Analysis of ease of insertions, its attempts and time taken to insert for i-gel and cLMA in paediatric cases.

Aim : Analysis of ease of insertions, its attempts and time taken to insert for i-gel and cLMA in paediatric cases. Methods : We did a prospective, randomised single-blind study on Eighty patients of either sex belonging to American Society of Anaesthesiologists (ASA) physical status class I or II, between 6 months to 8 years of age, scheduled to undergo elective surgery for less than one and half hour duration under general anaesthesia. In this study we analysed the ease of insertion, attempts and time were taken to insert the supraglottic airway device. Results: The ease of insertion observed was easy in 39(97.5%) in the i-gel group and 35(87.5%) in cLMA group in our study. The i-gel was placed successfully in 39 out of 40 (97.5%) patients in the first attempt, and achieved 100% insertion on the second attempt. Correct positioning of cLMA in the first attempt was seen in 35 out of 40 (87.5%) patients. The remaining 5 patients (12.5%) required a second attempt. The average insertion time of cLMA (12.88 ± 1.771 seconds) was longer than the average time of insertion of i-gel (9.48 ± 1.037 seconds), and these differences were highly significant statistically (p= 0.000). Conclusion: To conclude, i-gel and cLMA is effective and safe devices for use in children. Both are easy to insert and have insignificant morbidity, however, time taken and attempts of insertions for i-gel was lesser than cLMA. Also, the ease of insertion was relatively easy for i-gel than cLMA in pediatric cases.

The paediatric size i-gel have been introduced in January 2010. It is available in 5 sizes-1, 1.5, 2, 2.5 and 3. Like adult i-gel, it has a gastric drain except for size 1.
Studies done on i-gel by various investigators have found that i-gel is an effective device for airway management in children.
Beylacq et al performed an observational study on igel in 50 children above 30 kgs undergoing shortduration surgery. In their study it was possible to insert i-gel in the first attempt in all the cases. The authors concluded that the success rate of insertion of i-gel was 100% and was accompanied by very few complications. Also the author reported that igel could be an efficient and safe device for paediatric airway management Patients were then be randomly allocated to one of the two groups using a computer-generated sequence of random numbers, as follows: Group-1 -(n=40), LMA Classic was used as an airway conduit.
atracurium 0.5 mg kg-1 was used to facilitate airway device insertion. All patients were ventilated for two minutes via face mask and anaesthesia breathing system using sevoflurane 2% in 100% O2. The A difficult insertion was the one in which there is resistance to insertion or where more than one attempt was required to seat the device within the pharynx. In case it was not possible to insert the device in three attempts it was labelled as a failure.

Time of insertion:
The time interval between picking up the device and obtaining effective ventilation was recorded.

Number of attempts:
In the event of complete or partial airway obstruction or a significant leak the airway device was removed and reinsertion attempted. A maximum of three insertion attempts was allowed before the placement of the device was considered a failure. In case of failure alternative airway device was used to secure the airway.

Results
Different parameters including ease of insertion, time of insertion, number of attempts were studied.
Demographic Profile: The demographic details of the patients in our study had no significant difference between the groups in terms of age, sex and weight. The two groups were comparable concerning the duration of surgery and ASA physical status.

Time of insertion:
The time interval between picking up the device and obtaining effective ventilation was recorded.
The results in table 1, shows lesser time was required to achieve effective ventilation for i-gel cases as compared to cLMA. And the data showed it as highly significant statistically.    Thus i-gel needed a smaller number of attempts for insertion than cLMA but this difference was statistically non-significant when two groups were compared.

Ease of insertion:
The ease of insertion was graded on a three-point scale, easy, difficult, and failure. An easy insertion was defined as an insertion within the pharynx without resistance in a single manoeuvre. A difficult insertion was the one in which there is resistance to insertion or where more than one attempt was required to seat the device within the pharynx. In case it was not possible to insert the device in three attempts it was labelled as a failure.
In our study i-gel had easy ease of insertion in 97.5%, and difficult in 2.5% of case. However, for cLMA easy ease of insertion was noted in 87.5% of cases and the rest of the cases (12.5%) had difficult ease of insertion (Table 3). When compared between two groups ease of insertion was found to be statistically non-significant (p-value= 0.090).

Discussion
The The two groups were similar demographically in terms of age, gender, weight, height and BMI. They were also similar concerning ASA physical status and duration of surgery. Therefore, we can say that results obtained after the study was purely due to the characteristics attributable to devices rather than any bias associated with the sample selected. In another randomized controlled study, Lee et al compared i-gel with cLMA in 99 children and found 96% and 100% success on the first and second attempt respectively with i-gel as compared to 92%

Attempts of insertion:
and 100% success with cLMA on first and second attempts respectively [10]. In our study the lesser number of attempts of i-gel can be explained by its less flexible stem that facilitates its easy insertion.
The They found the ease of insertion of the two devices were similar (i-gel=78% and cLMA=76%) and both devices were placed without any difficulty [10].  [11]. The shorter insertion time for i-gel compared with c-LMA was probably because the tube section is firmer in i-gel making insertion easier than cLMA. The firmness of the tube section in i-gel and it's natural oropharyngeal curvature allows the device to be smoothly inserted by grasping the proximal end of it which helps to glide the leading edge against the hard palate into the pharynx.
Also, there was no need for cuff inflation in i-gel in contrast to LMA. So the time required to secure the airway and give the first breath is less with i-gel.
The time taken to achieve effective airway for i-gel was higher in other studies than the time taken in our study, which could probably be due to differences in technique of insertion, the experience of the anaesthetist, demographic profile and other variables.

Conclusion
To conclude, both supraglottic airway devices are better and effective regarding attempts, time is taken and ease of insertion. Both are easy to insert and have insignificant morbidity, however the time taken for insertion of i-gel was less. Also, the ease of insertion was easy for i-gel as compared to cLMA. And attempts taken to insert i-gel was relatively lesser than cLMA. Making inference that i-gel a better airway device than cLMA in pediatric cases.
What does this study add to existing knowledge?  [Crossref] International Journal of Medical Research and Review 2021;9(2)