Comparison of I-Gel insertion conditions with two different induction methods in children: a prospective observational study

Abstract

Aim: Insufficient depth of anesthesia is one of the important causes of laryngospasm in pediatric patients undergoing surgery. Propofol is a widely used anesthetic agent for induction of anesthesia in children. Its use alone in induction may be insufficient to suppress laryngeal reflexes during laryngeal mask insertion and may lead to complications such as cough, hiccups, and laryngospasm. In this study, the effects of fentanyl-ketamine mixture and remifentanil used as co-induction in anesthesia induction in children on I-gel insertion conditions and hemodynamic stability were compared. In addition, the evaluation of propofol injection pain after the use of coinduction agent was made. Material and Method: The study included 60 patients aged 2-10 years, of ASA I-III class, who underwent ambulatory surgery. For anesthesia induction, the KF group (n:30) were administered intravenous (iv) 1 mcg/kg fentanyl + 0.5 mg/kg ketamine followed by 3 mg/kg propofol, and the R group (n:30) were administered iv 0.5 mcg/kg remifentanil followed by 3 mg propofol. The I-gel insertion conditions were evaluated by scoring the six variables of mouth opening, ease of insertion, swallowing, coughing, movement, and laryngospasm. Pain during propofol injection was graded using a four-point scale. Results: No statistically significant difference was determined between the groups in terms of I-gel insertion conditions total score values (p>0.05). The pain of the propofol injection was determined at a significantly higher level in Group R (p<0.05). Conclusion: Both induction methods were seen to be easy to apply and provide sufficient success in I-gel insertion. No laryngospasm was observed in either group. More effective relief of propofol injection pain in the fentanyl-ketamine group provided calmer and more stable induction conditions. In this respect, it may be preferable to use fentanyl and low-dose ketamine together as co-induction.

Keywords

• remifentanil
• ketamine
• fentanyl
• co-induction
• child

References

1. Chekol WB, Melesse DY. Incidence and associated factors of laryngospasm among pediatric patients who underwent surgery under general anesthesia, in University of Gondar Compressive Specialized Hospital, Northwest Ethiopia, 2019: a Cross-Sectional Study Anesthesiol Res Pract 2020; 2020: 6.
2. Aberra B, Aregawi A, Teklay G and Tasew H. Effect of ketofol versus propofol as an induction agent on ease of laryngeal mask airway insertion conditions and hemodynamic stability in pediatrics: an observational prospective cohort study BMC Anesthesiol 2019; 19: 41.
3. Rigby-Jones AE, Sneyd JR. Propofol and children – what we know and what we do not know. Review Artıcle Pediatric Anesthesia 2011; 21: 247–54.
4. Eftekhari J, Haki BK, Tizro P, Alizadeh V. A comparison to facilitate insertion of the laryngeal mask: term of recovery and postoperative nausea and vomiting after anesthesia with propofol-atracurium and thiopentalatracurium. Acta Medica Iranica 2015; 53: 117–21.
5. Kwak HJ, Kim JY, Kim YB, Chae YJ. The optimum bolus dose of remifentanil to facilitate laryngeal mask airway insertion with a single standard dose of propofol at induction in children. Anaesthesia 2008; 63: 954–58
6. Gupta A, Kaur S, Attri JP, Saini N. Comparative evaluation of ketamine-propofol, fentanyl-propofol and butorphanol-propofol on haemodynamics and laryngeal mask airway insertion conditions. J Anaesthesiol Clin Pharmacol 2011; 27: 74.
7. Yousef GT, Elsayed KM. A clinical comparison of ketofol (ketamine and propofol admixture) versus propofol as an induction agent on quality of laryngeal mask airway insertion and hemodynamic stability in children. Anesth Essays Res 2013; 7: 194.
8. Begec Z, Demirbilek S, Onal D, et al. Ketamine or alfentanil administration prior to propofol anaesthesia: The effects on proseal laryngeal mask airway insertion conditions and haemodynamic changes in children Anaesthesia 2009; 64: 282-6.

9. Cameron E, Johnston G, Crofts S, Morton NS. The minimum effective dose of lignocaine to prevent injection pain due to propofol in children. Anaesthesia 1992; 47: 604-6
10. Murphy KR, Myors B. Statistical power analysis: A simple and general model for traditional and modern hypothesis tests. 2nd ed. Mahwah, NJ: Lawrence Erlbaum Associates; 2004.
11. Yildirim Güçlü Ç, Karadağ Erkoç S, Bermede AO, et al. Comparison of ketamine-propofol vs remifentanyl-propofol induction on laryngeal mask insertion conditions: Which is the ideal induction agent combination? J Anesthesia JARSS 2017; 25: 11 – 5.
12. Goh PK, Chiu CL, Wang CY, Chan YK, Loo PL. Randomized double-blind comparison of ketamine-propofol, fentanyl-propofol and propofol-saline on haemodynamics and laryngeal mask airway insertion conditions. Anaesth Intensive Care 2005; 33: 223-8.
13. Goel S, Bhardwaj N, Jain K. Efficacy of ketamine and midazolam as co-induction agents with propofol for laryngeal mask insertion in children. Pediatr Anesth 2008; 18: 628–34
14. Singh R, Arora M, Vajifdar H. Randomized double-blind comparison of ketamine-propofol and fentanyl-propofol for the insertion of laryngeal mask airway in children. J Anaesthesiol Clin Pharmacol 2011; 27: 91–6
15. Sağır Ö, Balkaya AN, Özaslan S, et al. Comparison of the effects of fentanyl-propofol and ketamine-propofol on the insertion of proseal laryngeal mask airway and recovery time in ambulatory surgery. J Anesthesia - JARSS 2013; 21: 216–23.
16. Riedel W, Neeck G. Nociception, pain, and antinociception: Current concepts. Z Rheumatol 2001; 60: 404-15.
17. Mercandante S, Portenoy RK. Opioid poorly responsive cancer pain. Part 2: Mechanisms that could shift dose response for analgesia. J Pain Symptom Manage 2001; 21: 225-34.
18. Lee MP, Kua JS, Chiu WK. The use of remifentanil to facilitate the insertion of the laryngeal mask airway. Anesth Analg 2001; 93: 359–62.
19. Yazıcıoğlu H, Muslu S, Yamak B, Erdemli E. Laryngeal mask airway insertion with remifentanil. Acta Anaesthesiol Belg 2005; 56: 171-6.
20. Bouvet L, Da-Col X, Rimmelé T, Allaouchiche B, Chassard D, Boselli E. Optimal remifentanil dose for laryngeal mask airway insertion when co-administered with a single standard dose of propofol. Can J Anaesth 2010; 57: 222-9.
21. Kayhan GE, Begec Z, Sanli M, Gedik E, and Durmus M. Performance of size 1 I-Gel compared with size 1 proseal laryngeal mask in anesthetized ınfants and neonates. Scientific World J 2015; 2015: 42618.
22. Ghatak T, Singh D, Kapoor R, Bogra J. Effects of addition of ketamine, fentanyl and saline with Propofol induction on hemodynamics and laryngeal mask airway insertion conditions in oral clonidine premedicated children. Saudi J Anaesth 2012; 6: 140–4.
23. Cheam EW, Chui PT. Randomised double-blind comparison of fentanyl, mivacurium or placebo to facilitate laryngeal mask airway insertion. J Anaesthesia 2000; 55: 323–6.
24. Jalota L, Kalira V, George E, et al. Prevention of pain on injection of propofol: systematic review and meta-analysis BMJ 2011; 342: d1110.
25. Al-Refai AR, Al-Mujadi H, Ivanova MP, Marzouk HM, Batra YK, Al-Qattan AR. Prevention of pain on injection of propofol: a comparison of remifentanil with alfentanil in children Minerva Anestesiol 2007; 73: 219-23.
26. Basaranoglu G, Erden V, Delatioglu H. Reduction of pain on ınjection of propofol: a comparison of fentanyl with remifentanil. Anesth Analg 2002; 94: 1040–5.
27. Zhao G, Guo Y, Bao MS Meng L, Zhang L. Prevention of propofol-induced pain in children: pretreatment with small doses of ketamine. J Clin Anesthesia 2012: 24; 284-8.