User Guide - MidMeds Ltd
Contents
1. Ochroch AE Kush S Stuart S Hollander JE Levitan RM Assessment of laryngeal view in direct laryngoscopy The percentage of glottic opening POGO score compared to Cormack and Lehane grading Canadian Journal of Anesthesia 1999 46 987 90 Cooper RM Use of a new videolaryngoscope GlideScope in the management of a difficult airway Canadian Journal of Anesthesia 2003 50 611 3 Brimacombe J Berry A A proposed fiber optic scoring system to standardize the assessment of laryngeal mask airway position Anesthesia Analgesia 1993 76 45 Keller C Brimacombe J Mucosal pressure and oropharyngeal leak pressure with the ProSeal versus the classic laryngeal mask airway British Journal of Anaesthesia 2000 85 262 6 Brimacombe J Keller C Boehler M Puehringer F Positive pressure ventilation with the ProSeal versus Classic laryngeal mask airway A 3 randomized crossover study of healthy female patients Anesthesia Analgesia 2001 93 1351 Preoperative fasting for adults to prevent perioperative complications Brady M Kinn S Stuart P Cochrane Database Syst Rev 2003 4 CD004423 Brimacombe J Laryngeal Mask Anaesthesia Principes and Practice 2 edition 2004 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 regist2. 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 peri laryngeal framework is Figure 3 Soft non inflatable cuff maintained and helps to reduce the possibility of neurovascular compression trauma to the nerves Sliding beneath the pharyngo epiglottic folds it becomes narrower and deeper creating an outward movement to fit snugly into the potential space of the perilaryngeal pouch 1 2 2 Gastric channel The gastric channel runs through the device from its proximal opening at the right hand 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 the gastric channel allows for suctioning passing of a nasogastric tube and can facilitate venting 1 2 3 Epiglottis blocker 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 propensity
3. influence of cuff volume on oropharyngeal leak pressure and fibreoptic position with the laryngeal mask airway British Journal of Anaesthesia 1998 81 186 7 Brimacombe J Keller C Morris R Mecklem D A comparison of the disposable versus the reusable laryngeal mask airway in paralyzed adult patients Anesthesia amp Analgesia 1998 87 921 24 Twigg S Brown JM Williams R Swelling and cyanosis of the tongue associated with use of a laryngeal mask airway Anaesthesia amp Intensive Care 2000 28 449 50 Stewart A Lindsay WA Bilateral hypoglossal nerve injury following the use of the laryngeal mask airway Anaesthesia 2002 57 264 5 Drummond GB Influence of thiopentone on upper airway muscles British Journal of Anaesthesia 1989 63 12 21 17 18 19 20 21 22 23 24 25 26 27 Further reading Lowinger D Benjamin B Gadd L Recurrent laryngeal nerve injury caused by a laryngeal mask airway Anaesthesia amp Intensive Care 1999 27 202 5 Ouellette RG The effect of nitrous oxide on laryngeal mask cuff pressure American Association of Nurse Anesthetists Journal 2000 68 411 4 Agro F Cataldo R Carassiti M Costa F The seeing stylet A new device for tracheal intubation Resuscitation 2000 44 177 80 Levitan RM Ochroch AE Hollander J et al Assessment of Airway Visualization Validation of the Percent of Glottic Opening POGO Scale Academic Emergency Medicine 1998 5 919 23
4. intubation in cases of difficult or failed intubations 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 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 Establishing a clear airway in pre hospital or intra hospital cardio respiratory arrest patients where techniques to intubate the patient have failed or expertise to intubate the patient is not available 2 Use by an ambulance crew in difficult or unexpectedly difficult intubations in a pre hospital stage in order to achieve and maintain a clear airway 3 Securing a clear airway in difficult or unexpecte
5. the i gel back into the cage pack in preparation for insertion figure 11 Do not place the device onto the chest or pillow of the patient always use the tray provided Do not use unsterile gauze to help in lubricating the device Do not apply lubricant too long before insertion Remove dentures or removable plates from the mouth before attempting insertion of the device Figure 4 Figure 5 Figure 6 Figure 7 K Y Jelly is a registered trademark of Johnson and Johnson Inc i gel 8 Preparation for use Figure 8 Figure 9 Figure 10 Figure 11 6 0 Induction of Anaesthesia Ensuring an adequate depth of anaesthesia is of paramount importance for successful insertion of the i gel The use of pulse oximetry and capnography is recommended The following methods for induction of anaesthesia can be used 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 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 use a muscle relaxant e g atracurium vecuronium or rocuronium etc 6 2 Other techniques of induction Pre medication with benzodiazepines and or opiates opioids Induction with thiopentone or other barbiturates etomidate or ketamine Induction should be followed by man
6. 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 NEVER OG CTI ONN si ocsi ea E E eE aE Ea 1 1 1 The i gel desig sinsdien adane ia aAa A aTa ERRERA 1 1 2 Key components and their TUMCUOM ois vicndaarctanesxotensitalaaanndendiedennetabialetaeadindemadeenstntcdegiawnes 2 1 2 1 Soit non inflatabl CUT nienn iinan dwiatetsdntaxtebuninhemadbantelanes 3 T22 ASIC CVAMING Lossitie eana AA ES 3 Vo E pPIOIORIS DOCK eerren Era eaa E a vetmianteiaimasMakaeds 3 1 24 Buccal cavity SIO ISS lrennevenarnzurs unten canenterneasnious ss tanguteainachunndencanemeetasaniaverstansesateccan 3 T29 Tomm COMING CO aetna cease tect thegs Aea R AN aia EaR 4 126 IIOP CAE key PONS eraeun a eE ai a a DTe 4 E ONS o encanto op via occ a ine Mins epee enw 5 COME AING ICAU ONS ice cece sates denen ceustnawennus EEEE ET EEEE RENTNER 6 WA UN o AE E E E E E A EE E E E TE A E TE 6 Preparation fOr US Copco etecee stan cictuee te cesmactw veo iemirebauth ie rsenictuwi eu naaawa aaae 7 I SS CON gece E AT T A A E AE TE A F gA Pree Chek es ea AE 7 5 3 Pre insertion LG Dl AON secrete cose poe ectacuecasc ces tootdioakacusnes aaalgegmeceaeertiecyansanciasssoreatints 8 Induction of ANAGCSINGS la visiccdccecd acicsentncscunsessxvanecsincentudsatcdentieccscdewesesvatcisiecestudestenes 9 6 1 Froierred WC NOUNS accra nett geese rece tnde r E R dacnesanaceaaasnededatlacenaseanaieasnncbeanstceen 9 6 2 Other techniques OF INDUC OM sacesnssenexcaccn
7. aceosecidsensesaceegsanceeietencsniasleseainehivaeuieideaemtcoueeeeee 9 Insertion technique sasssnssnnsnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn mnnn nnn mennene 10 7 1 Recommended insertion teChnique ccccccssecccseeeceesecceueeeceeseceuseeceaeeeseueessuseeseaes 10 7 2 Important notes to the recommended insertion teCNnique cccccceseeeeeeeeeeeeeeeeees 11 Maintenance of Anaesthesia ccccceesceeeeeeeeseeeeeeeeeeeeeeeeeeeseneeeseeeeseeaeneeeeseeens 12 Emergence from Anaesthesia cccccssseeencsssseeecnseeeseeenseeseaaenensenansesseneneeeses 12 Recovery phase of Anaesthesia and i gel removal cccseseeeeeeeeeeeeees 12 How to use the gastric Channell ccccceseeeeeseeeeeeeeeeeeeeeeeeeeeeeeeeesseneensnenenseeees 13 TOTS ON UN asuna aa E aa Da Eia Moonee E aE 14 Adverse OUTCOMES osorioi aaa 15 Further reading ssssssssssssnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn mnnn nnn 16 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 compression trauma This device has been developed after extensive literature searches related to supraglottic extraglotti
8. c periglottic and intraglottic airway devices dating back as far as the eighteenth century Fresh cadaveric neck dissections direct and indirect pharyngo laryngeal endoscopies X rays CT and MRI imaging data were all utilised in order to ensure the i gel s shape softness and contours accurately mirror those of the pharyngeal laryngeal and perilaryngeal framework The i gel is a truly anatomical device achieving a mirrored impression of those structures without causing multidirectional forces of 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 Figure 1 1 2 3 4 5 9 7 O Q 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 1 Introduction A supraglottic airway without an inflatable cuff has several potential advantages including easier insertion 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 single patient use device The buccal cavity stabiliser has a widened elliptical symmetrical and laterally
9. complicating the anaesthetic outcome 7 Do not leave the device in situ for more than 4 hours Do not reuse or attempt to reprocess the i gel Patients with any condition which may increase the risk of a full stomach e g hiatus hernia sepsis diabetes melitus obesity pregnancy or a history of upper gastro intestinal surgery etc 4 0 Warnings 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 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 Maintaining the sterility of the device during preparation and prior to insertion is important Packaging is in the shape of a twin tray and tyvek pack The inner tray acts as a stand mount for the device and helps to maintain sterility until inserted 5 1 Size selection Select the appropriate size i gel by assessing the patient s anatomy Please note the i gel may look smaller than traditional supraglottic devices with an inflatable cuff Patient size Patient weight guidance kg If the seal is not adequate particularly during intermittent positive p
10. dly difficult intubations in airway management of a patient in the operating theatre 4 In an elective difficult or unexpectedly difficult intubation for intubating the patient by passing a cuffed endotracheal tube CETT through the device igelsie Maximum size of Cuffed Endotrachael Tube S a a 5 In a difficult or unexpectedly difficult intubation to pass a gum elastic bougie blindly but gently through the device in situ into the trachea and to rail road the CETT over it 6 In a known difficult or unexpectedly difficult intubation to pass a fibre optic scope through the device to provide visualisation of the glottic opening to aid intubation 7 In the Intensive Care patient for weaning a certain category of the population where an endotracheal tube is not well tolerated 8 In difficult mouth opening situations i gel can also be inserted under direct vision with the help of a laryngoscope 3 0 Contraindications Oona A OUN Non fasted patients for routine and emergency anaesthetic procedures Patients with an ASA or Mallampati score of III and above Trismus limited mouth opening pharyngo perilaryngeal abscess or mass Do not allow peak airway pressure of ventilation to exceed 40cm H O Do not use excessive force to insert the device or nasogastric tube Inadequate levels of anaesthesia which may lead to coughing bucking excessive salivation retching laryngospasm or breath holding thus
11. ered trademark of Intersurgical The information provided in this document are correct at the time of publication Intersurgical reserves the right to improve or modify the product without prior notification INi EROUNGILA Intersurgical Ltd Crane House Molly Millars Lane Wokingham Berkshire RG41 2RZ T 44 0 118 9656 300 F 44 0 118 9656 356 info intersurgical com www intersurgical com 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 370 387 66611 info intersurgical It Nederland T 0413 243860 info intersurgical nl Poccua T 095 771 6809 info 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 9279 Issue 2 12 06
12. f 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 E Figure 18 Ideal position of teeth 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 probably not seated properly In such instances remove the device and reinsert with a gentle jaw thrust applied by an assistant Excessive air leak through a nasogastric tube NG Tube inserted through the gastric channel means it is likely the NG Tube is in the trachea or even further down into the lungs Should this occur remove the i gel along with the NG Tube and reinsert the i gel with a gentle jaw thrust and then reinsert the NG Tube as before 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 H20 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 following 1 Hand ventilate the patient with gentle and sl
13. flattened cross sectional shape providing good vertical stability upon insertion This houses a standard airway and a separate 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 inserted by grasping the proximal end of the i gel and helps to 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 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 hypopharynx An integrated gastric channel is provided for the suction of gastric contents or to allow the passage of a nasogastric tube to empty the stomach 1 2 Key components and their function 15mm connector Proximal end of r T gastric channel af Buccal cavity stabiliser Integral bite block Epiglottis blocker Distal end of Soft non inflatable cuff gastric channel Figure 2 Key components of the i gel i gel 2 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
14. gastric channel of the i gel into the patient s stomach and the stomach emptied The nasogastric tube can be left in situ until the end of the anaesthetic 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 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 Incorrect position A horizontal line at the middle of the integral bite block represents the correct position of the teeth Figure 18 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 Coughing and breath holding In the presence of 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 I
15. ir position Figure 12 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 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 13 or Insertion with Deep Rotation Figure 14 is recommended Figure 12 Patient in the sniffing the morning air position just prior to insertion Insertion technique Figure 13 Jaw thrust Figure 14 Deep rotation 5 At this point the tip of the airway should be located into the upper oesophageal opening Figure 15a and the cuff should be located against the laryngeal framework Figure 15b The incisors should be resting on the integral bite block Figure 15c 6 In general the i gel is self retaining However i gel may be taped or tied down by the anaesthetic assistant if required Figure 16 Figure 15 Correct placement of the i gel Figure 16 Fixing of the i gel in place using adhesive tape The i gel should always be used in accordance with recognised airway management prac
16. n of the Proseal with the Classic laryngeal mask airway in unparalysed anaesthetized patients British Journal of Anaesthesia 2002 88 527 33 Brimacombe J Keller C Fullekrug B Agro F Rosenblatt W Dierdorf SF Garcia de Lucas E Capdevila X Brimacombe N A multicenter study comparing the ProSeal with the Classic laryngeal mask airway in anesthetized nonparalyzed patients Anesthesiology 2002 96 289 95 Brimacombe J Keller C The ProSeal laryngeal mask airway A randomized crossover study with the standard laryngeal mask airway in paralyzed anesthetized patients Anesthesiology 2000 93 104 9 Brain AlJ Verghese C Strube PJ The LMA ProSeal A laryngeal mask with an oesophageal vent British Journal of Anaesthesia 2000 84 650 4 Keller C Brimacombe J Keller K Morris R A comparison of four methods for assessing airway sealing pressure with the laryngeal mask airway in adult patients British Journal of Anaesthesia 1999 82 286 7 Brimacombe J Keller C Giampalmo M Sparr HJ Berry A Direct measurement of mucosal pressures exerted by cuff and non cuff portions of tracheal tubes with different cuff volumes and head and neck positions British Journal of Anaesthesia 1999 82 708 1 Brimacombe J Keller C A comparison of pharyngeal mucosal pressure and airway sealing pressure with the laryngeal mask airway in anesthetized adult patients Anesthesia amp Analgesia 1998 87 1379 82 Keller C Puehringer F Brimacombe J The
17. o hard by squeezing the reservoir bag this may cause gastric insufflation and distension which will increase the risk of regurgitation and post Operative 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 re inserted with a gentle jaw thrust and correct placement checked 10 11 12 13 14 19 16 Further reading R M Levitan and W C Kinkle Initial anatomic investigations of the l gel airway a novel supraglottic airway without inflatable cuff Anaesthesia 2005 Oct 60 10 1022 6 Miller DM A proposed classification and scoring system for supraglottic sealing airways A brief review Anesthesia and Analgesia 2004 99 1553 1559 Brimacombe J Berry A The incidence of aspiration associated with the laryngeal mask airway a meta analysis of published literature J Clin Anesth 1995 7 297 30 Brimacombe J Keller C Aspiration of gastric contents during use of a ProSeal laryngeal mask airway secondary to unidentified foldover malposition Anesthesia Analgesia 2003 97 1192 4 British Journal of Anaesthesia Cook TM Nolan JP Verghese C Strube PJ Lees M Millar JM Baskett PJ Randomized crossover compariso
18. okers 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 fully opened their mouth or opens their mouth spontaneously Figure 17 Figure 17 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 0 igelsie Maximum size of Naso Gastric Tube FG Physiologically every fasted patient for routine 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 25 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
19. ow 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 H O 4 Assess the depth of anaesthesia and muscle relaxation 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 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 are extremely low with the i gel compared to other supraglottic devices Down folding of the epiglottis can occasionally occur 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 to
20. ressure ventilation IPPV one size larger may be required 5 2 Pre use checks Inspect the packaging and ensure it is not damaged prior to opening 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 part embedded in the bowl s posterior wall is intact Discard the device if the airway tube or the body of the device looks abnormal Check the 15mm connector fits the patient connection Preparation for use 5 3 Pre insertion preparation 1 Always wear gloves 2 Open the i gel package and on a flat surface take out the cage pack containing the device figure 4 3 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 5 6 and 7 4 Grasp the i gel along the integral bite block and lubricate the front back and sides 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 8 9 and 10 5 Place
21. 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 before the end of the operative procedure and the patient allowed to wake up whilst breathing near 100 oxygen through the anaesthetic system 9 2 Patients with IPPV It is advisable 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 is 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 breath 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 sm
22. tice for supraglottic airway devices 7 2 Important notes to the recommended insertion technique 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 pbharyngo epiglottic folds 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 No more than three attempts in one patient should be attempted i gel 11 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 breaths 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
23. 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 i gel 3 Introduction 1 2 5 15mm connector The innovative connector serves a number of functions To provide a standard 15mm connection to the 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 An integral bite block this function is provided by the distal below the wing 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 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 internal diameter of the connector is the same as the internal diameter of the airway channel to facilitate fibre optically guided endotracheal
24. ual ventilation with a bag and mask with oxygen nitrous oxide and an inhalational agent until jaw relaxation of i gel 9 Induction of Anaesthesia the patient is achieved prior to attempting insertion of the i gel A guedel airway may be useful to facilitate manual ventilation Inhalational technique with oxygen nitrous oxide inhalational anaesthetic agent like sevoflurane desflurane isoflurane enflurane 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 technique is with oxygen nitrous oxide and sevoflurane 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 successful insertion of i gel Always pre oxygenate 7 1 Recommended insertion technique 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 12 2 The patient should be in the sniffing the morning a
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