Clinical

Consideration
s of SGAD
DR. ANJANA DR. VAISHAKH
DR. DHWANI DR. SRIDIVYA
Agents for facilitation of
LMA insertion
Propofol –
•without muscle relaxants dose of 2-2.5 mg/kg required
•with muscle relaxant lesser dose of 1.5 – 2 mg/kg can be
given.
Sevoflurane – dial setting of 8% to achieve MAC of more than 1
Also can be used -
Thiopentone sodium – supplements of opioids, local anaesthetics and
muscle relaxants required
Etomidate – associated with myoclonus, but preferred in patients prone
to hemodynamic changes. Requires muscle relaxants.
Muscle Relaxants – To Use or Not to
Use???
Advantage of using Muscle Relaxants
•Higher successful insertion rates
•Higher sealing pressures
•Lower leakage volume
•Lower difficulty of insertion as it provides complete jaw relaxation with
optimum mouth opening
•Decreased incidence of adverse respiratory events such as
laryngospasm, hypoxemia, and pharyngeal mucosal injury
LMA can be maintained without administration of muscle relaxants
If an adequate depth of anesthesia is maintained to suppress
• airway reflexes
• movement
• hemodynamic response to keep appropriate surgical conditions

•Although high MAC of inhalational agent or propofol infusion is

required which may cause hemodynamic instability
Residual effects of Muscle Relaxants
•Delays emergence from anaesthesia – increases OT/PACU stay, ICU
admissions
•Compromises airway patency
•Increases pharyngeal dysfunction, micro - aspiration
•Decreases ventilatory response to hypoxia and hypercarbia by blocking
of nicotinergic acetylcholine receptors in carotid bodies
• Post-operative residual curarization : PORC
• PORC is present when some level of NMB (TOF ratio<0.9) persists
after extubation
• It is impossible to predict recovery of NMB with pharmacological
reasoning as recovery time of NMBAs display wide inter
individual variances
• Reportedly about 30% of all patients who receive muscle
relaxants show signs of PORC when arriving in PACU
Possible Deleterious effects of PORC could be –
◦ Pneumonia
◦ Bronchitis
◦ Re-intubation in PACU/ICU
◦ Need for mechanical ventilation
◦ Cardiac insufficiency
◦ Myocardial infarction
Spontaneous vs Intermittent Positive Pressure Ventilation
•Possibility of gastric insufflation and aspiration with IPPV
•Therefore only second generation SGAD can be used
•IPPV with muscle relaxation preferred in surgeries which require a
deeper plane of anesthesia or whenever patient is in any position other
than supine
•Spontaneous only preferred in very short procedures or superficial
surgery
Special considerations
Limited Mouth Opening
Described as mouth opening less than 20 mm
Classic LMA
SLIPA – the hollow chamber maybe flattened to facilitate insertion
LMA flexible
King Laryngeal Tube
Combitube
Post Burn contracture
There are reported cases where Ambu LMA has been inserted with
upside down technique
The width at the junction of tube and mask is less than 2 cm.
Supreme or classic LMA can also be used- malleable
I gel and ILMA avoided due to their bulkiness
Intubation through
LMA
LMA can serve as conduit through which tracheal tube, bougie , or
fibrescope can be passed

ILMA
Classic
AMBU and SUPREME – have short stem
Pro seal – difficult as lumen is comparatively narrower

Advantage – ability to continue ventilating and anaesthetising the patient

till formal tracheal intubation is done.
Fibre optic guided
Intubation
Whether to remove LMA after tracheal intubation?
•Concern about pressure on soft tissue – LMA cuff can be deflated once
trachea has been intubated
•Need to keep away from surgical field
•Possible increase in gastro esophageal reflux
•Difficulty in placing gastric tube
Use in Pediatric patients

LMA insertion can be more difficult in children due to their anatomy

•Larger tongue
•Larger and floppier epiglottis
•More cephalad and anteriorly located larynx
•More acute angle of the posterior pharyngeal wall to floor of the mouth
•Tonsillar hypertrophy
IPPV without muscle relaxation is preferred to maintain depth of
anaesthesia for surgery
Pediatric airway is highly reactive and prone to laryngospasm and
bronchospasm
On spontaneous without IPPV they are prone to take decreased amount
of tidal volume
Ambu Aura gain, Aura I used as intubating LMA
Laparoscopic Surgery
Muscle relaxants used with Positive Pressure Ventilation
Increase in Intra abdominal pressure increases risk of regurgitation and
increases peak airway pressures
Second generation LMA provide higher airway seal pressure and allow
insertion of gastric tube
Proseal LMA permits application of Peak End Expiratory Pressure of
upto 10 cm H2O
Pressure control modalities – minimise peak pressures, provide higher
instantaneous flow peaks, improved Alveolar recruitment and
oxygenation
LAPAROSCOPIC TUBAL
LIGATION???
 Position other than
supine
Routine
Avoid using SGAD unless for
very short procedures
Intubation with ETT preferred
Emergency
As rescue any SGAD can be
inserted- i-gel preferred for ease
of insertion
In prone position Proseal preferred
as peak airway pressures increase
Use with Circuits
other than closed
circuit
Bains circuit –
•SGAD use to be avoided wherever possible.
•If used, there are high chances of hypercarbia which should be managed
•Can be used only for controlled ventilation- IPPV with relaxant

•Mapleson A or Magills circuit

•APL valve is at patient end which makes it bulky and prone for self
extubation
•Can be used only for spontaneous ventilation
Cuffless vs cuffed
LMA
Prevention of recurrent laryngeal nerve and hypoglossal nerve injury
caused by dilatation of the cuff
Pressure necrosis is avoided
Incidence of post operative throat pain and discomfort decreases
Increased risk of leaks and failures
Bailey Manoeuvre
Allows extubation under deep anaesthesia
Either ETT is removed and then SGAD is inserted or the SGAD is inserted
over the ETT and cuff inflated. The ETT cuff is then deflated and
removed leaving SGAD in place
Airway is maintained during emergence with minimal stimulation,
avoiding the coughing and bucking
THANK YOU!