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manuelacruci's picture
by on Sat, 2014-08-30 19:22

Good afternoon,
I have been a member of this "Uk Anesthetic community" since February this year.
Reading the nap4 the census identified that approximately 90% of UK sad use is classic LMA with only 10% of sads (and approximately 6% of all airway management) being with i-gels or proseal lMas. Most of the time those devices are used by trainee/very junior. I have had a discussion with a colleague of mine about how I was trained to use sec.generation seals (ex. lap choly also in pretty big patient). I would like to have, please, some feedback from you guys who use frequently those devices (electively and not).

Yesarek's picture
by on Fri, 2014-10-10 14:43

NAP4 recommends the use of second generation supraglottic airway where ever possible over the first generation LMAs.
The iGel and LMA supreme provide a better safety profile because of the gastric portal that potentially protects against aspiration.
However, it is not good practice to use them where a cuffed ET tube would be safer. A morbidly obese patient for lap chole should be tubed and ventilated. iGel is not the answer. Also the Et tube is a lot cheaper and better at protecting the airway.

tcook's picture
by on Sat, 2014-12-20 10:14

In my personal practice I agree with Krish and always use a 2nd gen SAD over a 1st gen. Why wouldn't you??
However NAP4 does not recommend 2nd generation SAD at all times - but rather that it should be considered in cases suitable for a SAD but with some increased risks and also that all hospitals have 2nd gen SADs. (Ch 11 P95 of the report).
I'm surprised this discussion is around igel and SLMA - the ProSeal is of course the 2nd gen SAD with the best performance overall in trials.
I completely agree with Krish about high risk lap choles and the need for a TT - but there is good evidence of effectiveness of the PLMA for lower risk lap choles and also that it is beter than a TT
The cost issue is interesting. I believe using a SAD (without NMBA- whether spont vent or ventuilated) is cheaper than using a TT (laryngoscope and handle - disposed of or sterliised, NMBA, NMB monitor, reversal) even before factoring inthe cost of increased complications of a TT
Merry Christmas!
Tim Cook

Yesarek's picture
by on Sat, 2014-12-20 12:56

As always Tim very good points!!
It will be interesting to calculate the cost of say hundred cases undergoing GA with ET tube and with say Igel or LMA supreme. I have not used Pro seal LMAs in a long time. We do not have many in our trust and they are not disposable!
I like IGels because of the convenience. 
If you already have some figures Tim, you may want to share them with us here.
Merry Christmas and A Happy New Year!

tcook's picture
by on Sat, 2014-12-20 13:54

Yes the PLMA being reusable is a huge advantage - it is very important because a) the build quality can be better b) the environmental cost is less - fewer made, fewer trucks distributing them c) less storage etc etc
It also enables you to use a device (PLMA) that has not been beaten in any head-to-head studies I know of and has the best airway seal and regudsrgitation protection characteristics. Does anyone else know of any head to head trials in which the PLMA is beaten?
Re cost you can work it out on a sinlge case
SAD - cost of the device and decontaminiation/packaging if reusable. + 0.5% of the cost of intubation to cover the 1 in 200 case when SAD fails
TT- cost of device and cost of laryngoscope and handle and batteries (and decontamination/packaging if reused), bougie for every 10th intubation, other adjuncts 1 in 20 intubations, cost of NMB and reversal, cost of extra time on list for intubation and extubation, cost of complications of intubation and drugs used (airway trauma, anaphylaxis, awareness... etc etc). It all adds up.
For me it is a myth that intubation is cheaper - no, not a myth: an error.

manuelacruci's picture
by on Wed, 2015-01-14 15:55

Good afternoon,
Thank you prof. Radhakrishna and prof. Cook for all your answers. Recently I have started working in my country where the use of second-gen.supraglottic devices is massive. I really want to know what do you think about using those devices in a PRONE position. (I saw this use just in some youg patients during sinus pironidalis excision)
Have a productive 2015,

Yesarek's picture
by on Sun, 2015-01-18 17:55

Prone Patients are best intubated. LMA is not a good option. 
NAP4 chapter 11 lists some complications associated with LMA use.
"Correct use of a device, carefully following
the manufacturer’s ‘instructions for use’ should be routine
practice, but the reality is that many anaesthetists have
probably never read these instructions"

Limitation of use to appropriate surgery
Several complications occurred during surgery that was
at the extremes of what might be considered safe for use
of a SAD. While the boundaries of safe use of SADs are
continuously explored and seemingly expanding, it was
notable that many of these reports involved standard
laryngeal masks used by juniors.
Cases in these categories included obese patients whose
surgery was performed in the lithotomy position and/or
head down position. In others surgery was performed for
very prolonged operations. Finally, surgery was performed
in positions that made airway access difficult such as
prone or nearly prone. 


tcook's picture
by on Sun, 2015-01-18 19:13

In general I agree with Krish
I'm not a big fan of SADs being used in the prone position.
It can be done and it has been done - indeed there are quite large series of cases in the prone position in the literature. The question is does the benefit justify the risk and what are you going to do if it displaces or there is another problem. In my view doing it for rthe sake of it is difficult to justify. There may be the occasional situation where it can be justifid - but it would have to be several factors that added up, not just one. I have used a PLMA in a handful of case for prone surgery (years ago). In each case they were cases where I could turn the patient supine safely and promptly (eg achiles tendon surgery, pilonidal sinus surgery) whereas I think using it for something like spinal surgery is a step up again in risk. I had a clear plan for replacement in the case of problems (bougie into the oesophagus and railroad the PLMA, if that fails turn supiine). I reflected on these cases and considered whether I was doing it for patient benefit or to see if it worked/push boundaries. After this reflection I stopped using this technique. 

tleeuwenburg's picture
by on Sat, 2015-12-12 23:36

Wondered how the data is now stacking up pLMA - sLMA - IGel etc
...and thinking that whilst Tim Cooks point on cost (inc environmental) is well made, the use of 2nd gen SADs for cases where used to do on ETT can lead to deskilling of trainees
COI - dinosaur

tcook's picture
by on Tue, 2015-12-15 09:53

Re the PLMA / SLMA / i-Gel
They all work fine and dandy
The trouble wirth many studies and indeed metanalyses is they focus on efficacy not safety. For safety evidence you need to look elsewhere.
My analysis of the data is that the PLMA does everything any of the others can do - usually better. I'm not aware of any study in which another SAD out-perform the PLMA. In terms of safety the PLMA has the biggest drain, the best airway seal and a high oesopheageal seal. I know what I'm going to use - but I won't recommend it for a non- anaesthetists at a cardiac arrest - see a longer discussion in "Time to abandon the 'vintage' LMA......" Editorial BJA 2015: 115: 497-9.
Re the deskilling of trainees by not intubating. I'm afraid we had that discussion 15 years ago - patients are not manikins for us to learn on and the SAD is a lower risk airway device that the TT for those patients who do not need a TT. how we get anc maintainn our skils is a seperate discussion from how we treat our patients best. The knack is determining who does and doesn't need a TT/SAD. In our hospital we're not at around 33% TTS (national figures 45%).
There - that's me off the fence.