Is i-gel (intubation gel) suitable for neonatal anesthesia?

I-gel for Neonatal Anesthesia

The i-gel supraglottic airway device is suitable for neonatal anesthesia in infants ≥34 weeks gestation and can be used as an effective alternative to face mask ventilation during resuscitation and as an airway management tool during anesthesia, though its use requires appropriate training and vigilance for device positioning. 1

Evidence for Use in Neonatal Resuscitation

The 2022 International Consensus on Cardiopulmonary Resuscitation provides the strongest guideline support for i-gel use in neonates:

• Supraglottic airways (including i-gel) may be used in place of face masks for positive pressure ventilation in newborns ≥34 weeks gestation during resuscitation immediately after birth 1

• Meta-analysis of 6 RCTs involving 1,823 newborns demonstrated that SGAs reduced failure to improve with the device by 105 fewer per 1,000 infants compared to face masks (moderate certainty evidence) 1

• SGAs reduced the need for endotracheal intubation during resuscitation by 41 fewer per 1,000 infants (low certainty evidence) 1

• Time to achieve heart rate >100 bpm was 66 seconds shorter with SGA use compared to face masks 1

• Subgroup analysis specifically examining i-gel versus other SGA devices showed no significant difference in outcomes (P=0.29), indicating i-gel performs comparably to other SGAs 1

Evidence for Use During Anesthesia

Research studies demonstrate i-gel effectiveness in pediatric anesthesia, though most data comes from older infants and children:

• In 154 children (median age 4 years 11 months), first insertion attempt success rate was 93.5%, with median insertion time of 14 seconds and median leak pressure of 20 cmH₂O 2

• A cohort of 120 children showed successful insertion in 99% (110 first attempt, 8 second attempt, 1 third attempt), with median leak pressure of 20 cmH₂O and ability to establish adequate ventilation in 94% 3

• In 50 children >30 kg, all devices were inserted on first attempt with mean seal pressure of 25 cmH₂O and no gastric inflation 4

• A 2024 review of case reports specifically in newborns with anatomical abnormalities found i-gel effective even when placed by inexperienced clinicians, suggesting potential use as first-choice device in selected patients 5

Critical Practical Considerations

Device Positioning and Vigilance

The i-gel has a tendency to displace upward out of the mouth, and extension/flexion of the proximal tube significantly alters airway quality 2. This requires:

• Careful fixation in the mouth to prevent displacement 2
• Continuous monitoring of airway patency throughout the procedure 2
• Awareness that 16 manipulations were required in 11 of 120 children (9%) to maintain adequate airway 3

Gestational Age and Weight Limitations

• Current guideline recommendations apply to infants ≥34 weeks gestation 1
• Traditional teaching suggests use in infants >2000 g, though emerging evidence suggests potential use in smaller infants requires further study 5

Gastric Access

• The i-gel includes a gastric drain tube, allowing stomach decompression 4, 2
• Gastric tube placement was successful in 90% of cases in one study 2
• This feature is particularly important for minimizing aspiration risk, as second-generation SGAs with drain tubes allow stomach content suctioning 1

Comparison to Alternative Airway Devices

Advantages Over Face Mask

• Reduced failure to improve during resuscitation 1
• Decreased need for endotracheal intubation 1
• Faster achievement of adequate heart rate 1
• Hands-free ventilation once positioned 3, 4

Advantages Over Endotracheal Intubation

• Faster insertion (median 14 seconds) 3, 2
• No need for laryngoscopy skills 3, 4
• Can be placed by less experienced providers 5
• No cuff inflation required 4, 6

Limitations

• Device abandonment rate of 4.5% in one pediatric series due to inadequate airway 2
• Excess leak precluding adequate tidal volume in 2.5% of cases 3
• Higher cost than first-generation devices 2
• Requires vigilance for positioning throughout procedure 2

Safety Profile

• Complications occurred in 20% of patients but were predominantly minor 2
• One case of regurgitation without aspiration in 120 children 3
• No air leaks or soft tissue injuries in neonatal resuscitation trials 1
• Fiberoptic examination showed vocal cords visible in 97% of cases, confirming appropriate positioning 2

Common Pitfalls to Avoid

1. Inadequate fixation: The device's tendency to displace requires secure fixation and continuous monitoring 2

2. Tube manipulation: Avoid excessive flexion toward feet or extension toward forehead of the proximal tube, as this degrades airway quality 2

3. Use in preterm infants <34 weeks: Current evidence does not support routine use below this gestational age 1

4. Assuming "set and forget": Unlike some airway devices, i-gel requires ongoing vigilance for position maintenance 3, 2