Correspondence Anaesthesia, 2009, 64, pages 687–697 . ....................................................................................................................................................................................................................
of laryngeal view: percentage of glottic opening score vs. Cormach and Lehane grading. Canadian Journal of Anaesthesia 1999; 46: 987–90. 3 Hirabayashi Y, Seo N. The Airtraq laryngoscope for placement of double lumen endobronchial tube. Canadian Journal of Anaesthesia 2007; 54: 955–7. 4 Henderson J. Airtraq for awake tracheal intubation. Anaesthesia 2007; 62: 744– 55. 5 Hirabayashi Y, Okada O, Seo N. Airtraq laryngoscope for insertion of a Transesophageal Echocardiography probe. Journal of Cardiothoracic and Vascular Anesthesia 2008; 22: 331–2. Tongue trauma associated with the i-gel supraglottic airway
We would like to report three cases with complications associated with insertion of i-gel (Intersurgical, Wokingham, Berkshire, UK) supraglottic airways. In the first, insertion of the i-gel was performed by a paramedic under direct supervision. The insertion was difficult, resistance was felt, the depth of insertion seemed quite superficial and ventilation was ineffective. The i-gel was immediately removed and trauma to the frenulum with significant bleeding was noted. An ENT surgeon was called to cauterise the lesion. In the second patient, the tongue was initially caught inside the i-gel bowl during insertion but after re-positioning the device provided a good seal and the procedure completed. On removal of the device, a small amount of blood was noted on the surface of the i-gel, with swelling of frenulum and minor oozing of blood. The patient reported a sore tongue lasting 3 days. The third patient underwent an uncomplicated breast procedure with controlled ventilation lasting 2 h. In this case the i-gel was inserted on the first attempt without a complication. Postoperatively, however the patient reported a sore tongue with apical hypoaesthesia and loss of taste lasting 3 weeks. All devices were appropriately lubricated in advance of insertion, as recommended by the manufacturers. 692
The i-gel was introduced into clinical practice in 2007 and initial clinical reports of its use have been promising [1, 2]. Apart from airway maintenance in selected elective cases, it may be used as a conduit for fibreoptic intubation in the patients with difficult airways [3]. However, in certain patients, insertion may prove difficult and the tongue can get caught in the bowl. We have experience of over 1100 insertions of this device and would like to recommend two modifications to insertion technique that help overcome the potential for tongue trauma. In the first, the gloved thumb of the nondominant hand is inserted into the patient’s mouth. The index and middle fingers are placed under the chin and can be used to apply jaw thrust. The device is then passed over the thumb into the mouth. This avoids the potential for the tongue getting caught in the bowl of the device. With the second modification, the i-gel is inserted with the bowl turned laterally and after resistance is felt it is rotated and advanced into its final position. A similar technique is also recommended by the manufacturer [4]. We believe that our findings can improve device efficiency and minimise the risk of tongue trauma especially in those patients with limited mouth opening. P. Michalek W. J. Donaldson J. D. Hinds Antrim Area Hospital, Antrim, Northern Ireland, UK E-mail:
[email protected]
References 1 Richez B, Saltel L, Banchereau F, Torrielli R, Cros AM. A new single use supraglottic airway device with a noninflatable cuff and an esophageal vent: an observational study of the i-gel. Anesthesia and Analgesia 2008; 106: 1137–9. 2 Gatward JJ, Cook TM, Seller C, et al. Evaluation of the size 4 i-gel airway in one-hundred non-paralyzed patients. Anaesthesia 2008; 63: 1124–30. 3 Michalek P, Hodgkinson P, Donaldson W. Fibreoptic intubation through an I-Gel supraglottic airway in two patients with predicted difficult airway
and intellectual disability. Anesthesia and Analgesia 2008; 106: 1501–4. 4 Intersurgical. I-gel User Guide. Wokingham, Berks, UK: Intersurgical, 2005.
A reply We would like to thank Dr Michalek et al. for their letter and Anaesthesia for providing us with an opportunity to comment. As the authors confirm, initial clinical reports regarding i-gel have been encouraging, with high insertion success rates and very low levels of complications [1–5]. Most problems can be avoided by following the guidance provided in the i-gel Instructions For Use [6] and User Guide [7]. However, as with any airway management device, problems can occasionally occur. We note the authors’ confirmation that in these particular cases the i-gel was adequately lubricated. This is important, as is ensuring the device is not lubricated too early, since in such cases the lubricant can dry out, limiting its capacity to provide smooth passage of the device over the tongue and along the hard palate. It is also important to ensure the selection of the correct size of i-gel. In addition to the patient weight guidance, it is also recommended in the User Guide [7] that an assessment of the patient’s anatomy be considered when deciding the most appropriate size of device to select. This may include, but not be limited to, measurement of thyromental distance, neck width and length and patient height. The combination of correct size selection, adequate lubrication on all four sides of the device cuff, optimal patient position prior to insertion and adherence to the recommended insertion technique, should reduce the potential for trauma. The authors clearly have considerable experience with i-gel and we welcome their report of two techniques they have successfully used. One of these techniques, as the authors confirm, is already described in the i-gel User Guide [7]. The other, where the gloved thumb of the non-dominant hand is inserted into the patient’s mouth, we agree may prove beneficial in cases where passage
2009 The Association of Anaesthetists of Great Britain and Ireland
