The i-gel as a conduit for the Aintree intubation catheter for

The i-gel as a conduit for the Aintree intubation catheter for subsequent fiberoptic intubation
Romanian Journal of Anaesthesia and Intensive Care 2014 Vol 21 No 2, 131-133
CASE REPORTS
The i-gel as a conduit for the Aintree intubation catheter for
subsequent fiberoptic intubation
Alexander Izakson1, Guy Cherniavsky1, Alexey Lazutkin1, Tiberiu Ezri2*
1
Department of Anesthesia Sieff Medical Center, Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
Department of Anesthesia, Wolfson Medical Center, Affiliated to Tel Aviv University, Israel
* Outcomes Research Consortium, Cleveland, OH
2
Abstract
We report a clinical case of an 128 kg, 53 year old male, who was scheduled for sleeve gastrectomy
surgery. Video laryngoscope (GlideScope – Verathron) assisted intubation was attempted. Despite
repositioning of the head and neck and external laryngeal manipulations, two attempts to lift the epiglottis
were unsuccessful. An i-gel (Intersurgical, Wokingham, Berkshire, United Kingdom) supraglottic device
was successfully placed and normal oxygenation and ventilation was established with pressure controlled
ventilation. An Aintree intubation catheter (AIC, Cook Medical, USA) pre-loaded onto a pediatric fiberoptic
bronchoscope (FOB) was advanced through the i-gel. After fiber optic visualization of the vocal cords, the
AIC and FOB were successfully placed into the patient’s trachea.
We conclude that the i-gel may not only serve as a substitute for failed tracheal intubation, but is also
useful as a conduit for subsequent fiberoptic intubation.
Keywords: difficult intubation, i-gel, Aintree intubation catheter, fiber optic bronchoscope, fiber optic
intubation
Rom J Anaesth Int Care 2014; 21: 131-133
Case description
Introduction
The insertion of a supraglottic airway (SGA) and
tracheal intubation through it may be indicated in
resuscitation or other scenarios whenever conventional
laryngoscopy fails. Various SGA devices have been
used as conduits for tracheal intubation, including the
intubating laryngeal mask airway (ILMA), C-trach
laryngeal mask and the i-gel supraglottic airway. The
‘i-gel’ which has been developed in 2007 has several
distinctive features compared to the other supraglottic
airways.
Adress for correspondence:
Prof. Tiberiu Ezri, MD
Department of Anesthesia
Wolfson Medical Center
Holon 58100, Israel
E-mail: [email protected]
We report a case of an 128 kg, 53 year old male,
who was scheduled for sleeve gastrectomy surgery.
The preoperative airway evaluation revealed a slightly
limited mouth opening with an inter incisor gap of nearly
3.5 centimeters. He had a Mallampati – class 3 and
showed normal neck movement. His neck circumference was less than 40 cm. Based on that, we decided
to induce general anesthesia intravenously with
propofol and rocuronium and proceed with a video
laryngoscope assisted intubation (method A). Before
the induction of general anesthesia the patient was
placed in “ramped” intubation position. After induction
of anesthesia, bag-mask ventilation proved to be
difficult, though normal ventilation and oxygenation was
possible using a four-hands (two persons) mask
ventilation technique. Due to the limited mouth opening,
video laryngoscope (GlideScope – Verathron) assisted
intubation was attempted. Laryngoscopy revealed
grade 3 Cormack and Lehane view with large epiglottis. Despite repositioning of the head and neck and
external laryngeal manipulations, two attempts to lift
132 Izakson et al.
the epiglottis were unsuccessful. At this point, the
patient started to desaturate and mask ventilation
became more difficult. As a method B and escape
scenario, the i-gel size 4 (Intersurgical, Wokingham,
Berkshire, United Kingdom) supraglottic device was
successfully placed, according to the ASA difficult
airway algorithm (9). After the placement of the i-gel,
normal oxygenation and ventilation was established.
At this stage we decided to continue the case, performing fiberoptic assisted intubation (method C). A
4.7 mm inner diameter (ID) Aintree intubation catheter
(AIC, Cook Medical, USA) pre-loaded onto a 3.5 mm
pediatric fiber optic bronchoscope (FOB) was advanced through the i-gel, using a fiber optic elbow
connector, without discontinuation of mechanical
ventilation. After fiber optic visualization of the vocal
cords, the AIC and FOB were successfully placed into
the patient’s trachea, above the carina. The i-gel and
FOB were subsequently removed and an 8 mm ID
endotracheal tube was successfully railroaded over
AIC into the patient’s trachea.
The patient had uneventful surgery and was successfully extubated in a post anesthesia care unit, when
he was awake, pain free and cooperative and having
normal oxygenation and ventilation.
Discussion
To our knowledge, this is the single case report of
successful tracheal intubation using i-gel as a conduit for
an AIC fiber optic assisted intubation in an adult patient.
There are a few case reports of tracheal intubation
through i-gel conduit in the pediatric population [1, 2].
In both cases tracheal intubations were performed
using a fiber optic bronchoscope directly through an igel conduit without AIC.
We are aware of the three manikin studies comparing FOB guided intubation through both the classic
laryngeal mask airway (LMA) and the i-gel, via the
AIC sheathed over the FOB or directly over the FOB
[3-5]. These studies are equivocal in their conclusions.
de Lloyd et al. [3] concluded that the i-gel is likely to
be a more appropriate conduit than the classic LMA
for fiber optic scope guided intubation irrespective of
the intubation method used. The results of Michalek’s
study showed that, in manikins, fiber optic intubation
through both intubating LMA and i-gel is a highly
successful technique. Blind intubation through the igel showed a low success rate and should not be
attempted [4]. The findings of Ryusuke Ueki et al.
study suggest that the AIC is effective in reducing
collisions with the tracheal tube and thus will reduce
the risk of mechanical injury to the airway [5]. The
results of this study also conclude that intubation took
longer with the Fastrack-Single Use (FSU), and the
FSU had a higher failure rate than the other supraglottic
airway devices for tracheal intubation.
The Aintree Intubation Catheter (AIC) (Cook Critical Care, Bloomington, IN, USA) is a semi-rigid hollow catheter that can facilitate bronchoscope-guided
tracheal intubation. The device is 56 cm long with an
ID of 4.7 mm, which allows the catheter to be preloaded onto a 4.0 mm, or smaller, fiberoptic bronchoscope and leaves the distal 3-10 cm of the bronchoscope unsheathed for ease of manipulation. The AIC
allows endotracheal tube (ETT) ID 7.0 mm or greater
to be inserted. During tracheal intubation, the AIC is
mounted over a bronchoscope and the bronchoscope/
AIC assembly is inserted through the intubating SGA
device into the trachea. After the bronchoscope and
SGA are withdrawn, an ETT is railroaded over the
AIC into the trachea. During this process, the AIC
can also be used for ventilation through the use of a
removable Rapi-Fit adapter.
The i-gel (Intersurgical Ltd, Wokingham, Berkshire,
UK) is a SGA device that features a non-inflatable
cuff and the possibility to introduce a gastric catheter.
Its successful use has been described in randomized
controlled studies [6, 7], including studies showing the
possibility to intubate through the i-gel [4, 8].
In our case, after routine airway evaluation, traditional approach to intubation was attempted but did
not succeed. Thus, an i-gel was inserted according
the ASA Difficult Airway Guidelines [9, 10] in order
to provide adequate oxygenation and ventilation to the
patient. An i-gel allowed stable airway management
when ventilation through a mask became difficult.
We conclude that the i-gel may not only serve as a
substitute for failed tracheal intubation, but is also useful
as a conduit for subsequent fiberoptic intubation.
One of the greatest advantages of the combination
of i-gel with AIC is the possibility to provide oxygenation and ventilation to the patient, using i-gel, and at
the same time having an opportunity to perform fiber
optic intubation through AIC. As a matter of fact,
having AIC which was advanced into the trachea fiber
optically guided, provided us a greater margin of safety
during the passage of the endotracheal tube over AIC.
Financial disclosure and Conflict of interest
Nothing to declare
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Utilizarea i-gel ca introductor pentru
cateterul Aintree premergător
intubaţiei fibroscopice
Rezumat
Prezentăm cazul clinic al unui bărbat în vârstă de
53 de ani şi de 128 kg, care a fost programat pentru o
intervenţie chirurgicală de gastrectomie longitudinală.
A fost încercată intubaţia oro-traheală asistată de
videolaringoscop (GlideScope – Verathron). În ciuda
repoziţionării capului şi gâtului şi a manipulării externe
a laringelui, două tentative de ridicare a epiglotei s-au
soldat cu eşec. Un dispozitiv supraglotic i-gel
(Intersurgical, Wokingham, Berkshire, United
Kingdom) a fost aplicat eficient asigurându-se astfel
oxigenarea normală şi ventilaţia pacientului în modul
pressure-controlled. Un cateter de intubaţie Aintree
(AIC, Cook Medical, USA), preîncărcat pe un bronhoscop fibrooptic pediatric (FOB), a fost avansat de-a
lungul dispozitivului i-gel. După vizualizarea fibrooptică
a corzilor vocale, AIC şi FOB au fost introduse cu
succes în trahee, ulterior plasându-se şi sonda de
intubaţie.
În concluzie, dispozitivul i-gel este util, atât ca substituent în cazul intubaţiei eşuate cât şi ca ghid în vederea
unei intubaţii fibrooptice consecutive.
Cuvinte cheie: intubaţie dificilă, i-gel, cateter de
intubaţie Aintree, bronhoscop fibrooptic, intubaţie
fibrooptică

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