation. We were thus able to provide stable ventilation at an FiO₂ of 0.3 during EAT in this patient with obstructive airway disease, avoiding airway fire and hypoxemia.

The Importance of Acknowledging an Intermediate Category of Airway Management Devices in the Prehospital Setting

Prehospital airway devices are often classified as either basic or advanced, with this latter category including both supraglottic airway (SGA) devices and instruments designed to perform endotracheal intubation (ETI). Therefore, many authors analyze the impact of SGA and ETI devices jointly. There are however fundamental differences between these instruments. Indeed, adequate airway protection can only be achieved through ETI, and SGA devices all have relatively low leak pressures which might compromise both oxygenation and ventilation when lung compliance is decreased. In addition, there is increasing evidence that SGA devices reduce carotid blood flow in case of cardiac arrest. Nevertheless, SGA devices might be particularly useful in the prehospital setting where many providers are not experienced enough to safely perform ETI. Compared to basic airway management (bag-valve-mask) devices, SGA devices enable better oxygenation, decrease the odds of aspiration, and allow for more reliable capnometric measurement by virtue of their enhanced airtightness. For all these reasons, we strongly believe that SGA devices should be categorized as "intermediate airway management devices" and be systematically analyzed separately from devices designed to perform ETI.

Risk factors for postoperative sore throat associated with i-gel™, a supraglottic airway device

i-gel™ is a supraglottic airway device widely used for airway management during general anesthesia as an alternative to tracheal intubation. It sometimes results in a sore throat postoperatively; however, the risk factors for a postoperative sore throat caused by i-gel remain unclear. Here, we clarify the risk factors for a postoperative sore throat associated with i-gel insertion. We retrospectively reviewed the data of 426 adult patients who received general anesthesia with i-gel at our institution from January 2018 to December 2019. The incidence of postoperative sore throat and intraoperative data (size of i-gel, number of insertion attempts, total insertion time, and dose of the neuromuscular blocker and opioid) were evaluated. Logistic regression analysis was performed to identify the risk factors. Postoperative sore throat following i-gel insertion occurred in 24/426 patients (5.6%). The insertion time was significantly associated with the incidence of postoperative sore throat in the univariate analysis, but not in the multivariate analysis (P=0.519). Increased doses of neuromuscular blockers before i-gel insertion (odds ratio [OR], 5.46; 95% confidence interval [CI], 1.50-19.80; P=0.001) and reduced doses of intraoperative fentanyl (OR, 0.51; 95% CI, 0.28-0.93; P=0.028) were risk factors in the univariate and multivariate analyses. In the subgroup that used neuromuscular blockers before i-gel insertion, only an increased dose of neuromuscular blocker (OR, 17.2; 95%, CI 1.06-280; P=0.046) was an associated risk factor in the univariate and multivariate analyses. Overall, increased doses of neuromuscular blockers before i-gel insertion could contribute to the development of postoperative sore throat.

Are Pediatric Manual Resuscitators Only Fit For Pediatric Use? A Comparison of Ventilation Volumes in a Moving Ambulance

BACKGROUND

The manual resuscitator device is the most common method of ventilating patients with respiratory failure, either with a facemask, or with an advanced airway such as an ETT. Barotrauma and gastric inflation from excessive ventilation volumes or pressure are concerning complications. Ventilating adult patients with pediatric manual resuscitator may provide more lung-protective tidal volumes based on stationary patient simulations. However, use of a pediatric manual resuscitator in mobile simulations contradictorily generates inadequate tidal volumes.

METHODS

Sixty-two EMS clinicians in a moving ambulance ventilated a manikin using pediatric and adult manual resuscitators in conjunction with oral-pharyngeal airway, i-gel, King LTS-D, or an endotracheal tube.

RESULTS

Oral-pharyngeal airway data were discarded due to EMS clinician inability to produce measurable tidal volumes. Mean ventilation volumes using the pediatric manual resuscitator were inadequate compared to those with the adult manual resuscitator on all other airway devices. In addition, i-gel, King LTS-D, and endotracheal tube volumes were statistically comparable. Paramedics ventilated larger volumes than emergency medical technicians.

CONCLUSIONS

Using a pediatric manual resuscitator on adult patients is not supported by our findings.

The Effect of Different Types of Laryngeal Mask Airways on Sound Quality: A Prospective Randomized Study

Background

Although the deterioration in sound quality is not as much as endotracheal intubation, it can also be seen after the use of laryngeal mask airway (LMA). The aim of this study is to investigate the effects of different LMA types on voice performance.

Methods

This study included 88 patients aged 18-80 years, whose surgical procedure was not planned to take longer than 120 minutes. In the acoustic voice analysis, F0, jitter%, and shimmer% were examined. In addition, the Voice Handicap Index (VHI)-30 questionnaire has completed an evaluation of voice quality. The patients were randomly divided into two groups (I-gel LMA [n=44]; Classic LMA [n=44]) according to the closed envelope method.

Results

A total of 88 patients were included in the study. Demographic data of the patients were statistically similar between the groups (p > 0.05). The changes in the preoperative and postoperative F0, jitter, and VHI-30 values in the I-gel group were statistically significant (p: 0.002, p: 0.001, p < 0.001). Shimmer values were not significantly different (p: 0.762). In the classical LMA group, preoperative and postoperative F0, jitter, shimmer, and VHI-30 values were statistically significantly different (p: 0.001, p: 0.012, p: 0.036, p < 0.001).

Conclusion

I-gel LMA and classic LMA negatively affect voice performance in the preoperative and postoperative periods. This situation was also observed in the VHI-30 index test. However, when this situation was evaluated in terms of shimmer analysis, the decrease in voice quality in the early postoperative period was more limited in the I-gel group.

Influence of temperature on volume, weight and density changes of i-gel masks

BACKGROUND

The i-gel mask is a second-generation, single-use supraglottic airway device which does not have an inflatable cuff. The cuff consists of a thermoplastic elastomer and its mechanism of sealing still remains unclear. Various theories such as temperature-dependent changes in hardness and volume expansion as well as fluid absorption have been discussed. The aim of the present study is to investigate changes in volume, weight and density caused by temperature changes.

MATERIAL AND METHODS

Three i-gel masks (sizes 3, 4 and 5) were heated in a water bath from 10°C to 50°C in 5°C steps. The changes in weight, volume, and density were measured at each temperature step. In a second study, the identical parameters of masks (n = 5 of sizes 3, 4 and 5) used in patients were investigated. Results of volume and density between benchtop and patient measurements were examined for correlation.

RESULTS

All masks investigated, regardless of the size, showed a significant linear temperature-dependent volume expansion (sizes 3, 4 and 5: P < 0.001), a weight increase (sizes 3: P = 0.018; 4: P = 0.027; and 5: P = 0.006) and a linear decrease in density (sizes 3, 4 and 5: P < 0.001). There was a very strong correlation between the results of benchtop and patient measurements (volume: P < 0.001; density: P < 0.001).

CONCLUSIONS

We observed significant changes in all three properties investigated. Thus, a temperature-dependent volume expansion and weight increasement was observed, which can be considered as a further explanation for improved sealing after insertion.

Comparison of the airway complications of subtypes of laryngeal mask airway and i-gel in child patients under general anaesthesia: a protocol for systematic review and network meta-analysis of randomised control trials

INTRODUCTION

Laryngeal mask airway (LMA), an alternative to traditional tracheal intubation, is widely used in clinical practice and is considered to be an effective device for airway management. LMA and i-gel have been widely used in anaesthesia and emergency situations in children. Some systematic reviews have evaluated the efficacy of LMA and i-gel in children, but they have not shown consistent results in clinical performance. This study aims to evaluate the airway complications of all subtypes of LMA and i-gel in child patients under general anaesthesia using a Bayesian network meta-analysis (NMA).

METHODS AND ANALYSIS

PubMed, EMBASE.com, the Cochrane library, Web of Science and Chinese Biomedical Literature Database will be searched from inception to January 2019. We will include prospective randomised controlled trials (RCTs) that reported the subtypes of LMA and i-gel regardless of sample size. The risk of bias assessment of the included RCTs will be conducted according to the Cochrane Handbook V.5.1.0. A Bayesian NMA will be performed using WinBUGS V.1.4.3. Grading of Recommendations Assessment, Development and Evaluation will be used to explore the quality of evidence.

ETHICS AND DISSEMINATION

Ethics approval and patient consent are not required as this study is an NMA based on published trials. The results of this NMA will be submitted to a peer-reviewed journal for publication.

PROSPERO REGISTRATION NUMBER

CRD42019127668.

Comparative study of fiber-optic guided tracheal intubation through intubating laryngeal mask airway LMA Fastrach™ and i-gel in adult paralyzed patients

Background:

The i-gel is a novel and innovative supraglottic airway management device used both as an airway rescue device and as a conduit for fiberoptic intubation. In this prospective randomized study, we compared fiberoptic-guided tracheal intubation through the i-gel and LMA Fastrach™ in adult paralyzed patients.

Materials and Methods:

After ethical committee approval and written informed consent, 60 patients of either sex were randomly allocated to either group of supraglottic airway device (SGAD). After successful insertion of the SGAD, the fiberoptic bronchoscope (FOB)-guided tracheal intubation was done through the respective SGAD. The primary objectives were the ease and time taken for fiberoptic-guided intubation in either group. Secondary variables included time taken for successful placement of SGAD, ease of insertion of SGAD, airway seal pressure, ease and time of removal of SGAD, variation in hemodynamic parameters, and complications if any.

Results:

Time taken for tracheal intubation in LMA Fastrach™ group was 69.53 ± 5.09 s and for the i-gel group it was 72.33 ± 6.73 s. It was seen that it was easy to insert the endotracheal tube (ETT) in 93.3% patients in the LMA Fastrach™ group and 96.7% patients in the i-gel group. Airway seal pressure was higher for the LMA Fastrach™ group. Both the SGADs were comparable in the number of attempts of insertion, ease of insertion, and insertion time. In addition, the hemodynamic variables noted did not show any increase after insertion of SGAD. There was no difficulty encountered in removal of either SGAD.

Conclusion:

I-gel may be a reliable and cost-effective alternative to LMA Fastrach™ for fibreoptic-guided tracheal intubation.

A Randomized Controlled Trial Comparing Ambu AuraGain and i-gel in Young Pediatric Patients

Supraglottic airway devices have been increasingly used because of their several advantages. Previous studies showed that the small-sized i-gel provides effective ventilation for young pediatric patients; however, few studies have reported the use of AuraGain in these patients. Herein, we compared the clinical performance of AuraGain and i-gel in young pediatric patients aged between 6 months and 6 years old and weighing 5–20 kg, who were scheduled to undergo extremity surgery under general anesthesia. In total, 68 patients were enrolled and randomly allocated into two groups: AuraGain group and i-gel group. The primary outcome was the requirement of additional airway maneuvers. We also analyzed insertion parameters, fiberoptic bronchoscopic view, oropharyngeal leak pressure, and peri-operative adverse effects. Compared with the AuraGain group, the i-gel group required more additional airway maneuvers during the placement of the device and maintenance of ventilation. The fiberoptic view was better in the AuraGain group than in the i-gel group. However, the oropharyngeal leak pressure was higher in the i-gel group. AuraGain might be a better choice over i-gel considering the requirement of additional airway maneuvers. However, when a higher oropharyngeal leak pressure is required, the i-gel is more beneficial than AuraGain.

Optimal propofol dosage for i-gel® insertion in healthy paralyzed patients

Background

Propofol is used for supraglottic airway device insertion, often with the i-gel. However, the propofol requirement for i-gel insertion has not been explored in paralyzed patients. This study was performed to explore hemodynamic changes and sedation level with different propofol doses in healthy paralyzed patients when the i-gel was inserted.

Methods

A total of 141 patients undergoing a urologic operation were randomly allocated to three groups depending on the propofol dose (1.5, 2, and 2.5 mg/kg; Groups P1.5, P2, and P2.5, respectively). After patients had been administered each propofol dose and rocuronium, the i-gel was inserted and changes in hemodynamic parameters and bispectral index were evaluated.

Results

Group P2 showed a lower incidence of complications (17%) such as hemodynamic instability and inadequate sedation than Group P1.5 (55.3%, P < 0.001) or Group P2.5 (40.4%, P = 0.012). The incidence and dose of additional propofol increased in Group P1.5 (51%, median [range]; 20 [0–50]) compared with those in the other groups (0%, 0 [0–0] in Group P2 and 8.5%, 0 [0–50] in Group P2.5, all P < 0.001), and the incidence and dose of additional ephedrine were significantly higher in Group P2.5 (31.9%; 0 [0–20]) than in Group P1.5 (10.6%, P = 0.012; 0 [0–5], P = 0.007, respectively).

Conclusions

For the stable maintenance of hemodynamic parameters and proper sedation level during i-gel insertion, 2 mg/kg propofol has an advantage over 1.5 mg/kg or 2.5 mg/kg propofol in healthy paralyzed patients.

Application of Discharge Criteria for Home Readiness Using Bispectral and Supraglottic Airway Devices in Day-care Surgery without Using Muscle Relaxants

Introduction

The availability of rapid and short-acting intravenous and volatile anesthetics has facilitated early recovery that is why nowadays ambulatory surgery is becoming more common. If the criteria used to discharge patients from the Postanesthesia Care Unit (PACU) are met in the operating room (OR), it would be appropriate to consider bypassing the PACU and transferring the patient directly to the step-down unit. This process is known as "fast-tracking" after ambulatory surgery.

Aims

To compare hemodynamic characteristics and recovery profile as per fast-track criteria (FTC) of recovery and postanesthesia discharge scoring system (PADSS) between sevoflurane and desflurane.

Materials and Methods

One hundred American Society of Anesthesiologists Class I-II patients aged 20-50 years were randomly divided into two groups. Following anesthesia induction with injection propofol and injection dexmedetomidine airway was secured with i-gel, Group D (n = 50) received desflurane + dexmedetomidine + O₂ + N₂O and Group S (n = 50) received sevoflurane in place of desflurane. Emergence time was noted and FTC was evaluated in the OR, Score >12 is considered as shifting criteria for ambulatory surgery unit (ASU). PADSS was noted in ASU at an interval of 15 min for 3 h and Score >9 is considered as ready to discharge home.

Results

Response to pain, verbal commands, and spontaneous eye opening in Group D was shorter than that in Group S (P = 0.001). Mean time to achieve FTC score >12 was 15 min in both the groups. Eighty-six percent of patients were ready to go home between 60 and 90 min using PADSS.

Conclusion

We concluded that early recovery is faster for desflurane, and there is no difference in ready to go home time between desflurane and sevoflurane.

Comparison of oropharyngeal leak pressure of air-Q™, i-gel™, and laryngeal mask airway supreme™ in adult patients during general anesthesia: A randomized controlled trial

Study Objective:

Various randomized controlled trials and a meta-analysis have compared i-gel™ and laryngeal mask airway Supreme™ (LMA-S™) in adult patients and found that both the devices provided equivalent oropharyngeal leak pressure (OLP). However, no randomized controlled trial has compared air-Q™ with i-gel™ and LMA-S™ in adult patient. Hence, we designed this study to compare air-Q™ with LMA-S™ and i-gel™ in adult patients.

Materials and Methods:

A total of 75 adult patients of the American Society of Anesthesiologists physical status I/II of both sexes, between 18 and 60 years, were included in this prospective randomized controlled trial conducted in a tertiary care center. Randomization of patients was done in three equal groups according to the insertion of supraglottic airway device by a computer-generated random number sequence: group air-Q™ (n = 25), group i-gel™ (n = 25), and group LMA-S™ (n = 25). Primary outcome of this study was OLP. We also recorded time for successful placement of device, ease of device insertion, number of attempts to insert device, and ease of gastric tube insertion along with postoperative complications.

Results:

The mean ± standard deviation OLP of air-Q™, i-gel™, and LMA-S™ was 26.13 ± 4.957 cm, 23.75 ± 5.439 cm, and 24.80 ± 4.78 cm H₂O (P = 0.279). The first insertion success rate for air-Q™, i-gel™, and LMA-S™ was 80%, 76%, and 92%, respectively (P = 0.353). The insertion time of air-Q™, i-gel™, and LMA-S™ was 20.6 ± 4.4, 14.8 ± 5.4, and 15.2 ± 4.7 s, respectively (P = 0.000). Time taken for air-Q™ insertion was significantly higher than time taken for i-gel™ (mean difference 5.8 s, P < 0.0001) and LMA-S™ (mean difference 5.4 s, P = 0.0001) insertion. Postoperative complications were similar with all three devices.

Conclusions:

We concluded that air-Q™, i-gel™, and LMA-S™ were equally efficacious in terms of routine airway management in adult patients with normal airway anatomy.

A comparison of i-gel™ and Laryngeal Mask Airway Supreme™ during general anesthesia in infants

Background

The i-gel™ (i-gel) and Laryngeal Mask Airway Supreme™ (LMA Supreme) have been safely used in children. We compared the airway performance of the i-gel and LMA Supreme in infants undergoing general anesthesia.

Methods

Sixty infants with American Society of Anesthesiologists physical status I or II were randomly assigned to place either the i-gel or the LMA Supreme. The size 1 or 1.5 of each airway was selected by the weight of infants. The primary outcome variable was oropharyngeal leak pressure (OLP). We also assessed insertion success rate, insertion time, fiberoptic view of the larynx, airway quality, airway manipulations, and perioperative complications.

Results

Demographic data did not differ between the two groups. Insertion success rate was similar in both groups. OLP for the i-gel (26.0 ± 3.8 cmH₂O) was higher than for the LMA Supreme (23.7 ± 3.2 cmH₂O) (P = 0.016). Insertion time for the i-gel (16.4 ± 2.8 s) was shorter than for the LMA Supreme (18.5 ± 2.7 s) (P = 0.002). There were no differences in fiberoptic view of the larynx, airway quality, airway manipulations, and complications between the two groups.

Conclusions

This study demonstrated that the i-gel and LMA Supreme provided a similar performance of airway in infants. Compared with the LMA Supreme, the i-gel provided shorter insertion time and higher OLP in infants.

Comparison of the clinical performance of i-gel, LMA Supreme and LMA ProSeal in elective surgery

INTRODUCTION

The LMA Supreme™, i-gel® and LMA ProSeal™ are second-generation supraglottic airway devices. We tested the hypothesis that these devices differ in performance when used for spontaneous ventilation during anaesthesia.

METHODS

150 patients who underwent general anaesthesia for elective surgery were randomly allocated into three groups. Data was collected on oropharyngeal leak pressures, ease and duration of device insertion, ease of gastric tube insertion, and airway safety.

RESULTS

Leak pressure, our primary outcome measure, was found to be higher for the i-gel than the Supreme and ProSeal (mean ± standard error of the mean: 27.31 ± 0.92 cmH2O, 23.60 ± 0.70 cmH2O and 24.44 ± 0.70 cmH2O, respectively; p = 0.003). Devices were inserted on the first attempt for 90%, 82% and 72% of patients in the i-gel, Supreme and ProSeal groups, respectively (p = 0.105); mean device placement times were 23.58 seconds, 25.10 seconds and 26.34 seconds, respectively (p = 0.477). Gastric tubes were inserted on the first attempt in 100% of patients in the Supreme group, and 94% of patients in the i-gel and ProSeal groups (p = 0.100). There was blood staining on removal in 9 (18%) patients in each of the Supreme and ProSeal groups, with none in the i-gel group (p = 0.007). The incidence of postoperative sore throat, dysphagia and hoarseness was lowest for the i-gel.

CONCLUSION

The three devices were comparable in terms of ease and duration of placement, but the i-gel had higher initial oropharyngeal leak pressure and lower airway morbidity compared with the ProSeal and Supreme.

A randomized comparison of volume- and pressure-controlled ventilation in children with the i-gel: Effects on peak inspiratory pressure, oropharyngeal leak pressure, and gastric insufflation

BACKGROUND

The i-gel provides good airway sealing but gastric insufflation may occur when peak inspiratory pressure (PIP) exceeds the sealing pressure of the i-gel without a gastric tube. Pressure-controlled ventilation (PCV) provides lower PIP compared with volume-controlled ventilation (VCV) and low PIP may reduce the incidence of gastric insufflation in children during positive pressure ventilation. This study was designed to evaluate PIP, oropharyngeal leak pressure, and gastric insufflation during VCV or PCV in children undergoing general anesthesia with i-gel without a gastric tube in situ.

METHODS

A prospective, randomized-controlled study was conducted. Thirty-four children, aged 6 to 84 months, were randomly allocated into the VCV or PCV group. Fiberoptic bronchoscopy was performed to confirm appropriate position of i-gel. Oropharyngeal leak pressure and PIP were measured after i-gel insertion, after caudal block, and after surgery. Ultrasonography was performed to detect gastric insufflation. Gastric tube was not inserted.

RESULTS

PIP in cm H2O was significantly lower in the PCV group than in the VCV group after i-gel insertion (10 [9-12] vs 12 [11-15], P = .021), after caudal block (11 [10-12] vs 13 [11-15], P = .014), and after surgery (10 [10-12] vs 13 [11-14], P = .002). There was no difference in the incidence of gastric insufflation between the 2 groups (4/17 in the VCV group and 3/17 in the PCV group) (P > .999).

CONCLUSION

When i-gel was used without a gastric tube, gastric insufflation occurred regardless of the ventilation modes, which provided different PIP.

I-Gel is a suitable alternative to endotracheal tubes in the laparoscopic pneumoperitoneum and trendelenburg position

Background

The use of supraglottic airway devices (SADs) in surgeries with laparoscopic pneumoperitoneum and Trendelenburg (LPT) positioning is controversial due to concerns about insufficient pulmonary ventilation and aspiration. In this prospective, randomized-controlled trial, we evaluated whether the i-gel, a new second generation SAD, provides an effective alternative to an endotracheal tube (ETT) by comparing respiratory parameters and perioperative respiratory complications in non-obese patients.

Methods

In a randomized controlled trial, forty anesthetized patients with ASA I-II were divided into equally sized i-gel and ETT groups. We evaluated the respiratory parameters in the supine and LPT position in comparison between the two groups. The leak fraction was our primary outcome, which was defined as the leak volume divided by the inspired tidal volume. The leak volume was the difference between the inspired and expired tidal volumes. We also monitored pulmonary aspiration and respiratory complications during the perioperative period.

Results

In the LPT position, there were no differences in the leak fraction (median [IQR]) between the i-gel and ETT groups (6.20[3.49] vs 6.38[3.71] %, P = 0.883). In the i-gel group, notably less leakage was observed in the LPT position than in the supine position (median [IQR]: 7.01[3.73] %). This phenomenon was not observed in the ETT group. The rate of postoperative sore throat was also significantly lower in the i-gel group than in the ETT group (3/17 vs 9/11). No vomitus nor any signs associated with aspiration were noted in our patients after extubation in the follow-up prior to discharge.

Conclusions

The i-gel provides a suitable alternative to an ETT for surgeries with LPT positioning in non-obese patients.

Trial registration

Registered at Clinicaltrials.gov NCT02462915, registered on 1 June 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s12871-016-0291-1) contains supplementary material, which is available to authorized users.

A randomised controlled trial comparing ProSeal laryngeal mask airway, i-gel and Laryngeal Tube Suction-D under general anaesthesia for elective surgical patients requiring controlled ventilation

Background and Aims:

The ProSeal™ laryngeal mask airway (PLMA), i-gel™ and Laryngeal Tube Suction-D (LTS-D™) have previously been evaluated alone or in pair-wise comparisons but differing study designs make it difficult to compare the results. The aim of this study was to compare the clinical performance of these three devices in terms of efficacy and safety in patients receiving mechanical ventilation during elective surgical procedures.

Methods:

This prospective, randomised, double-blind study was conducted on 150 American Society of Anesthesiologists physical status I–II patients, randomly allocated into 3 groups, undergoing elective surgical procedures under general anaesthesia. PLMA, i-gel™ or LTS-D™ appropriate for weight or/and height was inserted. Primary outcome measured was airway sealing pressure. Insertion time, ease of insertion, number of attempts, overall success rate and the incidence of airway trauma and complications were also recorded. Intergroup differences were compared using one-way analysis of variance with post hoc correction for continuous data and Chi-square test for categorical variables.

Results:

Overall success rate was comparable between the three devices (i-gel™ 100%, LTS-D™ 94%, PLMA 96%). Airway sealing pressure was lower with i-gel™ (23.38 ± 2.06 cm H₂O) compared to LTS-D™ (26.06 ± 2.11 cm H₂O) and PLMA (28.5 ± 2.8 cm H₂O; P < 0.0005). The mean insertion time was significantly more in PLMA (38.77 ± 3.2 s) compared to i-gel™ (27.9 ± 2.53 s) and LTS-D™ (21.66 ± 2.31 s; P < 0.0005).

Conclusion:

Airway sealing pressure and insertion time were significantly higher in PLMA compared to i-gel™ and LTS-D™.

Dexmedetomidine infusion as an anesthetic adjuvant to general anesthesia for appropriate surgical field visibility during modified radical mastectomy with i-gel®: a randomized control study

Background

Modified radical mastectomy is associated with appreciable blood loss, while endotracheal intubation leads to elevated hemodynamic responses. The present study aimed to evaluate the clinical efficacy of dexmedetomidine infusion as an anesthetic adjuvant to general anesthesia during modified radical mastectomy with I-Gel.

Methods

Sixty adult consenting female patients, of American Society of Anesthesiologists physical status 1 to 2 and aged 4,065 years, were blindly randomized into two groups of 30 patients each. The patients in Group I received intravenous dexmedetomidine at a loading dose of 1 µg/kg over 10 min, followed by maintenance infusion of 0.4 to 0.7 µg/kg/h, while patients in Group II were administered an identical amount of saline infusion until 15 min prior to the end of surgery. The primary end point was bleeding at the surgical field and hemodynamic changes; requirement of isoflurane, intraoperative fentanyl consumption and recovery time were assessed as secondary outcomes.

Results

The patients receiving dexmedetomidine infusion showed significantly less bleeding at the surgical field (P < 0.05). A statistically significant reduction was also observed in the percentage of isoflurane required (0.82 ± 0.80%) to maintain the systolic blood pressure between 100 and 110 mmHg in patients receiving dexmedetomidine infusion compared with the Group II (1.50 ± 0.90%). The mean intraoperative fentanyl consumption in patients in the Group I was also significantly lower compared with that of the Group II (38.43 ± 5.40 µg vs. 75.12 ± 4.60 µg). The mean recovery time from anesthesia did not show any clinically significant difference between the groups.

Conclusions

Dexmedetomidine infusion can be used safely to decrease the bleeding at the surgical field with smooth recovery from anesthesia.

Laryngeal mask airway ProSeal provides higher oropharyngeal leak pressure than i-gel in adult patients under general anesthesia: a meta-analysis

STUDY OBJECTIVE

i-gel is a single-use supraglottic airway device that has a gastric drain tube similar to laryngeal mask airway (LMA) ProSeal. Randomized trials, when compared i-gel with LMA ProSeal, reported a differing results. Primary objective of this study is to compare LMA ProSeal and i-gel in terms of oropharyngeal leak pressure.

DESIGN

Meta-analysis of randomized controlled trials where i-gel has been compared to LMA ProSeal in adult airway management during general anesthesia.

SETTING

Teaching institutions.

MEASUREMENTS

PubMed, PubMed Central, and Cochrane databases were searched with search words "i-gel," "i-gel laryngeal mask airway," "i-gel ProSeal," and "i-gel LMA ProSeal" to find out the randomized controlled trials that compared i-gel with LMA ProSeal in terms of safety and efficacy. A total of 10 prospective randomized trials have been included in this meta-analysis.

MAIN RESULTS

LMA ProSeal provides higher oropharyngeal leak pressure than i-gel (mean difference, 3.37 cm H2O; 95% confidence interval, 1.80-4.95 cm H2O; P< .0001). Time to insert the device, first insertion success rate, and ease of gastric tube insertion are similar with both the devices, but i-gel may be easier to insert. Although the reported complications are not frequent and not very serious, a significantly higher blood staining on the mask has been noted with LMA ProSeal (odds ratio, 0.27; 95% confidence interval, 0.13-0.56; P= .0004).

CONCLUSION

LMA ProSeal may still remain the supraglottic device of choice over i-gel in adult patients during general anesthesia as it provided better seal against leak pressure with comparable device insertion characteristics.

Muscle relaxant facilitates i-gel insertion by novice doctors: A prospective randomized controlled trial

STUDY OBJECTIVE

This study aimed to determine whether muscle relaxants facilitates insertion efficacy of the i-gel supraglottic device (i-gel) by novice doctors in anesthetized patients.

DESIGN

Randomized clinical trial.

SETTING

Operating room.

PATIENTS

Seventy adult patients scheduled for elective surgery under general anesthesia.

INTERVENTIONS

Seventy adult patients were assigned to the rocuronium (MR group; 35 patients) or control group (C group; 35 patients). Anesthesia was induced with propofol and remifentanil, and 0.9mgkg(-1) rocuronium was administered in the MR group.

MEASUREMENTS

The number of attempts to successful insertion, sealing pressure, and subjective difficulty of insertion were compared between the groups.

MAIN RESULTS

The total number of insertion attempts were as follows: one (MR group, 17 cases; C group, 4 cases), two (MR group, 13 cases; C group, 14 cases), three (MR group, 4 cases; C group, 14 cases), and failure (MR group, 1 case; C group, 3 cases), which was significantly different (P<.001). Sealing pressure was significantly higher in the MR group than in the C group (MR group, 22.1±5.4 cmH2O; C group, 18.7±3.2 cmH2O, P<.001). Subjective difficulty of insertion was significantly lower in the MR group than in the C group (C group, 72.4±19.0mm; MR group, 29.4±18.3mm; P<.001).

CONCLUSIONS

Our randomized clinical trial suggests that muscle relaxation facilitates i-gel insertion efficacy in anesthetized patients, as assessed by successful insertion rate, sealing pressure, and subjective difficulty of insertion.

Comparison of remifentanil EC50 for facilitating i-gel and laryngeal mask airway insertion with propofol anesthesia

OBJECTIVE

Each supraglottic airway requires different anesthetic depth because it has a specific structure and different compressive force in the oropharyngeal cavity. We designed the study to compare the effect-site concentration (Ce) of remifentanil in 50 % of patients (EC50) for successful insertion of the i-gel second-generation supraglottic airway device with that for laryngeal mask airway (LMA) insertion during target-controlled infusion (TCI) of propofol.

METHODS

Forty-one female patients were randomized to the i-gel group (n = 20) or the LMA group (n = 21). Anesthesia was induced with propofol Ce of 5 μg/ml and the predetermined remifentanil Ce, and the i-gel or LMA was inserted 5 min later. The remifentanil Ce was estimated by modified Dixon's up-and-down method (initial concentration: 3.0 ng/ml, step size: 0.5 ng/ml). The patient's response to device insertion was classified as either "success (no movement)" or "failure (movement)".

RESULTS

Using the Dixon's up-and-down method, EC50 of remifentanil Ce for the i-gel (1.58 ± 0.41 ng/ml) was significantly lower than that for LMA (2.25 ± 0.55 ng/ml) (p = 0.038). Using isotonic regression, EC50 (83 % CI) of remifentanil in the i-gel group [1.50 (1.37-1.80) ng/ml] was statistically lower than that in the LMA group [2.00 (1.82-2.34) ng/ml]. EC95 (95 % CI) of remifentanil in the i-gel group [2.38 (1.48-2.50) ng/ml] was statistically lower than that in the LMA group [3.35 (2.58-3.48) ng/ml].

CONCLUSIONS

We found that EC50 of remifentanil Ce for i-gel insertion (1.58 ng/ml) was significantly lower than that for LMA insertion (2.25 ng/ml) in female patients during propofol TCI without neuromuscular blockade.

A randomised trial to compare i-gel and ProSeal™ laryngeal mask airway for airway management in paediatric patients

Background and Aims:

i-gel™ is a newer supraglottic airway device with a unique non-inflatable cuff. We aimed to compare i-gel™ with ProSeal™ laryngeal mask airway (PLMA™) in children scheduled for surgery under general anaesthesia (GA) with controlled ventilation.

Methods:

This prospective, randomised controlled study was conducted in 100 surgical patients, aged 2–6 years of American Society of Anesthesiologists Physical Status I–II scheduled under GA. Patients were randomly allocated to receive either size 2 i-gel™ or PLMA™ as an airway device. The primary aim was oropharyngeal leak pressure assessed at 5 min following correct placement of the device. Secondary outcomes measured included number of attempts, ease of insertion, time of insertion, quality of initial airway, fibre-optic grading and effects on pulmonary mechanics. Statistical analysis was done using paired t-test and Chi-square test.

Results:

The demographic data were similar in both the groups. The oropharyngeal leak pressure in the i-gel™ group was 29.5 ± 2.5 cmH₂ O as compared to 26.1 ± 3.8 cmH₂ O in PLMA™ group (P = 0.002). The time taken for successful insertion in PLMA™ was longer as compared to i-gel (12.4 ± 2.7 vs. 10.2 ± 1.9 s, P = 0.007). The quality of initial airway was superior with i-gel™. The number of attempts, ease of insertion of supraglottic device, insertion of orogastric tube and pulmonary mechanics were similar in both the groups.

Conclusion:

Size 2 i-gel™ exhibited superior oropharyngeal leak pressure and quality of airway in paediatric patients with controlled ventilation as compared to PLMA™ although the pulmonary mechanics were similar.

Small is the new big: An overview of newer supraglottic airways for children

Almost all supraglottic airways (SGAs) are now available in pediatric sizes. The availability of these smaller sizes, especially in the last five years has brought a marked change in the whole approach to airway management in children. SGAs are now used for laparoscopic surgeries, head and neck surgeries, remote anesthesia; and for ventilation during resuscitation. A large number of reports have described the use of SGAs in difficult airway situations, either as a primary or a rescue airway. Despite this expanded usage, there remains little evidence to support its usage in prolonged surgeries and in the intensive care unit. This article presents an overview of the current options available, suitability of one over the other and reviews the published data relating to each device. In this review, the author also addresses some of the general concerns regarding the use of SGAs and explores newer roles of their use in children.

A prospective study to evaluate and compare laryngeal mask airway ProSeal and i-gel airway in the prone position

Background:

Prone position is commonly used to provide surgical access to a variety of surgeries. In view of the advantages of induction of anesthesia in the prone position, we conducted a randomized study to evaluate and compare ProSeal laryngeal mask airway (LMA) and i-gel in the prone position.

Materials and Methods:

Totally, 40 patients of either sex as per American Society of Anesthesiologists physical status I or II, between 16 and 60 years of age, scheduled to undergo surgery in prone position were included in the study. After the patients positioned themselves prone on the operating table, anesthesia was induced by the standard technique. LMA ProSeal was used as an airway conduit in group 1 while i-gel was used in group 2. At the end of surgery, the airway device was removed in the same position.

Results:

Insertion of airway device was successful in first attempt in 16, and 17 cases in ProSeal laryngeal mask airway (PLMA) and i-gel groups, respectively. A second attempt was required to secure the airway in 4 and 3 patients in PLMA and i-gel groups, respectively. The mean insertion time was 21.8 ± 2.70 s for group 1 and 13.1 ± 2.24 s for group 2, the difference being statistically significant (P < 0.05). The mean seal pressure in group 1 was 36 ± 6.22 cm H₂ O and in group 2 was 25.4 ± 3.21 cm H₂ O. The difference was statistically significant (P < 0.05). 13 patients in group 1 had fiberoptic bronchoscopy (FOB) grade 1 while it was 6 for group 2. The remaining patients in both groups had FOB grade 2.

Conclusion:

Insertion of supraglottic airways and conduct of anesthesia with them is feasible in the prone position. The PLMA has a better seal while insertion is easier with i-gel.

The i-gel as a conduit for the Aintree intubation catheter for subsequent fiberoptic intubation

We report a clinical case of an 128 kg, 53 year old male, who was scheduled for sleeve gastrectomy surgery. Video laryngoscope (GlideScope - Verathron) assisted intubation was attempted. Despite repositioning of the head and neck and external laryngeal manipulations, two attempts to lift the epiglottis were unsuccessful. An i-gel (Intersurgical, Wokingham, Berkshire, United Kingdom) supraglottic device was successfully placed and normal oxygenation and ventilation was established with pressure controlled ventilation. An Aintree intubation catheter (AIC, Cook Medical, USA) pre-loaded onto a pediatric fiberoptic bronchoscope (FOB) was advanced through the i-gel. After fiber optic visualization of the vocal cords, the AIC and FOB were successfully placed into the patient's trachea. We conclude that the i-gel may not only serve as a substitute for failed tracheal intubation, but is also useful as a conduit for subsequent fiberoptic intubation.

A comparison of surfactant administration through i-gel and ET-tube in the treatment of respiratory distress syndrome in newborns weighing more than 2000 grams

BACKGROUND

Surfactant administration together with nasal Continuous Positive Airway Pressure (nCPAP) administration is considered to be the basis for Newborn's Respiratory Distress Syndrome (RDS) management. This study evaluated the method of directing the surfactant to the lungs in newborns affiliated with RDS through i-gel (i-gel surfactant administration/i-gelSA) compared to the standard care INSURE method, in a clinical trial.

MATERIALS AND METHODS

This randomized control trial (RCT) was done on newborns weighing ≥2000 g, with RDS, while being supported with Bubble-CPAP. Newborns, which required FiO2 ≥0.3 under Continuous Distending Pressure (CDP) ≥5 cm H2O for more than 30 minutes to maintain SpO2 in the range of 89 - 95%, were given 100 mg/kg of Survanta. In the interventional group or the i-gelSA (i-gel Surfactant Administration) group, 35 newborns experienced surfactant administration with i-gel and 35 newborns in the control or INSURE group. The average a/APO2 before and after surfactant administration, repeated need for surfactant administration, average nCPAP duration, need for invasive mechanical ventilation, pneumothorax, and the average duration of hospitalization in the Neonatal Intensive Care Unit (NICU) were compared.

RESULTS

Although the average a/APO2 showed no significant difference before the procedure; in the i-gelSA group, this average was meaningfully higher after the administration of the surfactant (P = 0.001). The other factors showed no significant difference.

CONCLUSION

According to the results of this study, the surfactant administration using i-gel was more successful in oxygenation improvement than the INSURE method, and the i-gel method could even be promoted to the standard care position. However, more research is needed in this area.

Comparison of I-gel with proseal LMA in adult patients undergoing elective surgical procedures under general anesthesia without paralysis: A prospective randomized study

Background:

We compared i-gel and ProSeal laryngeal mask airway (PLMA) regarding time taken for insertion, effective seal, fiberoptic view of larynx, ease of Ryle's tube insertion, and postoperative sore throat assessment.

Materials and Methods:

In a prospective, randomized manner, 48 adult patients of American Society of Anesthesiologists I-II of either gender between 18 and 60 years presenting for a short surgical procedure were assigned to undergo surgery under general anesthesia on spontaneous ventilation using either the i-gel or PLMA. An experienced nonblinded anesthesiologist inserted appropriate sized i-gel or PLMA in patients using standard insertion technique and assessed the intraoperative findings of the study regarding regarding time taken for respective device insertion, effective seal, fiberoptic view of larynx, ease of Ryle's tube insertion, and postoperative sore throat assessment. Postoperative assessment of sore throat was done by blinded anesthesia resident.

Results:

The time required for insertion of i-gel was lesser (21.98 ± 5.42 and 30.60 ± 8.51 s in Group I and Group P, respectively; P = 0.001). Numbers of attempts for successful insertions were comparable and in majority, device was inserted in first attempt. The mean airway leak pressures were comparable. However, there were more number of patients in Group P who had airway leak pressure >20 cm H₂O. The fiberoptic view of glottis, ease of Ryle's tube insertion, and incidence of complications were comparable.

Conclusion:

Time required for successful insertion of i-gel was less in adult patients undergoing short surgical procedure under general anesthesia on spontaneous ventilation. Patients with airway leak pressure >20 cm H₂O were more in PLMA group which indicates its better suitability for controlled ventilation.

Use of i-gel in magnetic resonance imaging

Anesthesia for magnetic resonance imaging (MRI) requires special equipment that can be used in the presence of a magnetic field. Endotracheal tube and various laryngeal mask airway devices have a variable quantity of ferromagnetic material in the pilot balloon that could reduce image quality and result in artifacts. The i-gel is a reliable, easily inserted airway device, and causes minimal interference in image quality. We used i-gel in 10 anaesthetized adult patients undergoing MRI. The quality of image, evidence of airway, tongue, and dental trauma were assessed throughout the procedure. All scans were diagnostically adequate. Therefore, we concluded that i-gel causes the least ferromagnetic interference compared with other devices and improves the quality of imaging and produces minimal artifact while scanning.

Comparison of the i-gel™ and the Laryngeal Mask Airway Classic™ in terms of clinical performance

PURPOSE

The i-gel™ is one of the second generation supraglottic airway devices. Our study was designed to compare the i-gel and the Laryngeal Mask Airway Classic™ with respect to the clinical performance.

METHODS

We compared the performance of the i-gel with that of the Laryngeal Mask Airway Classic in 120 patients undergoing urologic surgery during general anesthesia without muscle relaxant with respect to the number of attempts for successful insertion, insertion time, peak airway pressure, incidence of regurgitation, fiberoptic glottic view and postoperative complications. Second generation supraglottic airway devices were inserted by the same anesthesiologist, experienced in use of both devices (>200 uses and first time failure rate <5%). Methylene blue method was used to detect gastric regurgitation.

RESULTS

There was no statistical difference between the two groups regarding the success of insertion of second generation supraglottic airway device (p=0.951). The laryngeal mask insertion time for the i-gel group was significantly shorter than that for the Laryngeal Mask Airway Classic group (11.6±2.4s versus 13.1±1.8s [p=0.001]). The fiberoptic glottic view scores for the i-gel group was significantly better than that for the ones for the Laryngeal Mask Airway Classic group (p=0.001). On fiberoptic view, there was no sign of methylene blue dye at any time point in either group. In addition, there was no difference between the groups in patient response regarding the presence of a sore throat when questioned 24h after the procedure (p=0.752).

CONCLUSION

Both devices had good performance with low postoperative complications and without occurrence of regurgitation. The i-gel provided a shorter insertion time and a better fiberoptic view than the Laryngeal Mask Airway Classic.

Use of extraglottic airways in patients undergoing ambulatory laparoscopic surgery without the need for tracheal intubation

Background:

Second generation extraglottic airway devices with gastric access and separate breathing channels have ushered in a new era where their use is increasingly prevalent in surgical patients who would have been traditionally intubated for general anesthesia. New innovations like the i-gel, which is constructed of a thermoplastic elastomer, provide an airtight seal around patient's perilaryngeal anatomy without the inflatable cuff mechanism found in the laryngeal mask airway supreme (LMAS).

Methods:

We conducted a randomized controlled trial comparing the LMAS with the i-gel in 70 anesthetized paralyzed patients undergoing laparoscopic female sterilization. Our primary outcome measure was the oropharyngeal leak pressure (OLP). We studied secondary outcomes of successful first attempt insertion rates, time and ease of the airway and gastric tube insertion, leak fractions and pharyngeal morbidity.

Results:

We found no difference in the OLP between LMAS and i-gel, 25.9 (4.2) versus 24.4 (4.3) s, P=0.153. Both devices had similar first attempt insertion rates (LMAS 94% vs. i-gel 91%) with similar ease and comparable times to achieve an effective airway, LMAS 14.7 (2.7) versus i-gel 16.5 (9.6) s, P=0.306, although gastric tube insertion was easier and faster for the LMAS, 7.9 (1.9) versus i-gel 14.8 (7.7) s, P<0.005. Intraoperatively, there was a significantly greater leak fraction with the i-gel of 0.06 (0.03) versus 0.04 (0.02) with the LMAS, P=0.013. Three patients (8.6%) with LMAS had mild sore throat; one patient (2.9%) had mucosal injury. No complications were documented in the i-gel group.

Conclusions:

Both these extraglottic airway devices offer similar OLPs, high insertion success rates at the first attempt with similar ease and insertion times (albeit longer gastric tube insertion with i-gel). Both provided effective ventilation despite a higher leak fraction with i-gel that was clinically inconsequential.

Perfusion index versus non-invasive hemodynamic parameters during insertion of i-gel, classic laryngeal mask airway and endotracheal tube

Background:

Perfusion index (PI) is a non-invasive numerical value of peripheral perfusion obtained from a pulse oximeter. In this study, we evaluated the efficacy of PI for detecting haemodynamic stress responses to insertion of i-gel, laryngeal mask airway (LMA) and endotracheal tube and compare, its reliability with the conventional haemodynamic criteria in adults during general anaesthesia.

Methods:

Sixty patients scheduled for elective general surgery under general anaesthesia were randomised to three groups. (i-gel, LMA and ET groups (n=20/group). Heart rate (HR) (positive if ≥10 bpm), systolic blood pressure (SBP), diastolic blood pressure (DBP) (positive if ≥15 mm Hg) and PI (positive if ≤10%) were monitored for 5 min after insertion. Main outcome measures: SBP, DBP, HR and PI were measured before induction of anaesthesia and before and after insertion of the airway device.

Results:

Insertion of airway devices produced significant increases in HR, SBP and DBP in LMA and ET groups. Moreover, PI was decreased significantly by 40%, 100% and 100% in the three groups. Using the PI criterion, the sensitivity was 100% (CI 82.4-100.0%). Regarding the SBP and DBP criterions, the sensitivity was 44.4% (CI 24.6-66.3%), 55.6% (CI 33.7-75.4%) respectively. Also, significant change in the mean PI over time (from pre-insertion value to the 1^st min, 3^rd min, until the 4^th min after insertion without regard the device type), (P<0.001).

Conclusion:

PI is a reliable and easier alternative to conventional haemodynamic criteria for detection of stress response to insertion of i-gel, LMA and ET during propofol fentanyl isoflurane anaesthesia in adult patients.

Performance of the i-gel™ during pre-hospital cardiopulmonary resuscitation

BACKGROUND

Current cardiopulmonary resuscitation (CPR) guidelines recommend airway management and ventilation whilst minimising interruptions to chest compressions. We have assessed i-gel™ use during CPR.

METHODS

In an observational study of i-gel™ use during CPR we assessed the ease of i-gel™ insertion, adequacy of ventilation, the presence of a leak during ventilation, and whether ventilation was possible without interrupting chest compressions.

RESULTS

We analysed i-gel™ insertion by paramedics (n=63) and emergency physicians (n=7) in 70 pre-hospital CPR attempts. There was a 90% first attempt insertion success rate, 7% on the second attempt, and 3% on the third attempt. Insertion was reported as easy in 80% (n=56), moderately difficult in 16% (n=11), and difficult in 4% (n=3). Providers reported no leak on ventilation in 80% (n=56), a moderate leak in 17% (n=12), and a major leak with no chest rise in 3% (n=2). There was a significant association between ease of insertion and the quality of the seal (r=0.99, p=0.02). The i-gel™ enabled continuous chest compressions without pauses for ventilation in 74% (n=52) of CPR attempts. There was no difference in the incidence of leaks on ventilation between patients having continuous chest compressions and patients who had pauses in chest compressions for ventilation (83% versus 72%, p=0.33, 95% CI [-0.1282, 0.4037]). Ventilation during CPR was adequate during 96% of all CPR attempts.

CONCLUSIONS

The i-gel™ is an easy supraglottic airway device to insert and enables adequate ventilation during CPR.

Comparison of three supraglottic devices in anesthetised paralyzed children undergoing elective surgery

CONTEXT

The newest variation of the i-gel supraglottic airway is a pediatric version.

AIMS

This study was designed to investigate the usefulness of the size 2 i-gel compared with the ProSeal laryngeal mask airway (PLMA) and classic laryngeal mask airway (cLMA) of the same size in anesthetized, paralyzed children.

SETTINGS AND DESIGN

A prospective, randomized, single-blinded study was conducted in a tertiary care teaching hospital.

METHODS

Ninety ASA grade I-II patients undergoing lower abdominal, inguinal and orthopedic surgery were included in this prospective study. The patients were randomly assigned to the i-gel, PLMA and cLMA groups (30 patients in each group). Size 2 supraglottic airway was inserted according to the assigned group. We assessed ease of insertion, hemodynamic data, oropharyngeal sealing pressure and postoperative complications.

RESULTS

There were no differences in the demographic and hemodynamic data among the three groups. The airway leak pressure of the i-gel group (27.1±2.6 cmH(2)O) was significantly higher than that of the PLMA group (22.73±1.2 cmH(2)O) and the cLMA group (23.63±2.3 cmH(2)O). The success rates for first attempt of insertion were similar among the three devices. There were no differences in the incidence of postoperative airway trauma, sore throat or hoarse cry in the three groups.

CONCLUSIONS

Hemodynamic parameters, ease of insertion and postoperative complications were comparable among the i-gel, PLMA and cLMA groups, but airway sealing pressure was significantly higher in the i-gel group.

Comparison of i-gel™ supraglottic device with classic laryngeal mask airway in anesthetized paralyzed children undergoing elective surgery

CONTEXT

The newest variation of the i-gel supraglottic airway is a pediatric version.

AIMS

This study was designed to investigate the usefulness of the size 2 i-gel compared with the classic laryngeal mask airway (cLMA) of the same size in anesthetized, paralyzed children.

SETTINGS AND DESIGN

A prospective, randomized, single-blinded study was conducted in tertiary care teaching hospital.

SUBJECT AND METHODS

Sixty ASA grade I-II patients undergoing lower abdominal, inguinal, and orthopedic surgery were included in this prospective study. The patients were randomly assigned to i-gel and cLMA groups (30 patients in each group). Size 2 supraglottic airway was inserted according to the assigned group. We assessed ease of insertion, hemodynamic data, oropharyngeal sealing pressure, and postoperative complications.

STATISTICAL ANALYSIS USED

Parametric data were analyzed with the unpaired t-test and non-parametric data were analyzed with the Chi-square test. Unless otherwise stated, data are presented as mean (SD). Significance was taken as P < 0.05.

RESULTS

There were no differences in the demographic and hemodynamic data among the two groups. The airway leak pressure of the i-gel group (26.1 ± 2.4 cm H2O) was significantly higher than that of the cLMA group (22.64 ± 2.2 cm H2O). The success rates for first attempt of insertion were similar among the two devices. There were no differences in the incidence of postoperative airway morbidity among the two groups.

CONCLUSIONS

Hemodynamic parameters, ease of insertion, and postoperative complications were comparable between the i-gel and cLMA groups, but airway sealing pressure was significantly higher in i-gel group.

Randomized crossover comparison of the laryngeal mask airway classic with i-gel laryngeal mask airway in the management of difficult airway in post burn neck contracture patients

PURPOSE

The objective of the study was to compare the performance of i-gel supraglottic airway with cLMA in difficult airway management in post burn neck contracture patients and assess the feasibility of i-gel use for emergency airway management in difficult airway situation with reduced neck movement and limited mouth opening.

METHODS

Prospective, crossover, randomized controlled trial was performed amongst forty eight post burn neck contracture patients with limited mouth opening and neck movement. i-gel and cLMA were placed in random order in each patient. Primary outcome was overall success rate. Other measurements were time to successful ventilation, airway leak pressure, fiberoptic glottic view, visualization of square wave pattern.

RESULTS

Success rate for the i-gel was 91.7% versus 79.2% for the cLMA. i-gel required shorter insertion time (19.3 seconds vs. 23.5 seconds, P=0.000). Airway leak pressure difference was statistically significant (i-gel 21.2 cm H20; cLMA 16.9 cm H(2)0; P=0.00). Fiberoptic view through the i-gel showed there were less epiglottic downfolding and better fiberoptic view of the glottis than cLMA. Overall agreement in insertion outcome for i-gel was 22/24 (91.7%) successes and 2/24(8.3%) failure and for cLMA, 19/24 (79.16%) successes and 5/24 (16.7%) failure in the first attempt.

CONCLUSION

The i-gel is cheap, effective airway device which is easier to insert and has better clinical performance in the difficult airway management of the airway in the post burn contracture of the neck. Our study shows that i-gel is feasible for emergency airway management in difficult airway situation with reduced neck movement and limited mouth opening in post burn neck.