RevBrasAnestesiol.2016;66(2):219---221
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
OfficialPublicationoftheBrazilianSocietyofAnesthesiologywww.sba.com.br
CLINICAL
INFORMATION
Pressure
support
ventilation
with
the
I-gel
in
intensive
care
unit:
case
report
Belgin
Akan
∗,
Deniz
Erdem,
Mahinur
Demet
Albayrak,
Esra
Aksoy,
Fatma
Akdur,
Nermin
Gogus
DepartmentofAnaesthesiologyandReanimation,NumuneTrainingandResearchHospital,Ankara,Turkey
Received13September2013;accepted16October2013 Availableonline11November2013
KEYWORDS
I-Gel; LMA;
Difficultairway; Pressure-controlled ventilation; Intensivecareunit
Abstract
Backgroundandobjectives: TheI-gelsupraglotticairwayhasanon-inflatablecuffmadefrom agel-like thermoplasticelastomer.TheuseoftheI-gelduringanesthesiafor spontaneously breathingpatientsorintermittentpositivepressureventilationhasbeenreported.Butthere areafewpublishedreportsabouttheuseoftheI-gelwithpressure-controlledventilation.
Contentsandconclusions:In thiscase reportwe describedtheuse oftheI-gel supraglottic airwayalong48hinintensivecareunitforthemanagementofventilationinapatientneeded mechanicventilationbutinwhomtrachealintubationcouldnotbeperformed.
© 2013SociedadeBrasileirade Anestesiologia.Publishedby ElsevierEditoraLtda.Allrights reserved.
PALAVRAS-CHAVE
I-Gel;
Máscaraslaríngeas; Manuseiodasvias aéreas;
Ventilac¸ãocom pressãopositiva intermitente; Unidadedeterapia intensiva
Ventilac¸ãocontroladaporpressãocomI-gelemunidadedeterapiaintensiva:relato decaso
Resumo
Justificativaeobjetivos: OdispositivosupraglóticoI-gelparaomanejodasviasaéreastemum manguitonão insuflávelfeitodeumelastômerotermoplásticosemelhanteao gel.Hárelato sobreousodoI-gelempacientessobanestesiaparaaventilac¸ão,espontâneaoucompressão positivaintermitente.Porém,hápoucosrelatospublicadossobreousodoI-gelcomventilac¸ão controladaporpressão.
Conteúdoeconclusões: Descrevemosnesterelatodecasoousododispositivosupraglótico I-geldurante48horasemunidadedeterapiaintensivaparaomanejodasviasaéreasempaciente queprecisoudeventilac¸ãomecânica,masnoqualaintubac¸ãotraquealnãopôdeserfeita. ©2013SociedadeBrasileira deAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.
∗Correspondingauthor.
E-mail:belginakan@yahoo.com(B.Akan).
220 B.Akanetal.
Introduction
The I-gel is a new, non-inflatable supraglottic airway
designed for spontaneous or intermittent positive
pres-sure ventilation. It was introduced into clinical practice
in the United Kingdom in 2007.1 It has potential
advan-tages including easier insertion and use, minimal risk of
tissue compression and no position change after
inser-tion.Thedifficult airwaysocietyguidelinesrecommendto
use of laryngeal mask airway (LMA) to secure ventilation
andoxygenationafterfailedoptimizedattempts atdirect
laryngoscopy.2 The use of the I-gel during anesthesia for
spontaneouslybreathingpatientswasalsoreported.3There
areseveralpublished reports onthe useof the I-gel
dur-ingpressurecontrolledventilation(PCV)inoperatingroom.4
However,therearelimitednumberofreportsregardingthe
useoftheI-gelinintensivecareunit(ICU).
In this case report, we described the use of the I-gel
supraglotticairwayalong 48h in ICU for themanagement
ofventilationinapatientneedingmechanicalventilation.
Case
report
A 49 year old female, weighed 40kg, hospitalized in ICU
because of fever and respiratory distress lasting for one
week.Shehadbeen ona homecareprogramafterseveral
operations because of having end stage glioblastome
multiforme.Whenshewasadmittedtothehospital,
hemo-dynamicmonitorizationincludingheartrate,systemicblood
pressure,continuous oxygensaturation,andendtidalCO2
monitorizationwereobtained.Trachealintubationwas
nec-essary for respiratory insufficiency. She had an adequate
mouth opening, but when laryngoscopy was performed,
a Mallampati score of 4 was assigned.5 Three attempts
at tracheal intubation with a gum elastic bougie failed.
A size 3 I-gel (Intersurgical Ltd., Wokingham, Berkshire,
UK) was inserted with ease on the first attempt, and
thenthepatient’slungventilatedmechanicallywithDrager
Evita 4 ventilator. Satisfactory oxygenation and
ventila-tion were confirmed with continuous pulse oximetry and
capnography. The capnography monitor showed a square
capnogram and stable arterial oxygen saturation above
95%. Because there was visible chest movement with no
leakage around the device, the insertion was defined as
successful.Afterspontaneousrespirationwasreturned,the
lungswereventilatedmechanicallyatmaximum 25cmH2O
usingPCVatarateof12bpmandinspiratory-to-expiratory
ratio of 1:2 with no positive end expiratory pressure.
The gastric tube waspassed usingthe special channel of
the device with ease and then the stomach was
decom-pressed.Arterialblood gas analysiswas establishedevery
2h.Tracheostomy wasnotnecessary becauseofsufficient
ventilationwiththeI-gel.The patientwasfollowed upin
ICU along 48h with the I-gel until she died of a septic
shock.
Discussion
The LMA and similar supraglottic airway devices with an
inflatablecuffcanbeusedformechanicalventilation.One
of the most frequent undesired events when using these
devicesisthemovementofthedeviceduringinflation
aris-ingfromtheforcingofdistalwedgeofthemaskoutofthe
upperesophagus.TheI-gelairwaymadeupofagel-like
ther-moplastic elastomer.Ithaspotential advantagesincluding
easierinsertionanduse,minimalriskoftissuecompression
andstabilityafterinsertion.3Richezetal.carriedoutoneof
thefirststudiestoevaluatetheI-gel.Theyfoundthat
inser-tionsuccessratewas97%.Insertionwaseasyandperformed
atthefirstattemptinallofthepatients.6Therearestudies
tosupportitsuseasapotentialresuscitativedevice7andasa
rescuedevicefordifficultairways.8EmmerichandDummler
reportedanairwaymanagementduringinductionofgeneral
anesthesiainapatientwithknowndifficultieswith
intuba-tion.Afterfailedoptimizedattemptsatdirectlaryngoscopy,
ventilation wassecured withthe I-gelsuccesfully.9 In the
present case, trachealintubation wastried 3times byan
experiencedanesthesiologist.Itwasconsideredasgrade4
difficult airwayaccordingtotheMallampati classification.
An I-gel supraglotticairway wasplaced easily at the first
time.Itisusedintheambulatoryordaycasesurgerysetting
andasaprimaryairwaydeviceforshortproceduresunder
general anesthesia. Helmy et al. compared the LMA and
theI-gelregardingeasinessofinsertionofthedevice,leak
pressure,gastricinsufflations,endtidalCO2,oxygen
satura-tionandhemodynamicandpostoperativecomplications in
anesthetizedspontaneouslyventilatedadultpatients.They
reportedthatinsertionoftheI-gelissignificantlyeasierand
morerapidthaninsertionofLMA.Leakpressurewas
signifi-cantlyhigherwiththeI-gelthanwithLMA,thusincidenceof
gastricinsufflationswassignificantlylowerwiththeI-gel.10
Bordes etal. comparedPCV and volume-controlled
venti-lation(VCV)inchildrenwithLMA.TheyreportedthatPCV
is more efficientthan VCV for controlledventilation with
LMA.11 Uppal etal. comparedthe I-gel withthe
conven-tionaltrachealtube usingPCV inthe samepatientgroup.
Theycomparedthedevicesbythemeansofgasleaksand
reportedthattheI-gelwasasefficientandsafeastracheal
tubeinPCVmode.4InthepresentcasePCVmodewasused
after returning of spontaneous breathing. Because of the
adequacyof thetidalvolume,thelowerleakvolume,the
normal capnogram andthe normal periphericoxygen
sat-uration, it was continued to maintain ventilation by the
I-gel.
The I-gel has also been designed to separate the
gas-trointestinalandtherespiratory tracts.Itallowsa gastric
tube to pass into the stomach, thereby possibly avoiding
theproblemsofregurgitationandpotentialaspiration.12We
benefitedfromthiseasinessinthepresentcasefor
decom-pressionofthestomach.
To our knowledge there is no report on the long time
use of the I-gel in ICU. We did not encounter any
prob-leminmechanicalventilationlastingfor48hinPCVmode.
Our findings show that the I-gel can be used in order to
obtain airwaycontrolandthereafter maintaining
mechan-ical ventilation in difficult tracheal intubation cases in
ICUs.
Conflicts
of
interest
PressuresupportventilationwiththeI-gel:casereport 221
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