Aspiration recognition with an i-gel airway

Comparison of oropharyngeal leak pressure and clinical performance of LMA ProSeal™ and i-gel® in adults: Meta-analysis and systematic review

Background

A meta-analysis and systematic review of randomized controlled trials to compare the oropharyngeal leak pressure (OLP) and clinical performance of LMA ProSeal™ (Teleflex® Inc., Wayne, PA, USA) and i-gel® (Intersurgical Ltd, Wokingham, UK) in adults undergoing general anesthesia.

Methods

Searches of MEDLINE®, EMBASE®, CENTRAL, KoreaMed and Google Scholar® were performed. The primary objective was to compare OLP; secondary objectives included comparison of clinical performance and complications.

Results

Fourteen RCTs were included. OLP was significantly higher with LMA ProSeal™ than with i-gel® (mean difference [MD] −2.95 cmH₂O; 95% confidence interval [CI] −4.30, −1.60). The i-gel® had shorter device insertion time (MD −3.01 s; 95% CI −5.80, −0.21), and lower incidences of blood on device after removal (risk ratio [RR] 0.32; 95% CI 0.18, 0.56) and sore throat (RR 0.56; 95% CI 0.35, 0.89) than LMA ProSeal™.

Conclusion

LMA ProSeal™ provides superior airway sealing compared to i-gel®.

Complications Associated with the Use of Supraglottic Airway Devices in Perioperative Medicine

Supraglottic airway devices are routinely used for airway maintenance in elective surgical procedures where aspiration is not a significant risk and also as rescue devices in difficult airway management. Some devices now have features mitigating risk of aspiration, such as drain tubes or compartments to manage regurgitated content. Despite this, the use of these device may be associated with various complications including aspiration. This review highlights the types and incidence of these complications. They include regurgitation and aspiration of gastric contents, compression of vascular structures, trauma, and nerve injury. The incidence of such complications is quite low, but as some carry with them a significant degree of morbidity the need to follow manufacturers' advice is underlined. The incidence of gastric content aspiration associated with the devices is estimated to be as low as 0.02% with perioperative regurgitation being significantly higher but underreported. Other serious, but extremely rare, complications include pharyngeal rupture, pneumomediastinum, mediastinitis, or arytenoid dislocation. Mild short-lasting adverse effects of the devices have significantly higher incidence than serious complications and involve postoperative sore throat, dysphagia, pain on swallowing, or hoarseness. Devices may have deleterious effect on cervical mucosa or vasculature depending on their cuff volume and pressure.

Is I-gel airway a better option to endotracheal tube airway for sevoflurane-fentanyl anesthesia during cardiac surgery?

BACKGROUND

Anesthetists used lower doses of fentanyl, successfully with hemodynamic control by titrating volatile anesthetic agents or vasodilators for fast-tracking in cardiac surgery.

HYPOTHESIS

Lower total doses of anesthetics and fentanyl could be required with hemodynamic control by use of supraglottic devices than endotracheal tube (ETT) and helps in fast-tracking.

DESIGN

A prospective randomized observational clinical trial study.

AIMS

The authors compared the utility of I-gel airway with a conventional ETT during the induction and maintenance of anesthesia with sevoflurane and fentanyl in adults undergoing cardiac surgery.

PATIENTS AND METHODS

A total of 49 adult patients underwent cardiac surgery were randomized into two groups according to the airway management: I-gel group (n = 23) and ETT group (n = 26). Doses of fentanyl and hemodynamic parameters (heart rate [HR], mean arterial pressure [MAP] central venous pressure [CVP], pulmonary artery pressure [PAP], and pulmonary capillary wedge pressure [PCWP]) were recorded preoperative, 5 min following tracheal intubation or I-gel airway insertion, after skin incision, after stenotomy, and after weaning off bypass.

RESULTS

None of the patients in the I-gel group required additional doses of fentanyl during the I-gel insertion, compared with 74% of the patients during laryngoscopy and endotracheal insertion in the ETT group, for an average total dose of 22.6 ± 0.6 μg/kg. The MAP and HR did not significantly differ from the baseline values at any point of measurement in either group. Furthermore, CVP, PAP, and PCWP measured during the procedure were significantly lower in I-gel group than ETT group. Extubation required more amount of time in ETT than I- gel group.

CONCLUSION

The I-gel airway is well-tolerated by adult patients undergoing cardiac surgery, and requires lower total doses of anesthetics than endotracheal intubation with hemodynamic control and helps in fast-tracking.

Intraocular pressure and haemodynamic responses to insertion of the i-gel, laryngeal mask airway or endotracheal tube

CONTEXT

We hypothesised that the effects of insertion of an i-gel supraglottic airway management device on intraocular pressure (IOP) and haemodynamic variables would be milder than those associated with insertion of a laryngeal mask airway (LMA) or an endotracheal tube.

OBJECTIVES

This study evaluated IOP and haemodynamic responses following insertion of an i-gel airway, LMA or endotracheal tube.

DESIGN AND SETTING

This was a randomised controlled study in a tertiary care centre in which 60 adults scheduled for elective non-ophthalmic procedures under general anaesthesia were allocated to one of three groups. Patients with pre-existing glaucoma, cardiovascular, pulmonary or metabolic diseases or anticipated difficult intubation were excluded.

INTERVENTIONS

Following induction of general anaesthesia, an endotracheal tube, LMA or i-gel device was inserted.

MAIN OUTCOME MEASURES

IOP, SBP, DBP, heart rate (HR) and perfusion index were measured before induction of anaesthesia and before and after insertion of the airway device.

RESULTS

Insertion of the i-gel did not increase IOP. Insertion of an endotracheal tube increased IOP from 11.6 ± 1.6 to 16.5 ± 1.7 mmHg (P < 0.001). The post-insertion IOP exceeded the pre-induction value (P < 0.05). Insertion of the LMA increased IOP from 13.0 ± 1.5 to 14.7 ± 1.8 mmHg (P < 0.01), but this did not exceed the pre-induction value. Tracheal intubation significantly increased HR, SBP and DBP. Insertion of the LMA significantly increased HR and SBP. These increases were significantly higher than those which followed insertion of the i-gel device. Insertion of the endotracheal tube or LMA resulted in a significant decrease in perfusion index which was maintained for 5 min following tracheal intubation and for 2 min after insertion of the LMA. Insertion of the i-gel device did not change perfusion index significantly.

CONCLUSION

Insertion of the i-gel device provides better stability of IOP and the haemodynamic system compared with insertion of an endotracheal tube or LMA in patients undergoing elective non-ophthalmic surgery.