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A study of ease of I-GEL insertion

 

 

Abstract               Background and Aims: This randomized, open label experimental study was undertaken to observe the ease of insertion and time taken for insertion of I-GEL. Methods: Thirty adult patients undergoing elective surgery under general anaesthesia were assessed. Ease of insertion of I-GEL was assessed with number of attempts required for insertion. Time taken for insertion and post-operative side effects of I-GEL insertion were also observed. Results: The demographic profile of patients was comparable. In our study out of 30 patients, I-gel was inserted in first attempt in 25 (83.3%) patients, only 5 (16.7%) patient’s required second attempt. Mean time taken for insertion of I-gel was 7.27±2.74 seconds. Hemodynamic response to insertion were similar in all patients and adverse effects were not significant. Conclusion: The I-GEL takes approximately 8 seconds for insertion, with non-significant post-operative adverse effects. I-GEL can be considered as preferred choice of airway for elective surgeries under general anaesthesia.

Key Words: Supraglottic airways, I-GEL, General anaesthesia

 

 

INTRODUCTION

Supraglottic airway devices (SAD) have been the standard fixture in airway management. ¹ It conveniently and effectively fills the bridge in securing airway between tracheal intubation and use of face mask. It has the advantage of being less traumatic and effortless insertion, without the necessity for laryngoscopy. ² Laryngeal mask airway classic is a first generation supraglottic airway device, originally developed by Dr. Archie Brain in 1981. ³ The introduction of laryngeal mask airway (LMA) marked landmark advancement in airway management.⁴ In 1996 LMA even gained entry into the American Society of Anaesthesiologists (ASA) difficult airway algorithm. ⁵ First generation supraglottic airway devices provide little protection against gastric regurgitation and aspiration. Newer devices have incorporated designed elements to minimize this risk.They provide higher airway leak pressure ⁶ than the classic LMA and can be used for spontaneous as well as positive pressure ventilation. The I-gel airway is a novel device having non inflatable anatomical seal of the pharyngeal, laryngeal and peri-laryngeal structures. ^6,7. They have a passage for gastric tube insertion which can be used for gastric deflation and due to this advantage; use of these devices has been increased over a decade. Here, we have observed the ease of insertion, time taken to insert and post operatively occurring side effects of I-GEL.

 

MATERIALS AND METHODS

A randomized, open label experimental study was conducted in 30 patients in Department of Anesthesia in MGM Hospital, Aurangabad over a period of two years from November 2016 to September 2018 after approval from ethical committee. Patients aged between 18-60years with MPC (Mallampatti Classification) grade I and II and accepted under ASA grade I and II for elective surgeries under general anaesthesia were included in the study. Patients with MPC grade III and IV or mouth opening <2cm, history of URI or BMI >35kg/m2 and any abnormality of the neck were excluded form the study. Materials used were I-GEL number 3 and 4, water based lubricant jelly and 12 Fr gastric tube. A written informed consent was obtained from all patients before including them in the study. Patients were kept NPO (nilper oral) for 6 hours prior to surgery. All patients were advised Tablet alprazolam 0.5 mg and Tablet Omeprazole 40 mg or all yat night before surgery. The size of the device was decided based on patient’s body weight and standard recommendation¹ I-gel- size 3:- for patients weighing between 30-50 kg, Size 4 :- for patients between 50-90kg. Intravenous (IV) Line was secured with angiocath number 20 gauge. All patients received Inj.Glycopyrrolate 0.005mg/kg IV, Inj. Midazolam 0.03mg/kg IV and Inj.Fortwin 0.5 mg/kg as premedication and preoperative baseline parameters like Pulse rate, Systolic Blood Pressure, diastolic blood pressure, Mean arterial pressure, SPO2 were noted. After 3 minutes of preoxygenation, General anaesthesia was induced by Inj.Propofol 2mg/kg. I-gel insertion was facilitated with Inj.Suxamethonium (2mg/kg IV). We waited for45 seconds after giving i.v.Suxamethonium. A water based jelly was applied to I-gel. The anaesthesiologist inserted device from the head end of patient, while an assistant was opening jaw from the right hand side of the patient. We judged ease of insertion on the basis of number of insertion attempts. Number of insertion attempts was noted. When it was not possible to insert the device or ventilate through it, two more attempts of insertion were allowed. If placement was failed after three attempts, the procedure was abandoned and this case was considered as a failed attempt. Endotracheal intubation was performed and case was excluded from the study. Time of insertion was noted from the time the operator picked up I-gel till the ventilation was established. We clinically judged adequate ventilation by chest rise and minimal leak. Hemodynamic responses (HR,SBP,DBP,MBP,SPO2) were recorded at the time of insertion of device i.e. 0minute and then at 1, 3,5,10,15,20 minutes after insertion of I-gel. Anaesthesia was maintained with isoflurane in oxygen and nitrous oxide (50%-50%). Atracurium in a dose of 0.5mg/kg initial first dose and then 0.1 mg/kg for maintenance was given every 20min to maintain muscle relaxation. Adequate IV fluids were given in the form of crystalloids. Gastric tube of 12Fr was inserted through I-gel. Placement of gastric tube was confirmed by gastric content aspiration or by Woosh Test(8)(20ml air was pushed through gastric tube and a characteristic whooshing sound auscultated on epigastrium using diaphragm of stethoscope).

Grading of ease of insertion of gastric tube(10) (9)-

We divided ease of gastric tube insertion in three grades.

O Grade1= Easy,

O Grade2=Difficult,

O Grade3=Impossible.

After completion of surgery, stomach was emptied and nasogastric tube was removed. Residual neuromuscular blockade was reversed with inj. Neostigmine 0.005mg/kg+ inj. Glycopyrrolate 0.001mg/kg. I-gel were removed when patient was obeying verbal commands. Patient was oxygenated for 10minutes after removal of device. Any visible blood staining on the I-gel was noted at removal. The lip, tongue, teeth were inspected for evidence of trauma in the immediate post-operative period. Incidence of sore throat, hoarseness and dysphagia was noted after 24 hours of surgery.

 

 

Table 1: Age of patients

 

Table 2: Gender of patients

 

 

 

Table 3: ASA Grade of Patients

 

Table 4: Number of insertion attempts

 

Table 5: Meantime taken for insertion (secs)

 

Table 6: Ease of insertion

 

Table 7: Adverse effects in patients

 

DISCUSSION

I-gel is a second generation supraglottic airway device. It has a passage for gastric tube insertion which can be used for gastric deflation. In our institute, we routinely use this device for surgeries under general anaesthesia and thus we have designed this study to observe insertion of I-gel. We selected 30 patients who were electively posted for surgery under general anaesthesia. Primary aim of our study was to observe I-gel for ease of insertion i.e. number of attempts, time taken for insertion, hemodynamic changes, ease of insertion of gastric tube and adverse events like regurgitation , aspiration, tongue, lip or dental trauma, post-operative sore throat.

 

• Number of insertion attempts:- In our study out of 30 patients, I-gel was inserted in first attempt in 25 (83.3%) patients, only 5 (16.7%) patient’s required second attempt.

 

 

 

• Time taken for insertion:- Mean time taken for insertion of I-gel was 7.27±2.74 seconds.

 

• Ease of gastric tube insertion :- In our study we divided ease of gastric tube insertionin three grades. Grade 1= Easy, Grade 2=Difficult, Grade 3=Impossible.It was Easy (grade 1) in73.3% patients, difficult (grade 2) in 6.7% patients and impossible to insert (grade 3) in 20% patients.