The i-gel (Intersurgical, Wokingham, UK) is a novel SAD. The i-gel is a second-generation supraglottic airway device that seals the airway without the use of air inflation and includes a soft anatomically formed cuff. The i-gel has a very low coefficient of friction when lubricated and doesn't have an inflatable cuff, which makes it very simple to insert. More official assessments are being conducted, and the majority of them report favourable results. Success rates for initial insertion are greater than 85%, and after three attempts, this figure approaches 100% [1].

This device has been used for routine elective anesthesia and has also been effective in pre hospital emergency airway management [2]. It is used to oxygenate, ventilate and to give anaesthetic gases to patients under GA. The i-gel is a useful alternative to tracheal intubation in patients undergoing elective surgery. The i-gel can also be used as a conduit for fibreoptic bronchoscopy guided tracheal intubation in patients with difficult airways [3].

The i-gel is a useful alternative to tracheal intubation in patients undergoing elective surgeries and useful tool in emergency airway management. Therefore, correct positioning of the device is very crucial to accomplish proper oxygenation and ventilation.

There have been no previous studies regarding the efficacy of rotational and triple maneuver techniques for i-gel insertion when searching web based data. The present study hypothesizes that the rotational and triple airway maneuver techniques would decrease tongue folding by reducing resistance between device and tongue, allowing the i-gel to smoothly advance into the posterior hypopharynx compared to the standard technique. Hence it would be worthwhile to compare the three different techniques in terms of hemodynamic parametres.

Aim and Objectives

To compare the haemodynamic variables of three different techniques of i-gel insertion i.e. standard, rotational, triple airway maneuver in anaesthetised paralysed adults both before and after i-gel insertion.

• Study Area: Department of Anaesthesiology, Dr. R.P.G.M.C. Kangra at Tanda, Himachal Pradesh

• Study Population: After approval by institutional ethnics committee, this study was carried out on 150 patients, 50 in each group, planned to undergo surgery under general anaesthesia with i-gel as a primary airway device.

• Study Duration: After approval by Institutional Ethics Committee (IEC), this prospective randomized study was conducted for period of 12 months including data collection, data organization, presentation, and data analysis and data interpretation.   

• Sample Size: All patients within this duration and fulfilling our inclusion criteria were included in the study. For all three groups, 50 patients in each group were evaluated after randomization.

Inclusion Criteria

• Patients with age 18-65 years.

• Patients with ASA I and ASA II.

• BMI – 18.5-29.9 kg/m2.

Exclusion Criteria

• Duration of surgery > 4 hours

• Mouth opening <2.5 cm

• Presence of sore throat

• Any contraindication for SGA placement e.g., facial trauma, facial deformity

• Pregnancy

• Patient at risk of aspiration e.g. patients of gastroesophageal reflux disorder, previous history of PONV and hiatus hernia

• Patient refusal to give consent for study

Study Design

The study commenced after obtaining institutional scientific review, protocol and ethics committee approval. It was a prospective and randomized study. The patients were randomly assigned to three groups (Group-A) standard (n = 50), (Group-B) rotational (n = 50), and (Group-C) triple airway maneuver (n = 50) group using computer generated random numbers. Randomisation sequences were kept in opaque sealed envelopes and were opened at time of induction of GA by a person not involved in the study and handed over to anaesthesia team.

Methodology

Standard ASA fasting guidelines was followed in all patients. The patients were pre-medicated using oral alprazolam 0.25 mg a night before surgery. On patient’s arrival in operating room, the standard anaesthesia monitoring i.e. ECG, NIBP, and SPO2 were applied. Following preoxygenation with 100% oxygen for 3 min, anaesthesia was induced with propofol 2 mg/kg, fentanyl 2 µg/kg and atracurium 0.5 mg/kg. The i-gel insertion was performed after 4 minutes of administration of injection atracurium. The i-gel was inserted by using one of the study insertion techniques. I-gel size was standardized by weight (i-gel size 3 for 30-60 kg and size 4 for 50 to 90 kg and size 5 for more than 90 kg). 

In the Group-A (Standard group) (n = 50), the i-gel was inserted using the standard method described by AI Brain [4]. In the Group-B (Rotational group) (n = 50), i-gel was inserted using the rotational technique. The i-gel was inserted back-to-front, like a Guedel airway, and then rotated counterclockwise through 180 degrees as it was pushed into the hypopharynx. In the Group-C (Triple airway maneuver group) (n = 50), the technique involved the following steps described by Kuvaki et al. [5] It involves:

• Holding the i-gel from the middle third between the Index finger and thumb of the dominant hand

• Performing a triple airway maneuver, the combination of head extension, mouth opening, and jaw thrust

• Pressing the i-gel directly (front-to-back) against the hard palate and pushing it along the posterior palatopharyngeal curve using the index finger and thumb 

• When the index finger and thumb reach the mouth, the position of the index finger was adjusted so that it pulled upward on the lower surface of the tube

• Pushing the i-gel into its final position holding the shaft

After i-gel insertion, anaesthesia was maintained with isoflurane, oxygen and nitrous oxide. An anaesthesiologist with a clinical experience of 50 i-gel insertion with standard technique placed the i-gel in one of the three techniques and judged the effectiveness of the i-gel based on a square-wave capnograph trace and no audible leak with peak airway pressures≥10 cm H2O during manual ventilation. If air leak occurred at peak airway pressures < 10 cm H2O, the attempt was considered a failure and the i-gel was reinserted using the same technique. The numbers of insertion attempts were noted. 

The insertion time defined as the time from picking up the i-gel until the initiation of mechanical ventilation was recorded. We allowed a maximum of two i-gel insertion attempts, with 60 seconds permitted for each attempt. 

After completion of procedure, patient was reversed with neostigmine 0.05 mg/kg and glycopyrrolate 0.01mg/kg and the i-gel was removed when the patient was able to breathe spontaneously and open his/her eyes to command. Any bloodstaining on the device was recorded. The incidence of sore throat was assessed at 1hr and 24 hrs post anaesthesia. All three groups were evaluated for hemodynamic response before and after I-Gel insertion.

Statistical Analysis

The data were recorded into Microsoft® Excel workbook 2019 and exported into SPSS v21.0 (IBM, USA) for statistical analysis. Categorical variables were expressed as frequency, percentage and compared using Chi square test. Quantitative variables were expressed as mean, standard deviation and compared using one-way analysis of variance (ANOVA). P value <0.05 was considered significant.

The present study was aimed to compare the hemodynamic response before and after I-Gel insertion in this study at Department of Anaesthesia, Dr. R.P.G.M.C. Kangra at Tanda during the study period.

Table 1: Distribution of Participants According To Socio-Demographic Variables

Table 2: Hemodynamic variables

The patients were divided into 3 groups with 50 patients each. The patients in group an included standard technique, group B with rotational technique, and group C included triple airway maneuver.

In this study, there was no significant difference of age between three groups (p = 0.422). In this study, male to female ratio was 0.4:1 in standard group, 0.7:1 inrotational group and 0.6:1 in triple airway maneuver group. There was no significant difference of gender distribution between three groups (p = 0.466). In this study, there was no significant difference of weight (p = 0.395), height (p = 0.321), and BMI (p = 0.660) between three groups (Table 1).

There was no statistically significant difference in HR, SBP, DBP, and MAP among all the three groups. Hence haemodynamic variables were comparable before and after i-gel insertion between all the groups (p>0.05) (Table 2).

Insertion of supraglottic airways using the standard technique is not always successful. Previous studies have reported varied success rates for the first attempt at inserting supraglottic airways. In addition, a degree of skill is required to place supraglottic airways correctly and suboptimal positioning of the device can give rise to such problems as air leakage or airway obstruction [6]. given the popularity of supraglottic airways among operators with a wide range of experience, alternative methods are required to improve the likelihood of successful insertion and obtain optimal positioning.

Various techniques have been described to ensure a high successful insertion rate. Among the alternative methods, the rotation technique derived from the back-to-front insertion technique of the Guedel airway and consists of inserting the device with a 90 or 180 degree rotation and then rotating it to the final position as it enters the hypopharynx.

The i-gel insertion with triple airway maneuver provides wider pharyngeal space and decreases the incidence of epiglottic downfolding by i-gel compared with the standard insertion method. There are very few studies that have shown improvement in successful placement of i-gel by rotational or triple airway maneuver technique. But no randomised controlled trial comparing all three techniques is conducted till now.

In the present study, three groups were compared with respect to hemodynamic parametres before and after i-gel insertion.

In our study, there was no statistically difference in HR, SBP, DBP, and MAP among all the three groups. Hence haemodynamic variables were comparable before and after i-gel insertion between all the groups (p>0.05).

In the study by Eglen et al, there was no statistically significant difference between standard, rotational and triple airway group according to hemodynamic responses (p>0.05) [7]. In the study by Sharda et al, standard and rotational groups were comparable with respect to hemodynamic variables (p>0.05) [8]. In the study by Bhardwaj et al, HR and MAP were comparable before and after i-gel insertion in standard, reverse and rotational groups [9].

Our study concluded that haemodynamic variables like HR, SBP, DBP and MAP were comparable before and after i-gel insertion between all three groups as there was no significant difference in Hemodynamic response before and after I-Gel insertion in Three Different Techniques of I-Gel Insertion I.E. Standard, Rotational, and Triple Airway Maneuver in Anaesthetised Paralysed Adults.

1. Gatward, J.J. et al. "Evaluation of the size 4 i-gel airway in one hundred non-paralysed patients." Anaesthesia, vol. 63, 2008, pp. 1124–1130.

2. Duckett, J. et al. "Introduction of the i-gel supraglottic airway device for prehospital airway management in a UK ambulance service." Emerg Med J, vol. 31, 2014, pp. 505–507.

3. Emmerich, M. and J. Tiesmeier. "The i-gel supraglottic airway: A useful tool in case of difficult fiberoptic intubation." Minerva Anestesiol, vol. 78, 2012, pp. 1169–1170.

4. Brain, A.I. "The laryngeal mask—A new concept in airway management." Br J Anaesth, vol. 55, 1983, pp. 801–805.

5. Kuvaki, B. et al. "The soft seal disposable laryngeal mask airway in adults: Comparison of two insertion techniques without intra-oral manipulation." Anaesthesia, vol. 63, 2008, pp. 1131–1134.

6. Ghai, B. et al. "Laryngeal mask airway insertion in children: Comparison between rotational, lateral and standard technique." Paediatr Anaesth, vol. 18, 2008, pp. 308–312.

7. Eglen, M. et al. "Comparison of three different insertion techniques with LMA-Unique™ in adults: Results of a randomized trial." Rev Bras Anestesiol, vol. 67, 2017, pp. 521–526.

8. Sharda, M. et al. "Insertion of i-gel™ by the reversed technique improves the success rate and reduces the time taken for its placement: A prospective, randomized, controlled, interventional trial." J Anaesthesiol Clin Pharmacol, vol. 33, 2017, pp. 226–230.

9. Bhardwaj, M. et al. "A prospective randomised trial to compare three insertion techniques for i-gel™ placement: Standard, reverse, and rotation." Indian J Anaesth, vol. 64, 2020, pp. 618–623.