European Journal of Cardiovascular Medicine

During general anaesthesia, supraglottic airway devices are an essential component of airway management. It is normal practice to utilize supraglottic devices in general anesthesia for elective procedures. These devices are gaining favour all over the world because they are a less intrusive alternative to tracheal intubation. 1

In the 1980s, Brain invented the first supraglottic device, which was called the laryngeal mask airway. This device consisted of an elliptical inflatable cuff that was coupled to an airway tube. His initial design served as a foundation for a number of modifications and new inventions that were developed in the years that followed.2

There is a wide variety of supraglottic airway devices that are currently available for purchase on the market. There are two major categories that can be used to classify them: base of tongue sealers and perilaryngeal sealers, with or without an inflatable cuff on the tongue. In addition, supraglottic airway devices vary in the technique that they employ to achieve this seal. These devices may rely on cuff inflation, a wedge seal, or they may be equipped with a self-inflating mechanism.3

These devices can also be divided according to Tim Cook’s classification into first and second-generation device. Second-generation devices possess an additional drainage channel for gastric content whereas first-generation airways do not. A hypothesis has been put forward suggesting that devices of the second generation would be more effective in preventing the aspiration of stomach contents.4

Dr. Nasir was the one who came up with the idea for the first i-gel supraglottic airway device in 2007. It was intended to be a single-use, latex-free, second- generation supraglottic airway device that featured an innovatively formed, non- inflatable cuff. In addition to being physically similar to the peri laryngeal anatomy, this cuff is constructed out of a thermoplastic elastomer that is flexible and gel-like.5It is designed to produce a seal by adhering to the perilaryngeal anatomy. This eliminates the need for the cuff to be inflated, which in turn reduces the amount of pressure damage that is caused to the local mucosa. This could result in the bowl of the device becoming slightly more pliable as the temperature rises, which would ultimately lead to an improvement in the seal pressure of the device while the patient is under anesthesia.6

Ensuring a secure airway is paramount in anesthesia. Identifying the most effective insertion technique can minimize the risk of airway complications, such as improper placement, airway trauma, and hypoxia.

A comparison of insertion techniques can highlight which method reduces the risk of adverse events, thereby improving overall patient safety during elective surgeries.

Understanding the differences in insertion success rates, time to secure the airway and the need for repositioning can lead to more efficient operating room procedures and better utilization of time and resources.

Results from this study can inform training programmes, ensuring that new anesthesiologists are taught the most effective and reliable techniques for I-Gel placement, thus enhancing the overall standard of care.

AIMS AND OBJECTIVES

AIM OF THE STUDY:

To study and compare between two insertion techniques i.e. Standard and Reverse Technique for I-gel placement in adult patients for elective surgical procedures

PRIMARY OBJECTIVE:

To compare the time taken for insertion at first attempt.

SECONDARY OBJECTIVES:

1. To study First attempt success rate
2. To study Ease of insertion
3. To study Complications

Study design: Hospital based prospective longitudinal study

Study period: A period of one year from the date of approval of my thesis work i.e. from August 2022 to July 2023 by Institutional Scientific and Ethical Committee.

Study setting and Subjects: This study was conducted on 100 patients posted for elective surgery done under general anesthesia at Department of Anesthesia, Kurnool Medical College and Hospital, Kurnool, during the period from August 2022 to July 2023

Method of collection of data:

The approval for commencement of this study was obtained by our Ethical committee. A written informed consent was taken from all the patients satisfying the below inclusion criteria

Inclusion criteria:

1. Adultpatient-18to60 years
2. Mallampati1and2
3. ASA physical status 1or 2

Patients undergoing elective surgery under General Anesthesia expected to last less than 1 hour.

Exclusion Criteria:

Gastro-oesophageal reflex disease Patients with BMI>30kg/m2 Pregnancy

Asthma

Mallampati grade 3 and 4 Mouth opening less than 3cm Difficulty Airway Laparoscopic Surgeries

Sample size: 100 (50 Patients in each group)

STUDY METHOD

Included patients were randomized by computer-generated random table into one of the two groups:

• Group A: Insertion by standard technique
• Group B: Insertion by Reverse technique The following parameters were noted in both groups

1. Insertion time at first attempt
2. First attempt success rate
3. Ease of Insertion
4. Complications

An anesthesiologist with an experience of more than 25 I-Gel insertions with standard technique inserted a well-lubricated I-Gel using technique based on the study group. The patients were placed supine with head in sniffing position using a 5 cm firm pillow. In group I, I-Gel was introduced in mouth with its concavity facing the mandible. Then it was pushed posteriorly while advancing along the hard palate, soft palate and posterior pharynx and placed in its final position. Group II I-Gel was inserted with its concavity facing toward the hard palate. On reaching the pharynx, the device was rotated 180oand placed in its final position to facilitate positive pressure ventilation. Appropriate placement of I-Gel was confirmed by observing a square wavecapno graph, auscultation, movement of chest wall, and no audible leak with peak airway pressure (PAP) ≥20 cm H2O during manual ventilation. If leak occurred at pressure of ≤20 cmH2O, then a variety of manipulations like chin lift, jaw thrust, head extension, neck flexion, gentle advancement, or withdrawal of I-Gel were applied to improve the ventilation.[8] If air leak persisted despite the manipulations, then the attempt was considered a failure and the I-Gel was reinserted using the same technique. In the second attempt gentle jaw thrust was applied by the assistant; if it did not resolve the problem, the none size smaller or larger was used.

The primary objective of the investigation was mean insertion time at first attempt. Secondary objectives were ease of insertion, first attempt and overall success rate, manoeuvres required, fiberoptic view of placement, OLP, ease of placement of nasogastric tube and postoperative complications if any.

HEMODYNAMIC RESPONSES

The patient’s HR, NIBP, MAP, SPO2 were recorded just before insertion and 1min, 3minand 5min after the initiation of insertion attempts.

After the end of surgery Ryle’s tube suctioning was done. When spontaneous breathing efforts were present, a thorough oral suction was done, and device was removed. Then the patient was shifted to the recovery room and monitored for an hour before shifting to the ward.

STATISTICAL ANALYSIS:

The collected data was coded in the excel spreadsheet and SPSS version 2 was used for analysis.

Table1: Distribution of Patients according to their Age

In the present study, the GROUP-A technique was most frequently used in the 31-40 age group (20 times). The GROUP-B technique was most frequently used in the 21-30 age group (10 times) and 31-40 age group (16 times). In the 51-60 age group, the GROUP-B technique was used almost twice as frequently (11 times) as the GROUP-A technique (6 times). The mean age in both groups was around 40 years. Both the groups were comparable with regard to age

Table 2: Distribution of Patients according to ASA Grade

The distribution of patients according to ASA Grade shows two distinct trends. For Group A, the continuous line starts at 42 patients for ASA Grade I and declines to 8 patients for ASA Grade II. Similarly, for Group B, the line starts at 44 patients for ASA Grade I and drops to 6 patients for ASA Grade II. The total line starts at 86 patients for ASA Grade I and decreases to 14 patients for ASA Grade II. These continuous lines effectively illustrate the reduction in patient numbers as the ASA grade increases from I to II for both groups and in total.

Table 3: Distribution of Patients according to Surgical Procedure in GROUP-A group

The distribution of surgical procedures in Group A covers a wide range of operations. Procedures like Excision Biopsy and Meshplasty are the most common, each with 11 cases. Incision and Drainage follows with 9 cases. Other procedures include Gastrostomy and feeding jejunostomy (2cases), Lumpectomy (2cases), and Wound debridement (3 cases). Less common surgeries include CRIF and K Wire Fixation, CRIF and K‐Wire insertion, CRIF and TENS Nailing, Herniorrhaphy, Implant Removal, Incisional biopsy, ORIF and LCP insertion, ORIF and Radial Head Excision, and Split Skin Graft, eachwith1case.This variety reflects a diverse range of surgical interventions in Group A.

Table 4: Distribution of Patients according to Surgical Procedure in GROUP-B group

The distribution of surgical procedures in Group B shows a diverse range of operations. Excision Biopsy is the most common procedure with 13 cases, followed by Meshplasty with 11 cases. Lumpectomy and Incision and Drainage each have 4 and 3 cases, respectively. CRIF and K Wire Fixation and Wound debridement also have 3 cases each. Other procedures include Herniorrhaphy (2 cases), and single cases of Fasciotomy and Z-plasty, Implant Realignment, Incisional biopsy, ORIF and K wire Fixation, ORIF and LCP Fixation, ORIF and LCP insertion, ORIF and plating,

Table 5: Distribution of Patients according to Size of I-gel Used

The distribution of patients according to I-Gel Size shows a clear trend. For I- Gel Size 3, both Group A and Group B start at 25 patients, total of 50 patients. The numbers decrease for I-Gel Size 4, with Group A at 22 patients and Group B at 20 patients, total of 42. For I-Gel Size 5, the numbers further drop, with Group A having 3 patients and Group B having 5 patients, total of 8. These continuous lines highlight the decrease in patient numbers as the I-Gel size increases from 3 to 5 across both groups and in total.

Table 6: Distribution of Patients according to Surgery Time

he distribution of patients according to surgery time reveals notable differences between Group A and Group B. For the 41–45-minute range, Group A has 2 patients while Group B has 6.In the 46–50-minute range, Group A significantly.

Exceeds Group B with 34 patients compared to14.For the 51–55-minute range, Group B leads with 23 patients, where as Group A has11.In the 56–60-minute range, Group B again has more patients (7) compared to Group A(3). The chi-square value (X²) is 17.74, with a p-value of 0.0004, indicating a statistically significant difference between the groups.

Table7: Distribution of Patients according to I-Gel Insertion attempts

The distribution of I-Gel insertion attempts shows differences between Group A and Group B. For the first attempt, Group A has 38 patients while Group B has 41.On the second attempt, Group A has 6 patients and Group B has 5.For the third attempt, Group A has 4 patients and Group B has 3. Failed attempts (F) are 2 in Group A and 1 in Group B. The chi-square value (X²) is 15, with a p-value of 0.001, indicating a statistically significant difference between the groups.

Table 8: Distribution of Patients according to I-Gel Insertion

The distribution of I-Gel insertion attempts shows differences between Group A and Group B. For the first attempt, Group A has 38 patients while Group B has 41.On the second attempt, Group A has 6 patients and Group B has 5.For the third attempt, Group A has 4 patients and Group B has 3. Failed attempts (F) are 2 in Group A and 1 in Group B. The chi-square value (X²) is 15, with a p-value of 0.001, indicating a statistically significant difference between the groups.

Table 9: Distribution of Patients according to Fiber-optic view grading

The distribution of Fiber-optic view grading between Group A and Group B shows varying patterns. For Grade1, Group A has 26 patients while Group B has33. In Grade 2, Group A has 12 patients compared to 6 in Group B. For Grade 3, Group A has 6 patients, and Group B has 9. Grade 4 has 6 patients in Group A and 2 in Group B. The chi-square value (X²) is 5.43 with a p-value of 0.14, indicating no statistically significant difference between the groups.

Table 10: Distribution of Patients according to Insertion Time (sec)

In the present study, the mean insertion time for Group-A placement was 25 sec compared to 15.2s in the Group-B. Group-B (Revers technique) was taken less time compared with Standard technique this was proven statistically significant and the P value was <0.0001.

Table 11: Distribution of Patients according to Insertion of Gastrictube placement

Out of the 50 cases, the drainage tube could be easily inserted in all the cases in Proseal group grading it easy. In the Group-B group also drainage tube could be easily inserted in the first attempt in all the 50 cases. In none of the cases, was there any failure to insert  it. Effective ventilation was possible in all cases.

Table 12: Comparison of Pulse rate between Pre-Induction and Post Induction in two Groups

The above table provides a comparison of pulse rates (PR) measured at different time points for two groups: GROUP-A and GROUP-B. Each entry in the table represents the mean pulse rate along with the standard deviation (SD) for the respective group and time point. Here is a detailed description:

Pre-Induction PR:

Group-A: The mean pulse rate before induction is 81.02 beats per minute (bpm)with a standard deviation of 13.94 bpm.

Group-B: The mean pulse rate before induction is 79.18 bpm with a standard deviationof14.68bpm.When compared between two groups there was no significant difference and P value was 0.28

Induction PR:

Group-A: The mean pulse rate during induction is 75.3bp m with a standard deviation of 13.4 bpm.

Group-B: The mean pulse rate during induction is 77.46 bpm with a standard deviation of 14.0 bpm. When compared between two groups there was no significant difference and P value was 0.22

1min PR:

Group-A: One minute after induction, the mean pulse rate is 80.16 bpm with a standard deviation of 14.71 bpm.

Group-B: One minute after induction, the mean pulse rate is 80.08 bpm with a standard deviation of 14.74bpm. When compared between two groups there was no significant difference and P value was 0.46

3 min PR:

Group-A: Three minutes after induction, the mean pulse rate is 81.36 bpm with a standard deviation of 13.41 bpm.

Group-B: Three minutes after induction, the mean pulse rate is 80.92 bpm with a standard deviation of 15.53bpm. When compared between two groups there was no significant difference and P value was 0.44

5 min PR:

Group-A: Five minutes after induction, the mean pulse rate is 80.46 bpm with a standard deviation of 12.31 bpm.

Group-B: Five minutes after induction, the mean pulse rate is 79.4 bpm with a standard deviation of 13.99 bpm. When compared between two groups there was no significant difference and P value was 0.34

Table 13: Comparison of Systolic Blood Pressure between Pre-Induction and Post Induction in two Groups

Pre-Induction SBP:

GROUP-A: The mean pre-induction systolic blood pressure is 113.04 mmHg with a standard deviation of 9.04 mmHg.

GROUP-B: The mean pre-induction systolic blood pressure is 109.96 mmHg with a standard deviation of 7.11 mmHg.

When compared between two groups there was no significant difference and Pvalue was 0.32

Induction SBP:

GROUP-A: During induction, the mean systolic blood pressure drops to103.34mmHg with a standard deviation of 6.06 mmHg.

GROUP-B: During induction, the mean systolic blood pressure drops to102.08mmHg with a standard deviation of 4.94 mmHg. When compared between two groups there was no significant difference and P value was 0.51

1min SBP:

GROUP-A : One minute after induction, the mean systolic blood pressure is108 mmHg with a standard deviation of 10.52 mmHg.

GROUP-B: One minute after induction, the mean systolic blood pressure is 108.66mmHg with a standard deviation of 9.87 mmHg.

When compared between two groups there was no significant difference and P value was 0.67

3 min SBP:

GROUP-A: Three minutes after induction, the mean systolic blood pressure is 108.1 mmHg with a standard deviation of 10.49 mmHg.

GROUP-B: Three minutes after induction, the mean systolic blood pressure is 108.8 mmHg with a standard deviation of 8.81 mmHg.

When compared between two groups there was no significant difference and P value was 0.09

5 min SBP:

GROUP-A: Five minutes after induction, the mean systolic blood pressure is 108.24 mmHg with a standard deviation of 11.17 mmHg.

GROUP-B: Five minutes after induction, the mean systolic blood pressure is109 mmHg with a standard deviation of 9.46 mmHg. When compared between two groups there was no significant difference and P value was 0.14

Table 14: Comparison of Diastolic Blood Pressure between Pre-Induction and Post Induction in two Groups

Pre-Induction DBP:

GROUP-A: The mean pre-induction diastolic blood pressure is 68.78 mmHg with a standard deviation of 4.67 mmHg.

GROUP-B: The mean pre-induction diastolic blood pressure is 67.56 mmHg with a standard deviation of 4.39 mmHg. When compared between two groups there was no significant difference and P value was 0.09

Induction DBP:

GROUP-A: During induction, the mean diastolic blood pressure drops to 62.42mmHg with a standard deviation of 3.87 mmHg.

GROUP-B: During induction, the mean diastolic blood pressure drops to 63 mmHg with a standard deviation of 2.74 mmHg. When compared between two groups there was no significant difference and P value was 0.19

1min DBP:

GROUP-A: One minute after induction, the mean diastolic blood pressure is 66.32 mmHg with a standard deviation of 6.3 mmHg.

GROUP-B: One minute after induction, the mean diastolic blood pressure is 66.52 mmHg with a standard deviation of 4.87 mmHg.

When compared between two groups there was no significant difference and P value was 0.42

3 min DBP:

GROUP-A: Three minutes after induction, the mean diastolic blood pressure is 66.74 mmHg with a standard deviation of 5.65 mmHg.

GROUP-B: Three minutes after induction, the mean diastolic blood pressure is67.62 mmHg with a standard deviation of 4.95 mmHg.

When compared between two groups there was no significant difference and P value was 0.21

5 min DBP:

GROUP-A: Five minutes after induction, the mean diastolic blood pressure is 67.32 mmHg with a standard deviation of 5.72 mmHg.

GROUP-B: Five minutes after induction, the mean diastolic blood pressure is 67.56 mmHg with a standard deviation of 5.46 mmHg.

When compared between two groups there was no significant difference and P value was 0.41.

Table15: Comparison of Mean Arterial Pressure between Pre-Induction and Post Induction in two Groups

Pre-Induction MAP:

GROUP-A: The mean pre-induction arterial pressure is 83.5 mmHg with a standard deviation of 5.65 mmHg.

GROUP-B: The mean pre-induction arterial pressure is 81.64 mmHg with a standard deviation of 4.84 mmHg.

When compared between two groups there was no significant difference and P value was 0.06

Induction MAP:

GROUP-A: During induction, the mean arterial pressure drops to 76.28 mmHg with a standard deviation of 3.24 mmHg.

GROUP-B: During induction, the mean arterial pressure drops to 75.96 mmHg with a standard deviation of 2.58 mmHg.

When compared between two groups there was no significant difference and P value was 0.5

1min MAP:

GROUP-A:One minute after induction, the mean arterial pressure is 80.32 mmHg with a standard deviation of 7.43 mmHg.

GROUP-B:One minute after induction, the mean arterial pressure is 80.72mmHg with a standard deviation of 6.15 mmHg.

When compared between two groups there was no significant difference and P value was 0.37

3 min MAP:

GROUP-A: Three minutes after induction, the mean arterial pressure is 80.54 mmHg with a standard deviation of 7.21 mmHg.

GROUP-B: Three minutes after induction, the mean arterial pressure is 81.4 mmHg with a standard deviation of 6.05 mmHg.

When compared between two groupstherewasnosignificant differenceandPvalue was 0.26

5 min MAP:

GROUP-A: Five minutes after induction, the mean arterial pressure is 81.04 mmHgwith a standard deviation of 7.71 mmHg.

GROUP-B: Five minutes after induction, the mean arterial pressure is 81.42 mmHg with a standard deviation of 6.64 mmHg.

When compared between two groups there was no significant difference and P value was 0.39

Table 16: Distribution of Patients according to Oropharyngeal leak pressure

The distribution of peak airway pressure (cmH2O) between Group A and Group B reveals significant differences. In the 6-10 cm H2O range, both groups have1patient each. For the 11-15 cmH2O range, Group A has 6 patients while Group B has 24. In the 16-20 cm H2O range, Group A has 14 patients compared to 10 in Group B. The 21-25 cm H2O range shows Group A with 21 patients and Group B with 7. The chi- square value (X²) is 18.47 with a p-value of 0.003, indicating a statistically significant difference between the groups.

Airway management is crucial in anesthesia, with the i-gel being a widely used supraglottic airway device for elective surgical procedures. The i-gel is favored for its ease of use, quick insertion, and reduced risk of complications compared to traditional endotracheal tubes.6,7,8Various techniques for i-gel insertion exist, each with potential advantages and limitations. There is a lack of comprehensive studies comparing the efficacy and safety of different i-gel insertion techniques in adult patients. This study aims to evaluate and compare the success rates, insertion times, and complications associated with two i-gel insertion techniques.

Findings may influence clinical guidelines and standard practices for i-gel placement in anesthesia. Previous research has shown limitations, highlighting the gap addressed by this study. Ethical considerations include ensuring ethical approval and informed consent processes. The study anticipates discovering a more efficient and safer i-gel insertion technique. Finally, the study suggests further research based on the outcomes to continue improving airway management practices.

This study was outlined to compare the clinical performance of the Proseal and I-Gel In terms of airway sealing pressure, ease of insertion, time for insertion and hemodynamic changes. It was conducted in100 patients of ASA grade I or II, aged >18years and<60years undergoing elective surgeries.

In our study the mean age, weight, BMI and sex ratio were comparable among both the groups.

Age

In the present study, the Group-A technique was most frequently used in the 31-40 age group (20 times). The Group-B technique was most frequently used in the 21-30 age group (10 times) and the 31-40 age group (16 times). In the 51-60 age group, the Group-B technique was used almost twice as frequently (11 times) as the Group-A technique (6times).The mean age in both groups was around 40 years. Both groups were comparable with regard to age.

Bhardwaj et al9 reported that The demographic characteristics of the patients across the three groups were evaluated. The mean age was 33.98 ± 11.15 years in Group I (Standard), 36.16 ± 10.61 years in Group II (Reverse), and 35.73 ± 10.79 years in Group III (Rotation), with a p-value of 0.062, indicating no significant difference.

Gender

In the current study, the Group-A technique has been used slightly more for males (27 times) compared to females (23 times). The Group-B technique was used very similarly between females (24 times) and males (26 times).

Bhardwaj et al 9 reported that the male-to-female ratio was 13/32 in Group I, 7/38 in GroupII, and6/39 in Group III, with a p-value of 0.129, showing no significant difference.

ASA Grade

The distribution of patients according to ASA Grade shows two distinct trends. For Group A, the continuous line starts at 42 patients for ASA Grade I and declines to 8 patients for ASA Grade II. Similarly, forGroupB, the line starts at 44 patients for ASA Grade I and drops to 6 patients for ASA Grade II. The total line starts at 86 patients for ASA Grade I and decreases to 14 patients for ASA Grade II. These continuous  Lines effectively illustrate the reduction in patient numbers as the ASA grade increases from I to II for both groups and in total.

Bhardwaj et al9 reported that ASA grade distribution was consistent across all groups with 43 patients in grade I and 2 in grade II, and a p-value of 1.000.

MPG Grade

The distribution of patients according to MPG Grade reveals distinct patterns across groups. For Group A, the continuous line begins at 37patients for MPG Grade I, decreasing to13patients for MPG Grade II. In Group B, the line starts at 41patients for MPG Grade I, dropping to 9 patients for MPG Grade II. The total line starts at 78 patients for MPG Grade I, reducing to 22 patients for MPG Grade II. These continuous lines effectively capture the varying trends in patient distribution across the different MPG grades for both groups and in total.

Bhardwaj et al 9 reported that The MPG grades I/II/III were distributed as 11/28/6 in Group I,10/28/7in Group II, and 8/30/7 in Group III, with a p-value of 0.731, showing no significant difference.

Distribution of surgical procedures

The distribution of surgical procedures in Group A covers a wide range of operations. Procedures like Excision Biopsy and Meshplasty are the most common, each with 11 cases. Incision and Drainage follows with 9 cases. Other procedures include Gastrostomy and feeding jejunostomy (2cases), Lumpectomy (2cases), and Wound debridement (3 cases). Less common surgeries include CRIF and K Wire Fixation, CRIF and K‐Wire insertion, CRIF and TENS Nailing, Herniorrhaphy, Implant Removal, Incisional biopsy, ORIF and LCP insertion, ORIF and Radial Head Excision, and Split Skin Graft, each with1case.This variety reflects a diverse range of surgical interventions in Group A.

The distribution of surgical procedures in Group B shows a diverse range of operations. Excision Biopsy is the most common procedure with 13 cases, followed by Meshplasty with 11 cases. Lumpectomy and Incision and Drainage each have 4 and 3 cases, respectively. CRIF and K Wire Fixation and Wound debridement also have 3 cases each. Other procedures include Herniorrhaphy (2 cases), and single cases of Fasciotomy and Z-plasty, Implant Realignment, Incisional biopsy, ORIF and K wire Fixation, ORIF and LCP Fixation, ORIF and LCP insertion, ORIF and plating, ORIF and Radial Head Excision, ORIF and Semitubular Plating, and Wound Closure. This highlights a variety of surgical interventions performed in Group B.

The distribution of patients according to I-Gel Size shows a clear trend. For I- Gel Size 3, both Group A and Group B start at 25 patients, totaling 50 patients. The numbers decrease for I-Gel Size 4, with Group A at 22 patients and Group B at 20 patients, totaling 42. For I-Gel Size 5, the numbers further drop, with Group A having 3 patients and Group B having 5 patients, totaling 8. These continuous lines highlight the decrease in patient numbers as the I-Gel size increases from 3 to 5 across both groups and in total.

Bhardwaj et al9reported that The sizes of i-gel™used were22/21/2inGroup I, 27/16/2 in Group II, and 25/17/3 in Group III, with a p-value of 0.269, indicating no significant difference.

Insertion Attempts

The distribution of I-Gel insertion attempts shows differences between Group A and Group B. For the first attempt, Group A has 38 patients while Group B has 41.On the second attempt, Group A has 6 patients and Group B has 5.For the third attempt, Group A has 4 patients and Group B has 3. Failed attempts (F) are 2 in Group Aand 1 in Group B. The chi-square value (X²) is 15, with a p-value of 0.001, indicating a statistically significant difference between the groups.

Bharadwaj et al 9 reported the success rate for first-attempt insertion was 82.2% for Group I, 89.0% for Group II, and 84.4% for Group III. The second-attempt success rate was 6.7% for Group I, 4.4% for Group II, and 6.7% for Group III. The third-attempt success rate was 2.2% across all groups.

Kim et al 10 reported Regarding the need for manipulations, 35 (39%) were required for the standard method and 26 (29%) for the rotational method, with a p- value of 0.209. The Brimacombe score distribution was as follows: score 1 was achieved by 39 (43%) in the standard group and 18 (20%) in the rotational group (p=0.001), score 2 by 29 (32%) in both groups, score 3 by 12 (13%) in both groups, and score 4 by 11 (12%) in the standard group and 31 (34%) in the rotational group.

NG tube placement

Bhardwaj et al 9 reported that the ease of NG tube placement was categorized as easy/difficult/failure with results of 38/3/0 for Group I, 40/2/1 for Group II, and 41/1/0 for Group III, with a p-value of 0.548, indicating no significant difference.

Fiber-opticView Grading

The distribution of Fiber-optic view grading between Group A and Group B shows varying patterns. For Grade1, Group A has 26 patients while Group B has 33. In Grade 2, Group A has 12 patients compared to 6 in Group B. For Grade 3, Group A has 6 patients, and Group B has 9. Grade 4 has 6 patients in Group A and 2 in Group B. The chi-square value (X²) is 5.43 with a p-value of 0.14, indicating no statistically significant difference between the groups.

Bhardwaj et al 9 reported that The fiber-optic view grading revealed significant differences with the distribution of grades (1/2/3/4) being22/11/4/4 in GroupI,31/9/3/0 in Group II, and 35/4/3/0 in Group III. The p-value was 0.024, indicating a significant difference particularly between Groups I and II. Notably, the differences in fiber-optic view grading were significant between Groups I and II.

Oropharyngeal Leak Pressure

Bhardwaj et al  9 reported that The oropharyngea lleak pressurewas24.8±5.83 cm H2O for Group I, 27.14 ±5.04 cmH2O for Group II, and28.26 ±4.96 cm H2Ofor Group III, with a p-value of 0.112, showing no significant difference.

Kim et al 10 reported Air leak pressure was 22.5 (10.4) cm H2O for the standard method and 27.1 (9.4) cm H2O for the rotational method, with a p-value of 0.002.

Insertion Time

In the present study, the mean insertion time for Group-A placement was 25 seconds compared to 15.2 seconds in Group-B. Group-B (Reverse technique) took less time compared with the Standard technique, and this was proven statistically significant with a p-value of <0.0001.

In addition to Sharda et al 6 did a study in a group of one hundred patients, they compared the reverse and conventional implantation of i-gel. According to their findings, the reverse group had a significantly shorter mean insertion time, and this difference was statistically significant (P=0.012).

Following the implantation of i-gel, they did not discover significant differences in HR or MAP between the groups. Despite the fact that the mean insertion time in the current study was much shorter in the reverse technique as compared to the normal technique, it is possible that a faster insertion of the device by a few seconds would not make any meaningful difference clinically because the success rate was comparable among the groups. A considerable improvement in fiberoptic image grading was observed in the rotation group in comparison to the standard. Due to the fact that the OLP was comparable across all groups, this situation will likewise not result in any substantial differences. Therefore, the three approaches to the deployment of i-gel are not clinically distinct from one another.

Bhardwaj et al 9 reported that the failure rate was 8.9% for Group I, 2.2% for Group II, and 6.7% for Group III. The overall success rate was 91.1% for Group I, 95.6% for Group II, and 93.3% for Group III, with a p-value of 0.7, indicating no significant difference in overall success rates between the groups.

The Study came to the conclusion that the rotating method was more effective than the regular way in terms of achieving a higher success rate of correct I-Gel placement on the first attempt technique. In addition, the rotating method offered additional benefits in comparison to the traditional method. These advantages included a shorter amount of time required for the installation of the I-Gel, improved airway patency, and a reduced number of perioperative problems that involved the airway. During the course of our research, we found that the rotating approach (Group B) resulted in a much greater success rate for the insertion of I-Gel during the initial try. When it comes to ensuring a quick and smooth insertion of I-Gelinthe paediatric population, our data indicate that the rotating approach is the superior alternative to the other two ways.

This study demonstrates that I-Gel placement employing the rotational method results in an increase in the success rate at the initial attempt, evidently suggestive of the fact that the rotational technique is a better alternative to the standard method. We recommend the use of the rotational technique for ensuring rapid and smooth placement of I-Gel in anaesthetized paediatric patients.

Conflict of Interest: None

Funding Support: Nil

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