User Guide - Docsinnovent
Contents
1. User Guide igel single use supraglottic airway Adult and paediatric sizes www i gel com 1 0 2 0 3 0 4 0 5 0 6 0 7 0 8 0 9 0 10 0 11 0 12 0 13 0 14 0 Contents DEVE OCC IOI ces e a AaS a eE eaS AEA eaS eaaa 3 1 1 The gel La ciranean dnt ected abe ig SERN EAEAN AN EANET ENEE LEE 3 1 2 Key components and their TUNCUON scccsissenicecsinscasuncdwnsvhaddsendanbsenvenantaduyseelsinannueanbonincandabea 4 1 2 1 Sot nonnilatabie CUM ssis aE a Ae iii 5 1 2 2 Gaste channel Eee ee ene eee EE E aE ETS ari 5 G aa STE FSS A AE TA E EEAS T EE T A E A 5 1 2 A Buccal cavity Sta DINGS ST santissimi r iiA E EEE aae Eni A EEES 5 1 2 5 15mm ONS ClO dat ee sree rece Pee ahead Sia 6 FG TO Mali ae HOIN armerede EEN EEE AEA E DREE ENEAN 6 dake Keine p AEN E EDER T 7 COMME AUC NOUN Suing ssc cae cs ece verve nears eeceennceveceseneenersarsaeenaneenaieuenvaxens 8 Wea NN ARRENE RADER E seek cb ste E A E EET EET EDEN 8 Preparation For use aa ireren sen eee aerau aa Aa aain 9 S SS LON samer EE E E ERN 9 Se ag CU Lote Bo cee a ee ee ee Ser TEE Eee ed ea re ele 9 5 3 Pre insertion preparation adult SIZOS cccccceeccccseeeceeeeceuseccueeecaueceseuseesaueessuseeseaes 10 5 4 Pre insertion preparation paediatric SIZES eee cece cecccceeeeceeeeeeaeeeeeaeeceseeeeesaeeeeseeeeeaees 10 induction of anaesthesia eisson 12 6 1 Preferred eC HMIGQUC a csccnesceccrcnaceconssanesenasxeshcezasncaneseed seas esimas p2. children but the i gel s cuff and airway channel have been designed in such a way that the chances of obstruction to the fresh gas flow FGF are minimal If the i gel is placed too high in the pharynx this may result in a poor seal and cause excessive leakage If the FGF is forced in too hard by squeezing the reservoir bag too quickly this may cause gastric insufflation and distension which will increase the risk of regurgitation and postoperative nausea and vomiting If the tip of the i gel enters into the glottic opening this can lead to an excessive air leak through the gastric channel which may result in obstruction to the FGF If a NG tube is then inserted through the i gel it will enter into the trachea and lungs It is recommended that if this situation is suspected the i gel is removed and reinserted with a gentle jaw thrust and correct placement checked 14 0 Further reading 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Bamgbade OA Macnab WR Khalaf WM Evaluation of the i gel airway in 300 patients Eur J Anaesthesiol 2008 Oct 25 10 865 6 Richez B Saltel L Banchereau F Torrielli Cros AM A new single use supraglottic airway with a noninflatable cuff and an esophageal vent An observational study of the i gel Anesth Analg 2008 Apr 106 4 1137 9 Gatward JJ Thomas MJC Nolan JP Cook TM Effect of chest compressions on the time taken to insert airway de
3. of upper gastro intestinal surgery The patient has bleeding clotting abnormalities Nasogastric tube insertion in the presence of inadequate levels of anaesthesia can lead to coughing bucking excessive salivation retching laryngospasm or breath holding 12 0 Problem solving 12 1 Incorrect position A horizontal line Adult sizes 3 4 and 5 only at the middle of the integral bite block represents the correct position of the teeth Figure 28 If the teeth are located lower than the distal tip of the bite block then it is likely the device has been incompletely inserted In this instance remove the i gel and reinsert with a gentle jaw thrust applied by an assistant If that does not resolve the problem use one size smaller i gel The paediatric sizes of i gel sizes 1 to 2 5 do not have a horizontal line on the integral bite block This is due to the greater variability in the length of the oro pharyngeal laryngeal arch in children As a result insertion should continue as with the adult sizes until definitive resistance is felt Once it has been established that ventilatory parameters are satisfactory and there is no leak through the gastric channel except size 1 which does not contain a gastric channel the i gel should be held in place whilst the device is secured with tape maxilla to maxilla Figure 26 E Figure 28 Ideal position of teeth adult sizes only 12 2 Coughing and breath holding In the presence o
4. user to ensure the procedures and techniques chosen are appropriate to the clinical situation depending on their level of training and experience of using the device 5 0 Preparation for use 5 1 Size selection Select the appropriate size i gel by assessing the patient s anatomy The i gel s cuff may look smaller than traditional supraglottic devices with an inflatable cuff of the same numerical size Patient weight guidance kg i gel size Patient size Neonate Infant Small paediatric Large paediatric Small adult Medium adult Large adult WARNING Whilst size selection on a weight basis should be applicable to the majority of patients individual anatomical variations mean the weight guidance provided should always be considered in conjunction with a clinical assessment of the patient s anatomy Patients with cylindrical necks or wide thyroid cricoid cartilages may require a larger size i gel than would normally be recommended on a weight basis Equally patients with a broad or stocky neck or smaller thyroid cricoid cartilage may require a smaller size i gel than would normally be recommended on a weight basis Patients with central obesity where the main weight distribution is around the abdomen and hips might in practice require an i gel of a size commensurate with the ideal body weight for their height rather than their actual body weight 5 2 Pre use checks e Inspect the packaging and e
5. 70 387 66611 info intersurgical lt Nederland T 0413 243860 info intersurgical nl Poccna T 495 771 6809 nfo intersurgical ru Ceska Republika T 272 940 951 info intersurgical cz South Africa T 011 444 7968 info intersurgical co za Philippines T 632 820 4124 info intersurgical ph Intersurgical Ltd Crane House Molly Millars Lane Wokingham Berkshire RG41 2RZ UK T 44 0 118 9656 300 F 44 0 118 9656 356 info intersurgical com www intersurgical com Japan Italia T 03 6379 4433 T 039 0535208 info intersurgical co jo info intersurgical Taiwan T 886 4 25605508 info intersurgical com tw 9989 issue 1 01 10
6. Indian Journal of Anaesthesia 2009 53 3 302 305 Theiler LG Kleine Brueggeney M Kaiser D Urwyler N Luyet C Vogt A Greif R Unibe MME Crossover comparison of the Laryngeal Mask Supreme and the i gel in simulated difficult airway scenario in anesthetised patients Anesthesiology 2009 111 55 62 Campbell J Michalek P Deighan M i gel supraglottic airway for rescue airway management and as a conduit for tracheal intubation in a patient with acute respiratory failure Resuscitation 2009 80 963 Nolan JP Soar J Airway techniques and ventilation strategies Current opinion in critical care 2008 14 3 279 86 Kumar MS Pandey R Khanna P Successful use of i gel airway in prone position surgery Pediatric Anesthesia 2009 Feb 19 2 176 7 All rights reserved No part of this publication may be reproduced stored in a retrieval system or transmitted in any form or by any means electrical mechanical photocopying recording or otherwise without the prior written permission of the publisher i gel is a registered trademark of Intersurgical The information provided in this document is correct at the time of publication Intersurgical reserves the right to improve or modify the product without prior notification Deutschland T 02241 311063 info intersurgical de France T 01 48 76 72 30 info intersurgical fr Espa a T 91 665 73 15 info intersurgical es com Portugal T 21 910 85 50 info intersurgical pt Lietuva T 3
7. acaubeduncencctiesamasscensencezeineneesie 12 6 2 Other techniques of INGUCUION visi ccicscectesstciczcecdsnenaiesdenedenatacsacanveadintandeqcbsocestedwenadedbestaedasde 12 Insertion techniqQuUe scener LEE ELLLER LEE E REELLE ELLE ELLE E REE LEE EEN 13 7 1 Recommended insertion teChnique ccccccsescccseeeceesecceusecseeseceueeeseueeesausessueeesaaes 13 7 2 Important notes to the recommended insertion teChnique ccccsseccseeeeeseeeeeees 14 Maintenance of anaesthesia cccccesceeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeseeeeeeeeaeeeeeesseees 15 Emergence from anaesthesia cccccssseeensseeeesseeseenseeeneeeseneneesseanenessneeeesens 15 Recovery phase of anaesthesia and i gel removal ccccseesseeseeeeneeeees 15 How to use the gastric Channel ccccceseeeeeseeeeeeeeeeeeeeeeeeeeeseeneeseeneeseeneesonees 16 Propi m SON MN acc ee cece sinc cen dc nectar lie 17 Adverse QUECOINECS neniiga E dani EREE E aS aia 18 Further reai aes raen E BEES ESTERE ETAETA ETETE 19 1 0 Introduction 1 1 The i gel design The i gel airway is a novel and innovative supraglottic airway management device made of a medical grade thermoplastic elastomer which is soft gel like and transparent The i gel is designed to create a non inflatable anatomical seal of the pharyngeal laryngeal and perilaryngeal structures whilst avoiding the compression trauma that can occur with inflatable supraglottic airway devices This
8. device has been developed after extensive literature searches related to supraglottic extraglottic periglottic and intraglottic airway devices dating back as far as the 5th century Dissected and preserved human cadaveric models fresh cadaveric neck and airway dissections direct and indirect pharyngo laryngeal endoscopies X rays CT and MRI imaging data were all studied in detail scientifically investigated and critically examined This knowledge was utilised to ensure the i gel s shape softness and contours accurately mirror and exert the least possible pressure onto the pharyngeal laryngeal and perilaryngeal framework The i gel is a truly anatomical device achieving a mirrored impression of the pharyngeal laryngeal and perilaryngeal structures without causing compression or displacement trauma to the tissues and structures in the vicinity The i gel has evolved as a device that accurately positions itself over the laryngeal framework providing a reliable perilaryngeal seal and therefore no cuff inflation is necessary 1 5 3 4 5 6 A D Figure 1 View of the i gel cuff in relation to the laryngeal framework 1 Tongue 6 Posterior cartilages 2 Base of tongue 7 Thyroid cartilage 3 Epiglottis 8 Cricoid cartilage 4 Aryepiglottic folds 9 Upper oesophageal opening 5 Piriform fossa i gel 3 Introduction A supraglottic airway without an inflatable cuff has several potential advantages including easier inser
9. e located into the upper oesophageal opening Figure 25a and the cuff should be located against the laryngeal framework Figure 25b The incisors should be resting on the integral bite block Figure 25c WARNING In order to avoid the possibility of the device moving up out of position prior to being secured in place it is essential that as soon as insertion has been successfully completed the i gel is held in the correct position until and whilst the device is secured in place Insertion technique Figure 23 Jaw thrust Figure 24 Deep rotation Figure 25 Correct placement of the i gel Figure 26 Fixing of the i gel in place using adhesive tape 6 i gel should be taped down from maxilla to maxilla Figure 26 7 If required an appropriate size nasogastric tube may be passed down the gastric channel see section 11 0 for further details on use of the gastric channel The i gel should always be used in accordance with recognised airway management practice for supraglottic airway devices 7 2 Important notes to the recommended insertion technique e Sometimes a feel of give way is felt before the end point resistance is met This is due to the passage of the bowl of the i gel through the faucial pillars pharyngo epiglottic folds e Once resistance is met and the teeth are located on the integral bite block do not repeatedly push i gel down or apply excessive force during insertion e No more than three a
10. e to monitor the neuromuscular blockade with a nerve stimulator At the end of the surgical procedure either reverse the neuromuscular blockade or let it wear off until the protective reflexes and regular breathing pattern are regained by the patient before the removal of the i gel 10 0 Recovery phase of anaesthesia and i gel removal The patient should continue to breathe higher concentrations of oxygen through an anaesthetic system or T piece in the recovery room whilst pulse and oxygen saturation are monitored continuously and the blood pressure is measured at regular intervals Once consciousness is regained and protective reflexes such as coughing and swallowing have returned gently suction around the airway device in the pharynx and hypopharynx Once the patient is awake or easily arousable with vocal commands the i gel can safely be removed by asking the patient to open his her mouth wide and replaced with an MC medium concentration oxygen mask In patients with the possibility of a heightened gag reflex i e smokers asthmatics or patients with COPD i gel should be removed in deeper planes of anaesthesia and after removal the airway maintained with a guedel airway and oxygen mask until protective reflexes have returned and the patient becomes arousable Recovery phase of anaesthesia and i gel removal NB DO NOT attempt to forcibly remove the device if the patient is biting on it Wait until the patient on vocal command has f
11. ement techniques and devices Paediatrics Securing and maintaining a patent airway in routine and emergency anaesthetics for operations of fasted patients during spontaneous or intermittent positive pressure ventilation IPPV i gel has not to date been evaluated in alternative applications and there are currently no data to support its use in such circumstances However it is believed as a supraglottic device it may be appropriate for use in areas where other such devices have proved to be beneficial Some examples of other potential applications are briefly described below 1 Use by the ambulance crew in difficult or unexpectedly difficult intubations in a pre hospital setting in order to quickly establish and maintain a clear airway 2 Securing a clear airway in difficult or unexpectedly difficult intubations in airway management of a patient in the operating theatre 3 In a known difficult or unexpectedly difficult intubation for intubating the patient by passing an endotracheal tube ETT through the device under fibre optic guidance i gel size Maximum size of Endotracheal Tube 4 In a difficult or unexpectedly difficult intubation to pass a gum elastic bougie blindly but gently through the device whilst in situ into the trachea and to rail road the ETT over it 5 In a known difficult or unexpectedly difficult intubation to pass a fibre optic scope through the device to provide visualisation of the
12. f inadequate anaesthesia at insertion or during maintenance of anaesthesia coughing and breath holding may occur signifying an inadequate depth of anaesthesia In this situation anaesthesia must be deepened by an intravenous injection of an agent like Propofol or with an inhalational anaesthetic agent e g Sevoflurane If the patient is being paralysed and ventilated then the adequacy of the muscle relaxation must also be checked with a nerve stimulator Should a patient show signs of gagging or coughing during the recovery phase remove the i gel and adequately suction the pharynx before reinserting the i gel 12 3 Air leakage through the gastric channel A small air leak air venting through the gastric channel may be a useful mechanism to protect against gastric insufflation but an excessive leak means the device is incompletely inserted In such instances remove the device and reinsert with a gentle jaw thrust applied by an assistant a deep rotation or triple maneouvre to achieve an optimum depth of insertion 12 4 Inadequate seal pressure If it is felt that a higher seal pressure is desired it is advised that a larger size than that recommended on weight basis is used However even if the seal pressure in a given patient would allow it peak airway pressure of ventilation must not exceed 40cm H O in order to prevent barotrauma Excessive air leak during IPPV If an excessive air leak during IPPV is noticed use one or all of the f
13. glottic opening to aid intubation 6 In the Intensive Care patient for weaning a certain category of the population in whom an endotracheal tube is not well tolerated 7 In difficult mouth opening situations i gel can also be inserted under direct vision with the help of a laryngoscope 3 0 Contraindications 1 Non fasted patients for routine and emergency anaesthetic procedures 2 Patients with an ASA or Mallampati score of III and above 3 Trismus limited mouth opening pharyngo perilaryngeal abscess trauma or mass 4 Do not allow peak airway pressure of ventilation to exceed 40cm HO 5 Do not use excessive force to insert the device or nasogastric tube 6 Inadequate levels of anaesthesia which may lead to coughing bucking excessive salivation retching laryngospasm or breath holding thus complicating the anaesthetic outcome 7 Do not leave the device in situ for more than 4 hours 8 Do not reuse or attempt to reprocess the i gel 9 Patients with any condition which may increase the risk of a full stomach e g hiatus hernia sepsis morbid obesity pregnancy or a history of upper gastro intestinal surgery etc 10 As with all supraglottic airway devices particular care should be taken with patients who have fragile and vulnerable dental work in accordance with recognised airway management practices and techniques 4 0 Warnings i gel must be lubricated according to the instructions for use The patient should a
14. he gastric channel allows for the passing of a nasogastric tube to empty the stomach contents and can facilitate the venting of gas from the stomach The gastric channel can also provide an early indication of regurgitation Please note the size one i gel does not have a gastric channel 1 2 3 Epiglottic rest An artificial epiglottis and a protective ridge help prevent the epiglottis from down folding or obstructing the distal opening of the airway The epiglottic ridge at the proximal end of the bowl rests at the base of the tongue thus keeping the device from moving upwards out of position and the tip from moving out of the upper oesophagus 1 2 4 Buccal cavity stabiliser The buccal cavity stabiliser has a built in natural curvature and an inherent propensity to adapt its shape to the oropharyngeal curvature of the patient It is anatomically widened and concaved to eliminate the potential for rotation thereby reducing the risk of malposition It also provides vertical strength to aid insertion Introduction 1 2 5 15mm connector The innovative connector serves a number of functions To provide a standard 15mm connection to the anaesthetic system or patient connection A port of entry for the gastric channel the port is independent of the main 15mm connection and is located on the right hand side of the connector wing Not applicable to size one i gel An integral bite block this function is provided by the distal below the w
15. induction Pre medication with benzodiazepines and or opiates opioids Induction with thiopentone or other barbiturates etomidate or ketamine Induction should be followed by manual ventilation with a bag and mask with oxygen nitrous oxide and an inhalational agent preferably sevoflurane or desflurane until jaw relaxation of the patient is achieved prior to attempting insertion of the i gel A guedel airway may be useful to facilitate manual ventilation An inhalational technique with oxygen nitrous oxide inhalational anaesthetic agent like sevoflurane desflurane or halothane until jaw relaxation of the patient is achieved for optimising the successful and easy insertion of i gel The most commonly used inhalational anaesthetic technique is with oxygen nitrous oxide and sevoflurane or oxygen and sevoflurane particularly in younger children NB For the purpose of IPPV use a muscle relaxant e g atracurium vecuronium or rocuronium etc 7 0 Insertion technique Make sure the appropriate size of i gel has been prepared prior to insertion as described in section 5 0 Always have a smaller and or larger size of the i gel readily available Adequate preparation proper lubrication of the device and correct positioning of the head and neck with optimum mouth opening is the key to a successful insertion of i gel Always pre oxygenate 7 1 Recommended insertion technique WARNING The i gel is supplied in a protective cradle or cage pack to ensure
16. ing part of the connector which runs through the centre of the proximal part of the buccal cavity stabiliser To reduce the possibility of the airway channel occluding the junction of the distal tip to the body of the connector is V shaped which significantly reduces the risk of kinking As a guide to correct positioning the integral part of the bite block is marked with a horizontally placed black line which signifies the optimum position of the teeth while the device is in situ not applicable to the paediatric sizes Easy visibility of key product information this includes size and recommended weight The information is located on the integrated bite block 1 2 6 Important key points The i gel does not use aperture bars like some supraglottic airways The cuff creates a deep tunnelling effect whilst in situ thus making it more difficult for a down folded epiglottis to block the distal airway channel The softness of the i gel is designed to match that of the pharyngeal laryngeal and perilaryngeal structures whilst being able to retain its shape to facilitate ease of insertion 2 0 Indications The i gel is indicated in Adults Securing and maintaining a patent airway in routine and emergency anesthetics of fasted patients during spontaneous or intermittent positive pressure ventilation and during resuscitation of the unconscious patient by personnel who are suitably trained and experienced in the use of airway manag
17. izes Paediatric sizes 15mm connector Proximal end of gastric channel Integral bite block Epiglottic rest Distal end of Soft non inflatable cuff gastric channel Figure 2 Key components of the i gel Please note the size one i gel does not have a gastric channel 4 i gel Introduction 1 2 1 Soft non inflatable cuff The novel soft non inflatable cuff fits snugly onto the perilaryngeal framework mirroring the shape of the epiglottis aryepiglottic folds piriform fossae peri thyroid peri cricoid posterior cartilages and spaces Each receives an impression fit thus supporting the seal by enveloping the laryngeal inlet The tip lies in the proximal opening of the oesophagus isolating the oesophageal opening from the laryngeal inlet The outer cuff shape ensures that the blood flow to the laryngeal and perilaryngeal framework is maintained and helps to reduce the possibility of neurovascular compression Sliding past the pharyngo epiglottic folds it becomes narrower and deeper creating an outward movement to fit snugly into the potential space of the perilaryngeal pouch Figure 3 Soft non inflatable cuff 1 2 2 Gastric channel The gastric channel runs through the device from its proximal opening at the side of the flat connector wing to the distal tip of the non inflatable cuff Since the distal tip of the device fits snugly and anatomically correctly into the upper oesophageal opening the distal opening of t
18. lways be in the sniffing the morning air position prior to insertion with the assistant helping to open the patient s mouth unless head neck movements are considered inadvisable or are contraindicated Optimum depth of anaesthetic must be achieved prior to attempting insertion i e absence of eyelash reflex easy up and down movement of the lower jaw no reaction to pressure applied to both angles of the mandible The leading edge of the i gel s tip must follow the curvature of the patient s hard palate upon insertion If there is a failure to achieve complete insertion after utilising the standard insertion technique and a jaw thrust deep rotation or triple manoeuvre has also failed then the device should be inserted under direct vision by laryngoscopy or one size smaller device should be used After insertion i gel should be taped down from maxilla to maxilla in accordance with the technique described in section 7 1 of this User Guide Excessive air leak during manual ventilation is primarily due to either sub optimal depth of anaesthesia or sub optimal depth of i gel insertion NB Additional warnings are provided throughout this User Guide in the section relevant to the issue involved The user should familiarise themselves with this User Guide before attempting to use the i gel Recommendations regarding anaesthetic technique are provided These are intended as general recommendations only and it remains the responsibility of the
19. nsure it is not damaged prior to opening e Inspect the device carefully check the airway is patent and confirm there are no foreign bodies or a BOLUS of lubricant obstructing the distal opening of the airway or gastric channel Carefully inspect inside the bowl of the device ensuring surfaces are smooth and intact and also that the gastric channel is patent Discard the device if the airway tube or the body of the device looks abnormal or deformed Check the 15mm connector fits the patient connection Preparation for use 5 3 Pre insertion preparation Adult i gel Sizes 3 4 and 5 2 Always wear gloves Open the i gel package and on a flat surface take out the protective cradle containing the device figure 4 In the final minute of pre oxygenation remove the i gel figure 5 and transfer it to the palm of the same hand that is holding the protective cradle supporting the device between the thumb and index finger figure 6 Place a small bolus of a water based lubricant such as K Y Jelly onto the middle of the smooth surface of the cradle in preparation for lubrication Do not use silicone based lubricants figure 7 Grasp the i gel with the opposite free hand along the integral bite block and lubricate the back sides and front of the cuff with a thin layer of lubricant This process may be repeated if lubrication is not adequate but after lubrication has been completed check that no BOLUS of lubricant remain
20. ollowing 1 Hand ventilate the patient with gentle and slow squeezing of the reservoir bag 2 Limit tidal volume to no more than 5ml kg 3 Limit the peak airway pressure to 15 20cm of H30 4 Assess the depth of anaesthesia and muscle relaxation 5 Use pressure controlled ventilation If all of the above fail then change to one size larger i gel 13 0 Adverse outcomes The anatomical design and soft material of the i gel are less likely to cause adverse outcomes when compared with other supraglottic devices As the i gel is manufactured from a soft gel like material it is unlikely to cause any trauma during insertion or whilst in situ thereby reducing the risk of postoperative complications and co morbidity The clinical evidence currently available suggests i gel may cause fewer secretions in the pharynx and hypopharynx than some other supraglottic airways Some of the known risks and complications of the use of supraglottic airway devices include laryngospasm sore throat trauma to the pharyngo laryngeal framework gastric insufflation regurgitation and inhalation of the gastric contents nerve injuries vocal cord paralysis lingual or hypoglossal nerve injuries tongue numbness and cyanosis The risk of rotation and malpositioning leading to partial or complete airway obstruction is extremely low with the i gel compared with other supraglottic devices Down folding of the epiglottis can occasionally occur and may be more common in
21. rile gauze to help in lubricating the device e Do not apply lubricant too long before insertion e Remove dentures or removable plates from the mouth before attempting insertion of the device K Y Jelly is a registered trademark of Johnson and Johnson Inc Preparation for use eee DA Figure 4 Figure 11 Figure 14 Figure 15 Figure 16 Figure 17 Figure 19 Figure 20 Figure 21 i gel 11 6 0 Induction of anaesthesia WARNING Ensure full compliance with local and national guidelines for patient monitoring Ensuring an adequate depth of anaesthesia is of paramount importance for successful insertion of i gel The patient can be checked to ensure they have reached the optimal level for i gel insertion by checking e There is a loss of eyelash reflex e The jaw can be moved up and down easily e There is no response to a painful stimulus at the angles of the mandible e Muscle relaxation with the use of a nerve stimulator 6 1 Preferred technique Pre medication with anxiolytics or opiates opioids preoxygenation and co induction with midazolam and short acting opioid like fentanyl alfentanil or remifentanil e Propofol 2 5 3mg kg as the induction agent of choice Please read the prescribing instructions for its use in various age groups NB For the purpose of IPPV a muscle relaxant can be used e g atracurium vecuronium or rocuronium etc 6 2 Other techniques of
22. s in the bowl of the cuff or elsewhere on the device Avoid touching the cuff of the device with your hands figures 8 9 10 and 11 Place the i gel back into the cradle in preparation for insertion figure 12 NB The i gel must always be separated from the cradle prior to insertion The cradle is not an introducer and must never be inserted into the patient s mouth 5 4 Pre insertion preparation Paediatric i gel Sizes 1 1 5 2 and 2 5 1 Always wear gloves 2 S Open the i gel package and on a flat surface take out the cage pack containing the device figure 13 In the final minute of pre oxygenation open the cage pack and transfer the device into the lid of the cage Place a small bolus of a water based lubricant such as K Y Jelly onto the smooth inner surface ready for use Do not use silicone based lubricants figures 14 15 and 16 Grasp the i gel along the integral bite block and lubricate the back sides and front of the cuff with a thin layer of lubricant Ensure after lubrication has been completed that no BOLUS of lubricant remains in the bowl of the cuff or elsewhere on the device Avoid touching the cuff of the device with your hands figures 17 18 19 and 20 Place the i gel back into the cage pack in preparation for insertion figure 21 WARNINGS e Do not place the device onto the chest or pillow of the patient always use the protective cradle cage pack provided e Do not use unste
23. the device is retained in the correct flexion prior to use and also acts as a base for lubrication The i gel must always be separated from the cradle or cage pack prior to insertion The cradle and cage pack are not introducers and must never be inserted into the patient s mouth A proficient user can achieve insertion of the i gel in less than 5 seconds 1 Grasp the lubricated i gel firmly along the integral bite block Position the device so that the i gel cuff outlet is facing towards the chin of the patient Figure 22 2 The patient should be in the sniffing the morning air position Figure 22 with head extended and neck flexed The chin should be gently pressed down before proceeding to insert the i gel 3 Introduce the leading soft tip into the mouth of the patient in a direction towards the hard palate 4 Glide the device downwards and backwards along the hard palate with a continuous but gentle push until a definitive resistance is felt Figure 22 Patient in the sniffing the morning air position just prior to insertion WARNING Do not apply excessive force on the device during insertion It is not necessary to insert fingers or thumbs into the patient s mouth during the process of inserting the device If there is early resistance during insertion a jaw thrust Figure 23 Insertion with deep rotation Figure 24 or triple maneouvre is recommended 5 At this point the tip of the airway should b
24. tion minimal risk of tissue compression and stability after insertion i e no position change with cuff inflation The i gel is designed as a latex free sterile single patient use device The buccal cavity stabiliser has a widened elliptical symmetrical and laterally flattened cross sectional shape but still round airway channel providing good vertical stability and axial strength upon insertion This houses a standard airway channel and a separate gastric channel Please note the size one i gel does not have a gastric channel The tube section is firmer than the soft bowl of the device The firmness of the tube section and its natural oropharyngeal curvature allows the device to be smoothly inserted by grasping the proximal end of the i gel which helps glide the leading edge against the hard palate into the pharynx It is not necessary to insert fingers into the mouth of the patient for achieving full insertion The smooth contiguous under surface of the device from the tip of the bowl and throughout the entire tube section allows the device to easily slide posteriorly along the hard palate pharynx and into the hypopharynx An integrated gastric channel can provide an early indication of regurgitation facilitates venting of gas from the stomach and allows for the passing of a nasogastric tube to empty the stomach contents Please note the size one i gel does not have a gastric channel 1 2 Key components and their function Adult s
25. tt CJ Extraglottic airway devices for use in diving medicine part 3 The i gel Diving and Hyperbaric Medicine Volume 38 Liew B John S Ahmed 2008 Aspiration recognition with an i gel airway Anaesthesia 2008 Jul 63 7 786 Joshi NA Baird M Cook TM Use of an i gel for airway rescue Anaesthesia 2008 Sep 63 9 1020 1 Uppal V Fletcher G Kinsella J Comparison of the i gel with the cuffed tracheal tube during pressure controlled ventilation British Journal of Anaesthesia 2009 102 2 264 8 Beylacq L Bordes M Semjen F AM Cros The i gel a single use supraglottic airway device with a non inflatable cuff and an esophageal vent an observational study in children Acta Anaesthesiol Scand 2009 53 376 379 Lloyd de L Hodzovic I Voisey S Wilkes AR Latto IP Comparison of fibreoptic guided intubation via the classic laryngeal mask airway and i gel in a manikin Anaesthesia 2010 65 pages 26 43 Francksen H Renner J Hanss R Scholz J Doerges V Bein B A comparison of the i gel with the LMA Unique in non paralysed anaesthetised adult patients Anaesthesia 2009 64 pages 1118 1124 Wiese CHR Bahr J Popov AF Hinz JM Graf BM Influence of airway management strategy on no flow time in a standardized single rescuer manikin scenario a comparison between LTS D and i gel Resuscitation 2009 80 100 103 Singh Gupta M Tandon M Comparison of clinical performance of i gel with LMA Proseal in Elective surgeries
26. ttempts in one patient should be attempted 14 i gel 8 0 Maintenance of anaesthesia An inhalation technique involving oxygen nitrous oxide and halothane isoflurane sevoflurane or desflurane is the most commonly used maintenance anaesthetic technique More recently Total Intravenous Anaesthesia TIVA involving a propofol infusion along with an infusion of an opioid fentanyl alfentanil or remifentanil while the patient breathes 30 50 oxygen in air is gaining widespread popularity Patients requiring IPPV will need adequate doses of the chosen muscle relaxant given either by a continuous infusion or by intermittent boluses on an as and when required basis whilst muscle relaxation is monitored by a nerve stimulator 9 0 Emergence from anaesthesia Towards the end of the surgery and anaesthetic 9 1 Spontaneously Breathing Patients If the inhalation technique for the maintenance of anaesthesia was used the anaesthetic agents should be stopped at the end of the operation except oxygen The patient will continue to breathe near 100 oxygen and the residual anaesthetic gases in the breathing system before waking up If TIVA was used then standard practice should be followed with TIVA stopped just after the end of the operative procedure a longer acting opioid or opiate is given and the patient allowed to wake up whilst breathing near 100 oxygen through the anaesthetic system 9 2 Patients with IPPV It is advisabl
27. ully opened their mouth or opens their mouth spontaneously Figure 27 Figure 27 Do not attempt to remove the i gel if the patient is biting on it 11 0 How to use the gastric channel Select the appropriate size of nasogastric NG tube i gel size Maximum size of Nasogastric Tube FG Physiologically every fasted patient for routine elective procedures has approximately 25 200ml of residual gastric contents at any one time This group of patients may not have any predisposing factors for regurgitation If regurgitation is suspected or noticed during anaesthesia then it is recommended the patient head end of the operating table is tilted down and if the timing of the surgical procedure allows the patient is turned onto a left or right lateral position i gel should then be removed thorough suctioning of the pharynx and hypopharynx undertaken and the patient intubated for definitive securing of the airway If regurgitation is anticipated then it is recommended that a nasogastric tube is passed through the gastric channel of the i gel into the patient s stomach and the stomach emptied The nasogastric tube can be left in situ during the whole duration of the operation anaesthetic 11 1 DO NOT USE THE GASTRIC CHANNEL IF There is an excessive air leak through the gastric channel There are oesophageal varices or evidence of upper gastro intestinal bleed In cases of oesophageal trauma There is a history
28. vices in a manikin Br J Anaesth 2008 Mar 100 3 351 6 Gatward JJ Cook TM Seller C Handel J Simpson T Vanek V Kelly F Evaluation of the size 4 l gel airway in one hundred non paralysed patients Anaesthesia 2008 Oct 63 10 1124 30 Wharton NM Gibbison B Gabbott DA Haslam GM Muchatuta N Cook TM I gel insertion by novices in manikins and patients Anaesthesia 2008 Sep 63 9 991 5 Levitan RM Kinkle WC Initial anatomic investigations of the i gel airway a novel supraglottic airway without inflatable cuff Anaesthesia 2005 Oct 60 10 1022 6 Gabbott DA Beringer R The i gel supraglottic airway A potential role for resuscitation Resuscitation 2007 Apr 73 1 161 2 Sharma S Rogers R Popat M The i gel airway for ventilation and rescue intubation Anaesthesia 2007 Apr 62 4 419 20 Jackson KM Cook TM Evaluation of four airway training manikins as patient simulators for the insertion of eight types of supraglottic airway devices Anaesthesia 2007 Apr 62 4 388 93 Soar J The i gel supraglottic airway and resuscitation some initial thoughts Resuscitation 2007 Jul 74 1 197 UK Resuscitation Council Advanced Life Support Guide 5th Edition Revised June 2008 Schmidbauer W Bercker S Volk T Bogusch G Mager G Kerner T Oesophageal seal of the novel supralaryngeal airway device i gel in comparison with the laryngeal mask airways Classic and ProSeal using a cadaver model Br J Anaesth 2009 Jan 102 1 135 9 Aco
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