I-gel insertion with modified jaw thrust technique.

Abstract

Sir, Since the introduction of i-gel in modern anaesthesia practice, it is widely used by the anaesthesiologists, accident and emergency department personnel and in pre-hospital care setting. The reported first attempt success rate is 86%[1] with primary (manufacturer's recommended) insertion technique. The manufacturers have also advised alternative manoeuvres to overcome the i-gel insertion difficulties by use of reverse i-gel insertion technique and jaw thrust. Rotational i-gel insertion[2] technique and tongue stabilization manoeuvre[3] are other useful methods. However, manufacturer's recommended jaw thrust manoeuvre technique is not widely supported.[3] Manufacturer's jaw thrust i-gel insertion technique is to seek the help of other's hand (requesting assistant help) to thrust the jaw while inserting the i-gel. The operator harmonisation is the key for successful placement with this technique. Lack of synchronisation may lead to insertion failure, trauma and prolong insertion time. This is mainly due to incoordination between the operator and the ‘helping’ hand. We have devised a modified jaw thrust i-gel insertion technique. Once the pre-insertion preparation is ensured and patient is in sniffing morning air position, the i-gel is grasped firmly along with the integral bite block with cuff facing the patient's chin. Chin needs to be gently pressed down before inserting i-gel into patient's mouth. Then it is slid towards hard palate with a gentle push until it reaches the soft palate or oropharynx. Then modified jaw thrust technique is applied by lifting the angle of mandible with little fingers and other fingers to stabilise the jaw [Figure 1a], and then gently pushing the i-gel with thumbs [Figure 1b] till the final placement position by checking for the integral bite block mark at incisor teeth. Figure 1 (a) Index finger lifting angle of mandible and other fingers stabilizing the jaw (b) i-gel pushed to final position using thumbs This technique creates room at hypopharynx by displacing tongue and other oral cavity structures. The force of thumb allows the i-gel to stay in centre and to the correct final position. This smooth insertion technique is favourable in terms of minimal possibility of oral cavity abrasions, trauma and displacement. After encountering repeated difficulties with i-gel insertion by standard insertion technique, we now use the modified jaw thrust technique routinely; it is easier, takes shorter insertion time and is less traumatic then the standard insertion technique. This technique can be considered as an alternative to standard insertion techniques and true efficacy can be ascertained by randomised controlled trials.