Letter:
We read with interest the article 'Looped suction catheter in an i-gel™; something to worry about or much ado about nothing?' published recently in the Indian Journal of Anaesthesia.[1] The authors have reported an interesting observation of the looping back of the suction catheter into the airway port of the i-gel, which could lead to potentially disastrous complications, including gastric aspiration, if overlooked. We recently experienced a similar clinical situation of a patient undergoing laparoscopic cholecystectomy with i-gel in-situ, wherein the inserted suction catheter through the gastric port of an i-gel™(size 4) was found misdirected and emerging retrograde through the airway channel. However, unlike the authors, in our case, the misdirected catheter could not be seen through the transparent body of i-gel during the surgery and was found only at the end of surgery [Figure 1]. There are several additional points of clinical significance which we want to discuss through this letter.
Figure 1.
(a and b) show the misdirected and retrograde position of the suction catheter in an i-gel airway with an elongated loop outside the i-gel and a small portion of it in the airway port (red arrow) which might not be visible through the transparent i-gel
We agree with the authors that the immediate visual inspection of the transparent body of i-gel shows the misdirected suction catheter tip, but this may not always be true as happened in our case. The suction catheter may make an elongated loop before entering the airway port so that it is not visible from outside [Figure 1]. Secondly, the auscultatory method may help in deciding whether the suction catheter is placed correctly in the stomach, but again it is not a foolproof method of ensuring its correct placement.[2] Moreover, since the i-gel is a low sealing pressure device among the other available supraglottic devices, we feel that it should be used cautiously in surgeries where there is a risk of aspiration.[3,4] Although, in our case, there was no aspiration; theoretically the combination of low-pressure devices like i-gel with a misdirected catheter in patients being operated by laparoscopy (where there is a risk of aspiration due to increase in intra-abdominal pressure) can be a catastrophe waiting to happen. Unless we are aware of the possibility of this risk, such rare complications cannot be averted.
To conclude, after inserting the gastric tube through the gastric port of a supraglottic airway, we should always confirm the position of the gastric port by auscultation at the epigastrium, aspiration of the gastric contents through a suction catheter or by observing for resistance encountered during the passage of the tube. If any of the aforementioned methods are suspicious for a misdirected catheter, fibreoptic is an option to confirm. However, to avoid the rare possibility of a misdirected suction catheter with an elongated loop that is not visible through the airway lumen of i-gel, it is safe to avoid i-gel altogether, especially in cases where there is a high risk of aspiration.
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Conflicts of interest
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REFERENCES
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