text:
Year : 2018 | Volume : 62 | Issue : 11 | Page : 858-864
A comparative evaluation of ProSeal laryngeal mask airway, I-gel and Supreme laryngeal mask airway in adult patients undergoing elective surgery: A randomised trial
Anisha Singh, Anju R Bhalotra, Raktima Anand
Department of Anesthesia, Maulana Azad Medical College, New Delhi, India
Date of Web Publication 2-Nov-2018
Dr. Anisha Singh
Department of Anesthesia, Maulana Azad Medical College, New Delhi
Background and Aims: Second-generation supraglottic airway devices are widely used in current anaesthesia practice. This randomised study was undertaken to evaluate and compare laryngeal mask airway: ProSeal laryngeal mask airway (PLMA), Supreme laryngeal mask airway (SLMA) and I-gel. Methods: Eighty-four adult patients undergoing elective surgery were randomly allocated to three groups: group P (PLMA), group I (I-gel) and group S (SLMA) of 28 patients each. Insertion times, number of insertion attempts, haemodynamic response to insertion, ease of insertion of airway device and gastric tube, oropharyngeal leak pressure (OLP) and pharyngolaryngeal morbidity were assessed. The primary outcome measure was the OLP after successful device insertion. Statistical analysis was performed using Statistical Package for the Social Sciences version 18.0 software using Chi-squared/Fisher's exact test (categorical data) and analysis of variance (continuous data) tests. P < 0.05 was considered statistically significant. Results: The demographic profile of patients was comparable. OLP measured after insertion, 30 minutes later and at the end of surgery differed significantly between the three groups (P < 0.001). The mean OLP was 32.64 ± 4.14 cm·H2O in group P and 29.79 ± 3.70 cm·H2O in group S. In group I, the mean OLP after insertion was 26.71 ± 3.45 cm H2O, which increased to 27.36 ± 3.22 cm H2O at 30 minutes and to 27.50 ± 3.24 cm H2O towards the end of surgery. However, these increases were not statistically significant (P = 0.641). Device insertion time was longest for group P (P = 0.001) and gastric tube insertion time was longest for group I (P = 0.001). Haemodynamic response to insertion and pharyngolaryngeal morbidity were similar with all three devices. Conclusion: PLMA provides better sealing pressure but takes longer to insert. I-gel and SLMA have similar sealing pressures. I-gel insertion time is quicker.
Keywords: Anaesthesia, laryngeal mask, time, ventilation
Singh A, Bhalotra AR, Anand R. A comparative evaluation of ProSeal laryngeal mask airway, I-gel and Supreme laryngeal mask airway in adult patients undergoing elective surgery: A randomised trial. Indian J Anaesth 2018;62:858-64
Singh A, Bhalotra AR, Anand R. A comparative evaluation of ProSeal laryngeal mask airway, I-gel and Supreme laryngeal mask airway in adult patients undergoing elective surgery: A randomised trial. Indian J Anaesth [serial online] 2018 [cited 2019 Jul 16];62:858-64. Available from: http://www.ijaweb.org/text.asp?2018/62/11/858/244829
The endotracheal tube remains the gold standard airway device. However, laryngoscopy and endotracheal intubation may be associated with considerable morbidities ranging from minor side effects such as sore throat to more serious complications such as autonomic stimulation and difficult or failed intubation. Supraglottic airways (SGAs) offer distinct advantages including an increased speed and ease of placement, maintenance of haemodynamic stability during induction and emergence,[1] better oxygenation during emergence and lesser postoperative sore throat and voice alteration.[2] The second-generation SGAs have additional features to reduce the risk of aspiration and provide an improved pharyngeal seal making them more efficient and reliable in their performance. The ProSeal laryngeal mask airway (PLMA)[3] is a reusable SGA with a modified cuff made of silicone and a double tube arrangement. The I-gel[4] is a disposable SGA made of a soft, gel-like thermoplastic elastomer with a noninflatable cuff and is easier and faster to insert than other SGAs. The Supreme laryngeal mask airway (SLMA)[5] is an advanced form of the PLMA made of polyvinylchloride (PVC). There is paucity of literature comparing these three second-generation SGAs in a single study. This study was designed to compare the efficacy of PLMA, I-gel and SLMA as ventilatory devices during general anaesthesia with respect to insertion characteristics, haemodynamic response, oropharyngeal leak pressure (OLP) and pharyngolaryngeal morbidity.
After obtaining Institutional Ethical Committee approval and informed consent from patients, 84 adult patients of either sex admitted for various elective surgical procedures of less than 2-hour duration were included in the study. This randomised controlled trial was conducted in a tertiary care hospital in Delhi from September 2015 to September 2016 (CTRI/2017/08/009534). A detailed preoperative and airway assessment was done. Patients included in the study were of American Society of Anesthesiologists physical status I/II aged 18–60 years. Patients at an increased risk of aspiration (pregnancy, gastro-oesophageal reflux disease, hiatus hernia) and those undergoing head and neck surgery or procedures not performed in supine position were excluded from the study as were those with a known or predicted difficult airway, acute or chronic lung disease and obesity.
Eighty-four patients were randomly allocated into three groups: group P (n = 28) in whom PLMA was used to secure the airway, group I (n = 28) in which I-gel was used and group S (n = 28) in which SLMA was used. Randomisation was by computer-generated numbers and allocation into groups was done by the supervisor opening a sealed opaque envelope just prior to surgery. Patients were blinded to their group allocation. All device insertions were supervised by senior anaesthesiologists and performed by anaesthesia trainees with a prior experience of at least 20 successful insertions of each of the devices. Selection of size of the device was as per manufacturer's guidelines based on the patient's weight. For I-gel, size 3 was used in patients weighing 30–60 kg; size 4 in 50–90 kg and size 5 in patients weighing >90 kg. For PLMA and SLMA, size 3 was used in patients weighing 30–50 kg; size 4 in 50–70 kg and size 5 in 70–100 kg.
All patients were fasted overnight and received the tablet alprazolam 0.25 mg on the night before and 2 hours before surgery. In the operation theatre, intravenous (iv) access was secured and monitoring instituted consisting of electrocardiogram, capnogram (ETCO2), pulse oximeter (SpO2), non-invasive blood pressure (NIBP) and neuromuscular junction monitoring. The patients were placed supine with the head in sniffing position using a 7-cm high firm pillow and administered iv fentanyl 2 μg/kg, 5 minutes before induction. After preoxygenation for 3 minutes, general anaesthesia was induced with iv propofol 1.5–2 mg/kg and muscle relaxation facilitated by iv rocuronium 0.6 mg/kg. The lungs were manually ventilated with a facemask with 1–1.5% isoflurane in oxygen and nitrous oxide (1:2) for 3 minutes. Although complete neuromuscular block is not mandatory for insertion of these airway devices, neuromuscular blockade was confirmed using train-of-four (TOF) stimulation using TOF-Watch® SX monitoring software and the airway device inserted once TOF count was zero in order to ensure comparable conditions for device insertion in the three study groups.
All the devices were checked, prepared, inserted and secured according to the corresponding manufacturer's recommendations. The PLMA and SLMA were deflated fully before insertion. Insertion of the PLMA was performed using the introducer tool as this is the method recommended by the manufacturer and also converts the device into a preformed device for better comparison with the other two preformed devices. Insertion time was recorded as the time from picking up the device until the appearance of first square wave capnogram. If satisfactory placement was not achieved, the device was removed and reinserted. The number of insertion attempts was recorded. A failed attempt was defined as removal of the device after insertion. A maximum of two attempts were permitted before the device was considered a failure. Each 'attempt' was defined as reinsertion of the airway device into the mouth, and respective times were taken as T1 and T2. Effective airway time was calculated by adding T1 and T2. If, at any time, SpO2 fell below 90%, the patients were mask ventilated with 100% oxygen till optimal SpO2 level was reached (>95%) and this time of ventilation was not included in effective airway time. A satisfactory placement was defined by the presence of normal thoracoabdominal movement and a square wave capnograph trace. After insertion, the cuffs of the SLMA and PLMA were inflated to an intracuff pressure of 60 cm·H2O and maintained at that pressure throughout surgery using an automatic cuff controller (VBM Medizintechnik, Germany). The ease of insertion of the SGA was assessed on a 3-point scale as 1 = easy, 2 = some difficulty during insertion or 3 = impossible, by the anaesthesiologist inserting the device. If ventilation was inadequate, the following manipulations were allowed in the following order: adjusting of head and neck position or depth of insertion, chin lift, jaw thrust, and finally by changing the size of the device. In all three groups, an appropriate size (as suggested by the manufacturer) lubricated nasogastric tube was inserted through the gastric drain channel. Ease of insertion of the gastric tube was also assessed by the anaesthesiologist inserting the device on a 3-point scale as 1 = easy, 2 = some difficulty during insertion and 3 = impossible to pass. Proper placement was confirmed by auscultation of injected air over the epigastrium and aspiration of gastric contents. The time taken to pass the gastric tube was recorded. All times were recorded by an anaesthesiologist separate from the investigator inserting the device.
The patients were ventilated to maintain end-tidal carbon dioxide (EtCO2) between 35 and 40 mm Hg. Intraoperative heart rate (HR), NIBP (systolic, diastolic, mean), oxygen saturation and EtCO2 were recorded before induction (baseline), before device insertion (T0), every minute for the first 5 minutes after SGA insertion and henceforth every 5 minutes for the duration of surgery. OLP was recorded using the manometer stability test. The fresh gas flow was set at 3 l/minute of oxygen and the adjustable pressure limiting valve of the circle system was closed. The aneroid manometer dial was observed as the pressure from the breathing system increased and the airway pressure at which the dial reached stability was noted as OLP. A maximum pressure of 40 cm H2O was allowed during the test. Three measurements of OLP were taken: OLP1 (after successful insertion of SGA), OLP2 (10 minutes later) and OLP3 (at tend of surgery). Also, the patients in the study underwent various surgical procedures and the type of surgery was not standardised and included both laparoscopic and nonlaparoscopic procedures. However, in those patients who were undergoing laparoscopy, positioning and gas insufflation were not allowed for the first 10 minutes until haemodynamics and OLP2 had been recorded and OLP3 was recorded at the end after desufflation of pneumoperitoneum and once patient was supine to avoid any bias.
Anaesthesia was maintained with isoflurane in oxygen and nitrous oxide (1:2) and intermittent boluses of rocuronium when TOF count was >2. At the end of surgery, residual muscle paralysis was reversed, with iv glycopyrrolate and neostigmine. The SGA was removed once the patient was awake. The presence of any visible blood on the device was documented. Pharyngolaryngeal morbidity was evaluated in the recovery room and 24 hours later by an anaesthesiologist not involved in the study and unaware of the airway device used. Hoarseness of voice was defined as a change in voice tone or painful phonation. Sore throat was defined as soreness of the throat. Dysphagia was defined as pain triggered by swallowing of saliva.
The primary outcome variable was the difference in OLP1. Secondary outcome variables included the time for insertion of the device, success of first attempt insertion, use of any manipulations, OLP2, OLP3, ease and time of gastric tube insertion, haemodynamic response to insertion, and incidence of visible blood on device and pharyngolaryngeal morbidity.
The sample size was calculated to be 28 in each group with an α error of 0.05 and power of 80%, considering at least 20% difference in the oropharyngeal leak pressure relative to the expected mean between the devices.[3] All data were statistically analysed using Statistical Package for the Social Sciences (SPSS) statistical software, Version 18. The quantitative data (OLP, times for insertion of SGA and gastric tube) were analysed using the one-way analysis of variance test and Bonferroni post hoc multiple comparison test. Qualitative data (ease of insertion of SGA and gastric tube, first attempt insertion success rate, number of insertion attempts and any complications) were compared using Chi-squared or Fisher's exact test. A P value of <0.05 was considered significant.
The demographic data and surgery details were comparable in all the groups [Table 1]. OLP was significantly different among the three groups (P < 0.001) at all times [Table 2]. The mean OLP1 was highest in group P (32.64 ± 4.14 cm·H2O). In group S, the mean OLP1 was 29.79 ± 3.70 cm·H2O. With PLMA and SLMA there was no change in OLP over time. However, in the I-gel group, the mean OLP1 was 26.71 ± 3.45 cm·H2O, which increased to 27.36 ± 3.22 cm·H2O at 10 minutes and to 27.50 ± 3.24 cm·H2O towards the end of surgery. This increase was not statistically significant (P = 0.641). Further intergroup comparison revealed the OLP to be significantly higher in the PLMA group compared to I-gel and SLMA groups at all times (P < 0.001). Although OLP1 was significantly higher with SLMA compared to I-gel, OLP2 and OLP3 were comparable [Table 3].
Table 1: Demographic characteristics
Table 2: OLP (cm·H2O) using manometer stability method
Table 3: Intergroup comparison of OLP using manometer stability test
In all three groups, insertion of the SGA was found to be easy and the device was placed successfully in the first attempt. Insertion time was significantly different among the three groups (P < 0.001). While the insertion time was similar in groups I and S (P = 1.000), there was a significant difference between groups P and I and groups P and S (P < 0.001). Insertion times were significantly longer with PLMA compared to SLMA and I-gel. The only manipulation required to facilitate successful insertion in all groups was jaw thrust. In group I, as many as 53.6% of patients required jaw thrust for easy placement but this was not significant when compared with other groups (P = 0.052).
In all three groups, insertion of Ryle's tube was easy. In PLMA and SLMA groups, a 14 F Ryle's tube was placed, whereas 12 F Ryle's tube were placed in the I-gel group. The time taken for gastric tube insertion was significantly different among all three groups (P < 0.001). Insertion time was longer in group I vs group P (P < 0.001) and in group I vs group S (P = 0.001), but no significant difference was found in group P vs group S (P = 1.000). Insertion of nasogastric tube was significantly longer with I-gel [Table 4].
Table 4: Insertion characteristics
The HR, diastolic blood pressure and mean arterial pressure were comparable in all three groups upto 10 minutes after device insertion (P > 0.05) [Table 5]. Systolic blood pressure (SBP) was also comparable among the three groups during first 5 minutes. However, 10 minutes after device insertion, the SBP was higher in group S compared to group I (P = 0.028) and similar in group I vs group P and group P vs group S. Pharyngolaryngeal morbidity was similar with all three devices [Table 6].
Table 5: Haemodynamic response to insertion
Table 6: Pharyngolaryngeal morbidity: immediate postoperatively and 24 hours later
SGAs have undergone a remarkable evolution since the introduction of the classic LMA. The PLMA, I-gel and SLMA have previously been evaluated alone or in pairwise comparisons but under different study designs, which makes it difficult to compare the results. To the best of our knowledge, there is a paucity of studies comparing these devices in a single study setting using controlled ventilation. In this study, 84 patients were taken and randomly allocated into three groups of 28 patients. Device insertion was successful in all patients, that is, 100% first attempt success rate was achieved which was similar to another study[6] in which first time success rates were 80% (I-gel), 84% (PLMA) and 100% (SLMA). One major study[7] also found the overall insertion success rate of I-gel to be 97% irrespective of the anaesthesiologist's previous experience of using the device.
All the SGAs were easy to insert in our study, which is also similar to other investigators.[6],[7] There was no trauma during insertion in any patient which is in contrast to another comparison by Eschertzhuber et al.[8] who reported a 4% incidence of trauma with insertion of PLMA and SLMA. A better acquaintance with SGAs, training on mannequins, proper patient positioning and device manipulations during insertion probably minimised airway trauma in our instance.
In our study, the insertion times for I-gel (13.5 ± 4.41 seconds) and SLMA (14.5 ± 4.71 seconds) were similar (P = 1.00) but significantly longer with PLMA (23 ± 2.58 seconds). This may be attributed to the additional time taken for removal of the introducer followed by inflation of the cuff of the PLMA. Both I-gel and SLMA are preformed devices and insertion does not require the use of an introducer. Various studies have found that insertion of I-gel is quicker due to the absence of an inflatable cuff. Bamgbade et al.[9] evaluated 300 I-gel insertions in 290 patients and reported an insertion time of 5 seconds, but they did not define insertion time. On the other hand, Teoh et al.[10] found similar insertion times for I-gel (15.4 ± 7.3 seconds) and SLMA (14.3 ± 4.7 seconds) which are similar to our study but they had defined them as time from insertion of airway device into patient's mouth to the first end-tidal carbon dioxide trace which differs from our definition.
To facilitate insertion of the SGA, the only manipulation required was jaw thrust. It is our impression that the use of a jaw thrust facilitates insertion of an I-gel and we used this in 15 (53.6%) of our study cases. We used jaw thrust in 7 patients in groupP and 8 patients in group S. The jaw thrust for I-gel has been recommended by the manufacturer if there is early resistance to insertion. Change in device size was not required in any patient. There is an overlap in the weight criteria of the manufacturer's recommendations for I-gel, that is, size 3 for 30–60 kg and size 4 for 50–90 kg. If the patient weighed between 50 and 60 kg, then size selection was left to the discretion of the conducting anaesthesiologist. Gatward et al.[11] have demonstrated the suitability of the size 4 I-gel in 100 nonparalysed patients weighing 42–113 kg.
In our study, insertion of a gastric tube was easy in all patients but took significantly longer in group I (12.21 ± 3.82 seconds). This is similar to the findings of Teoh et al.[10] who found gastric tube insertion times to be longer for I-gel (15 ± 7.3 seconds) compared to SLMA (9 ± 2.5 seconds). They suggested that the longer time to insert a gastric tube in the I-gel group can be attributed to the smaller aperture of the gastric port in the device which may increase the time to insert the leading edge of the tube into the gastric port aperture. The longer time to insert a gastric tube in the I-gel has been reported in earlier studies.[12] It seems likely that the suggestion of Teoh et al. may be a reasonable explanation for this longer gastric tube insertion time in our study too.
The haemodynamic response to laryngoscopy and intubation is a reflection of an increase in sympathoadrenal activity due to oropharyngeal and laryngotracheal stimulation.[13] There is a lesser cardiovascular response to insertion of an SGA compared to an endotracheal tube. In our study, haemodynamic response to insertion was similar in all the groups apart from the SBP at 10 minutes which was significantly lower in group I. In contrast to our findings, Teoh et al.[10] reported a comparable haemodynamic response to insertion with I-gel and SLMA. A likely cause for the lower SBP in the I-gel group could be the absence of an inflatable cuff in I gel which may provoke lesser pharyngolaryngeal stimulation when compared to the larger PVC cuff of the LMA supreme.
We found the OLP to be significantly higher in group P (32.64 ± 4.41 cm·H2O) compared to group S (29.50 ± 3.70 cm·H2O). This remained same for all three readings, that is, OLP1, OLP2 and OLP3. The higher OLP with PLMA may be attributed to the double cuff made of silicone rubber which conforms to the anatomy of the hypopharynx more favourably than the single larger cuff of the SLMA made of PVC.
The seal pressure or OLP of I-gel is expected to improve with time as the cuff is made up of medical grade thermoplastic elastomer which is soft, gel like and fits anatomically to perilaryngeal structures. Due to the thermoplastic nature of the cuff, the seal improves as the cuff attains body temperature and fits more snugly over perilaryngeal tissues. Hence we decided to assess OLP at three times. In our study, the OLP increased with time in the I-gel group, that is, OLP1 (26.71 ± 3.45 cm·H2O) < OLP2 (27.36 ± 3.22 cm·H2O) < OLP3 (27.50 ± 3.24 cm·H2O). This increase was, however, statistically insignificant. Mukadder et al.[14] had also reported that OLP of I-gel improved with time which is similar to our results.
Our results showed the highest mean OLP with the use of PLMA, similar to Van Zundert et al.[6] who found the mean OLP to be 33 ± 7 cm·H2O with PLMA, 32 ± 6 cm·H2O with SLMA and 30 ± 11 cm·H2O with I-gel. Shin et al.[15] compared I-gel, PLMA and classical LMA and reported an OLP 27 cm·H2O for I-gel and 29.8 cm·H2O for PLMA in paralyzed patients. In a recent study on the comparison of the clinical performance of I-gel, LMA Supreme and LMA ProSeal in elective surgery, Liew et al.[16] found highest OLP with I-gel (27.31 cm·H2O). However, in this study, patients were allowed to breathe spontaneously and the researchers modified weight-based size selection of I-gel.
In our study, pharyngolaryngeal morbidity was assessed immediately postoperatively and 24 hours later and was similar in all three groups. In contrast, Teoh et al.[10] found that two patients had blood on the device and four had a sore throat after use of SLMA, while only one patient in the I-gel group had blood on the device and a sore throat. However, in this study, intracuff pressure was not kept constant. In our study, the cuff pressure was maintained below 60 cm·H2O which may explain the comparable pharyngolaryngeal morbidity of PLMA and SLMA vs an uncuffed device like the I-gel.
Our study does have some limitations. In order to maintain the usual surgical turnover rate, we did not assess the anatomical position of the SGA in relation to the vocal cords using fibreoptic bronchoscopy. Also, there is evidence to suggest that checking the placement by fibre optic bronchoscopy does not have much clinical correlation and has not been suggested as a preuse check by the manufacturers. Another limitation is that the airway operator could not be blinded to the device being used and insertion data were collected by an unblinded investigator. This may introduce a potential for bias. Also, all device insertions were performed by a single experienced anaesthesiologist and these results may not be applicable to inexperienced users, although there is evidence to suggest that these devices can be inserted by inexperienced operators with a high rate of first attempt successful insertion.[17] Our study included only nonobese patients with normal airways and these results cannot be directly extrapolated to obese patients or those with a difficult airway. In our study, device insertion was done after administration of a muscle relaxant and it has been reported that the use of neuromuscular blockade can affect laryngeal mask airway seal pressure resulting in lower values of OLP.[18] Also, airway pressures and intra-abdominal pressures were not recorded in the laparoscopy cases to maintain uniformity in the methodology.
ProSeal LMA, I-gel and Supreme LMA were easy to insert with a 100% first attempt insertion success rate and similar pharyngolaryngeal morbidity. The PLMA provided a significantly higher OLP compared to the other two devices and can be suggested as the device of choice to be used in those patients and situations where a high OLP is required.
Dyer RA, Llewellyn RL, James MF. Total iv anaesthesia with propofol and the laryngeal mask for orthopaedic surgery. Br J Anaesth 1995;74:123-8.
Higgins PP, Chung F, Mezei G. Postoperative sore throat after ambulatory surgery. Br J Anaesth 2002;88:582-4.
Brain AI, Verghese C, Strube PJ. The LMA 'ProSeal'—A laryngeal mask with an oesophageal vent. Br J Anaesth 2000;84:650-4.
Janakiraman C, Chethan DB, Wilkes AR, Stacey MR, Goodwin N. A randomised crossover trial comparing the I-gel supraglottic airway and classic laryngeal mask airway. Anaesthesia 2009;64:674-8.
Verghese C, Ramaswamy B. LMA-Supreme™—A new single-use LMA™ with gastric access: A report on its clinical efficacy. Br J Anaesth 2008;101:405-10.
Van Zundert TC, Brimacombe JR. Similar oropharyngeal leak pressures during anaesthesia with I-gel™, LMA-ProSeal™ and LMA-Supreme™ Laryngeal Masks. Acta Anaesthesiol Belg 2012;63:35-41.
Richez B, Saltel L, Banchereau F, Torrielli R, Cros AM. A new single use supraglottic airway device with a noninflatable cuff and an esophageal vent: An observational study of the I-gel. Anesth Analg 2008;106:1137-9.
Eschertzhuber S, Brimacombe J, Hohlrieder M, Keller C. The Laryngeal Mask Airway Supreme™—A single use laryngeal mask airway with an oesophageal vent. A randomised, cross-over study with the Laryngeal Mask Airway ProSeal™ in paralysed, anaesthetised patients. Anaesthesia 2009;64:79-83.
Bamgbade OA, Macnab WR, Khalaf WM. Evaluation of the I-gel airway in 300 patients. Eur J Anaesthesiol 2008;25:865-6.
Teoh WH, Lee KM, Suhitharan T, Yahaya Z, Teo MM, Sia AT. Comparison of the LMA Supreme vs the I-gel™ in paralysed patients undergoing gynaecological laparoscopic surgery with controlled ventilation. Anaesthesia 2010;65:1173-9.
Gatward JJ, Cook TM, Seller C, Handel J, Simpson T, Vanek V, et al. Evaluation of the size 4 I-gel™ airway in one hundred non-paralysed patients. Anaesthesia 2008;63:1124-30.
Park SY, Rim JC, Kim H, Lee JH, Chung CJ. Comparison of I-gel® and LMA Supreme® during laparoscopic cholecystectomy. Korean J Anesthesiol 2015;68:455-61.
Shribman AJ, Smith G, Achola KJ. Cardiovascular and catecholamine responses to laryngoscopy with and without tracheal intubation. Br J Anaesth 1987;59:295-9.
Mukadder S, Zekine B, Erdogan KG, Ulku O, Muharrem U, Saim Y, et al. Comparison of the Proseal, Supreme, and I-gel SAD in gynecological laparoscopic surgeries. ScientificWorldJournal 2015;2015:634320.
Shin WJ, Cheong YS, Yang HS, Nishiyama T. The supraglottic airway I-gel in comparison with ProSeal laryngeal mask airway and classic laryngeal mask airway in anaesthetized patients. Euro J Anaesth 2010;27:598-601.
Liew GH, Yu ED, Shah SS, Kothandan H. Comparison of the clinical performance of I-gel, LMA Supreme and LMA ProSeal in elective surgery. Singapore Med J 2016;57:432-7.
Ragazzi R, Finessi L, Farinelli I, Alvisi R, Volta CA. LMA Supreme™ vs I-gel™–a comparison of insertion success in novices. Anaesthesia 2012;67:384-8.
Goldmann K, Hoch N, Wulf H. Influence of neuromuscular blockade on the airway leak pressure of the ProSeal laryngeal mask airway. Anasthesiologie, Intensivmedizin, Notfallmedizin, Schmerztherapie: AINS 2006;41:228-32.
Singh A
Bhalotra AR
Anand R
laryngeal mask


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Joe Abercrombie's Red Country: Review and Interview
We chat to fantasy author Joe Abercrombie and rate his latest release, Red Country
By Jodie Tyley	 22-10-12 10,144
60 seconds with Joe Abercrombie…
Now that you've gained such a big following, did you feel any additional pressure with the release of Red Country?
I suppose I've felt a fair bit of pressure with the last three or four books, though a lot of it is self-imposed. You always want to do bigger and better than you did last time. And writing is a strange profession in that people are generally responding to something that you wrote at least a year or two ago. If they don't like it, of course it's an outrage. But if they do like it, will they like what you're doing now?
What prompted you to attack the western genre?
It looked at me wrong.
I've been a big fan of westerns for years, from the John Wayne films I used to watch as daytime matinees as a kid, through the spaghetti westerns to revisionist things like Unforgiven and Deadwood. Although epic fantasy and westerns have a lot in common – tough people facing the dangers of the wilderness – I couldn't think of many books that consciously blend the two, so I thought I'd have a go…
Did it involve watching a lot of Clint Eastwood movies and smoking cigars?
Cigars tend to make me a little bit sick, but Clint Eastwood movies, definitely, along with plenty of Deadwood, Cormac McCarthy, Larry McMurty, Elmore Leonard, and others.
Are there any sub-genres left that you want to tackle?
Red Country wears its influences very much on its sleeve. The next couple of projects probably won't be quite so obviously flavoured.
First a cup of tea. Then my next move is to plan my next move. I wouldn't want to make any sudden moves.
Words: Daniel Cairns
Joe Abercrombie thanks Clint Eastwood in the acknowledgements at the start of his latest epic, which gives a pretty clear indication of what it's about. No it's not about a politically dubious, well past his prime pensioner making a complete berk out of himself by speaking to an imaginary friend at a Republican convention. Red Country has more in common with what Clint was famous for in the first place, those beautifully shot, riveting Sergio Leone Western features that made his name, despite the fact his character didn't actually have one. The fantasy comes in thanks to the fact they all wield swords for some reason.
Red Country is Abercrombie's love letter to the Western, and unlike many that make a complete hash of the spit and sawdust stereotypes that make up the genre, he gets it magnificently. There's much love here, but at the same time there's none of the rose tinted romanticism and certainly none of the cheesiness you'd associate with certain aspects of the Western. As such, Red Country ends up being more Deadwood than Dead boring. It's also part of his First Law series, which started as a trilogy but is now into its sixth book.
It's is the tale of Shy South, a former outlaw who decides that a quieter life would be one worth pursuing, returning to the family home. However -as is always the way- things are never that simple, and thanks to the kidnap of her brother and sister, South and her stepfather Lamb are off out again, returning to a life less savoury. Think The Searchers (classic John Wayne film) with more swearing and swordplay. Their journey has them delving headfirst into parts unknown, parts fraught with lawlessness, bloodshed and suffering (as is Abercrombie's usual want). Abercrombie's world in Red Country is a brutal, barren place, and Shy and Lamb have much to overcome if they want to return to their peaceful farming existence.
As you'd expect from Abercrombie this is chockfull of grim humour, action and violence, and very much aimed at the cynical, gritty end of the fantasy spectrum. He's nailed the formula now, and taken influences from some fine works in the process. There's a very obvious hint of Cormac McCarthy in here too (the grim callousness of Blood Meridian rather than the somewhat redemptive The Road). The aforementioned Deadwood (the best Western based bit of media ever incidentally) makes its voice heard too, thanks not only to the liberal bloodshed and fruity language, but also the questionable decisions some characters make. Nothing's black and white, and shades of grey prevail, with liberal lashings of claret to complete the picture. In fact so strong is Abercrombie's grasp of what makes a Western tick, that one sometimes wishes Red Country was a pure Western, without the more fantastical sword swishing elements.
Fans will get it already, but people unfamiliar with Abercrombie (especially those with a predilection for Westerns) will find this a fun starting point. Yee haw.
Tags: Dragons, fantasy, fantasy author, Joe Abercrombie, Robin Hobb, swords, western

redpajama_set_name: RedPajamaCommonCrawl


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Advergames – a few considerations
July 6, 2015 May 15, 2017 AdAsia Editor
Using branded online games for advertising and marketing purposes, so called Advergames, has been around as a tactic for years. At AdAsia we see that this tactic is increasingly part of the marketing mix of brands, now that costs have come down, while mobile broad band coverage and smart phone gaming grow rapidly. Here are a few considerations, observations and data points that Branded Mini-Games, a company active in this area, shared with us.
Some data points
Branded Mini-Games gave us a few data points about games and mobile in APAC. 46% of smart phone owners play games on a daily basis. Most smart phone users, 4 out of 5 in fact, have at least once played a game on their device. The sheer amount of mobile phone connections, which according to Wearesocial stands at 3.7 Billion in APAC, leads to the conclusion that there are nearly 2 Billion gamers on mobile alone. Advergames are forecasted to reach over US$2.67 billion by the year 2017 worldwide. They are set to grow in Asia too – with gaming accounting for 13% of total mobile ad spend. Industry analysts expect the growth to be an estimated 19% year-on-year in Asia.
Why games as ads?
Branded Mini-Games says that games are about interaction, while they also have a social component, because gamers generally like to share their results or play against or with others. Brands can benefit from the interaction and social components. Where online banners are usually one-dimensional, a well-designed game can be a more enticing proposition. It allows a gamer to discover a brand through interaction. In addition it increases the likelihood of recommendations through social media, provided the game experience is positive. This contributes to the NPS score. Brands and game-development companies alike claim that branded-games can have up to three times the conversion rates on call-to-actions, compared to online banner advertising.
The hurdles
Advergames as a channel or tactic should be approached with care, according to Branded Mini-Games. As stated before a game will only be successful if it is well designed. The game should have a purpose that goes beyond a simple 'play and stand a chance to win' concept. Discovery, purpose and relevance for a gamer, beyond the commercial objectives of a brand are of paramount importance. The branding can be very subtle and ideally increases only when the engagement, i.e. stages completed, increase.
Up till now producing a game was relatively expensive and required a lot of effort from both the brand's marketing team and the game development agency. Native apps e.g. can be prohibitively costly when you want to scale across the wild diversity of smartphones. Change is happening as there are a few companies out there that offer template, pre-developed game concepts that can be modified to fit a brand's identity, design and values and that scale more easily.
It is worth noting that most of these template-based games use html5 instead of a proprietary smart phone OS such as iOS or Android. If you think that this limits the interaction design of the game, you could be in for a surprise. There are some beautifully designed interfaces out there with a high complexity level, completely designed for and built with html5.
These apps run in a browser or in a browser-like app and can easier scale over the wide variety of smartphones currently available. Most will require a connection to function but with the increasing availability of fast mobile broadband, the use is no longer limited to home or work. Most Facebook games e.g. are developed in html5. In combination with Facebook advertising and the analytics engine behind it, Facebook is a very compelling game distribution and through that an advergame platform with global reach, except for China where other alternatives are available.
According to Branded Mini-Games, the availability of more affordable and scalable game concepts mean that it is no longer the privilege of large global brands to develop an advergame. Apart from a good design concept another question might be if your audience is ready to interact with your brand through a game.
With the growing popularity of games this might surprise you. There are examples of games for niche audiences and even for B2B. It is worth trying it out on a small scale, something that is now more affordable than before.
The information and data points in this article were provided by Branded Mini-Games, except for where otherwise indicated.
Branded Mini-Games can be contacted at: danielle.kuek@mbizglobal.co.uk
Article by Matthieu Vermeulen
Cyberspies News, DIGITAL WORLD, Feature Stories, Reports


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Albert Serran signs one-year extension with Bengaluru FC
Bengaluru FC defender Albert Serran during a training session. Photo courtesy: Bengaluru FC
Bengaluru FC have extended the contract of defender Albert Serran who has put pen to paper on a deal which keeps him with the Indian Super League champions till the end of 2019-20 season, the club announced on Wednesday. The 34-year-old defender thus becomes the fourth foreigner to stay on for Carles Cuadrat's side for the upcoming season.
Serran who joined Bengaluru FC after a trial in Spain, went on to become an important part in Cuadrat's defence, establishing a formidable partnership with fellow countryman Juanan Gonzalez at the heart of the backline. Starting 15 games, he made a total of 17 appearances as the Blues claimed their maiden Indian Super League title.
Excited at continuing his successful journey in India, the Spaniard spoke about his ambition for the new campaign. "I am so happy to be coming back to the Bengaluru FC family once again. It's a matter of pride for me to pull on the BFC blue for another year and I will be giving everything to the club's cause of challenging for the title again."
Head Coach Cuadrat who has frequently highlighted the importance of continuity in the squad was happy with the return of Serran. "Albert has come off a fantastic season with us, partnering with Juanan to lend our defence solidity. He's an experienced hand, a fantastic professional and above all a great team player. Handing him a new contract is in line with our efforts to retain as many players as possible from our championship-winning squad last year and I'm certain he will deliver yet another solid season for Bengaluru FC," said Cuadrat.
For the record, Serran, who becomes the third Spaniard in the team for the 2019-20 season after Juanan and Dimas Delgado, also notched up an impressive 88% passing accuracy last season while making 114 clearances in the ISL.
(Bengaluru FC)
Albert Serran, Bengaluru FC, contract extension, Indian Super League


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South Korean Schools Go Paperless. Can Others Follow?
South Korea's Education Ministry announced last week that it plans to replace all printed textbooks with digital versions in the next four years. It's part of a larger effort to integrate technology into all aspects of the South Korean education system, including moving all nationwide academic exams online and offering more online classes.
The Education Ministry says that it plans to have elementary-level content digitized by 2014, with high school level content ready by 2015.
But making textbooks available in an electronic format isn't a simple undertaking. Nor is it as easy as just offering digital versions of existing books. All of the supplementary material that often accompanies textbooks -- handouts, quizzes, study guides, and so on -- must also be digitized. A move to e-textbooks opens opportunities for new kinds of content as well, with more multimedia and interactivity available.
But there are also new challenges: how will this material be stored? Which format will it be offered? Will it be accessible to all students? What infrastructure needs to be in place -- for schools, for teachers, and for students -- to make sure that print textbooks really can be replaced?
According to Chosunilbo, the government wants to build a cloud-based computing system for all schools that will store a massive database of all digital textbooks. It also plans to help boost the WiFi infrastructure there, so that students and teachers can all access and download the materials. Furthermore the government says it will give tablets to low-income students.
"We don't expect the shift to digital textbooks to be difficult as students today are very accustomed to the digital environment,"said an Education Ministry official in the Chosunilbo article.
As we covered on MindShift earlier this year, South Korea has been on the cutting edge with adoption of a number of educational technologies and is experimenting with telepresence and robot instructors. As e-schoolnews points out, students in South Korea have scored higher than those in any other country on the Digital Reading Assessment exam -- part of the OECD's Program for International Student Assessment (PISA) tests. The Digital Reading Assessment exam measures students' ability to use and critically evaluate Web-based sources.
The commitment on the part of South Korea to go digital with its textbooks is part of a growing trend. The State of Florida, for example, has also expressed its interest in moving to a paperless classroom, and California is moving in that direction, as are other states. The South Korean plan will involve some W2.2 trillion (approximately $2.1 billion) of investment -- a hefty price tag for a school system that is already more "wired" than many U.S. classrooms. That begs the question, of course, as to the realities of which education systems will be able to follow the South Korean initiative.


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Farmer facing six months in labor camp for theft
Kim Yoo Jin
2019.09.18 9:00am
A tractor on a farm in North Korea. / Image: Todd Mecklem, Creative Commons, Flickr
A farmer in Paekam County, Ryanggang Province, has been sentenced to six months of forced labor after stealing unripened potatoes and barley, Daily NK learned from multiple sources in North Korea on Monday.
The stealing of corn, barley and potatoes by farmers without enough food to eat is becoming an increasing problem, one of the sources based in Ryanggang Province added.
"The man had nothing to eat, so he went into a farm to steal barley and potatoes. A guard at the farm saw him and followed him home," the source said. "The man was investigated for a month before receiving a six month sentence in a forced labor camp in early September."
The investigation by local authorities determined that the farmer had cooked and eaten the barley he had stolen.
Daily NK has long reported on the rising theft of corn and other grains from collective farms before the start of the harvest season, and has shed light on recent thefts perpetrated by both farmers and soldiers.
Following a rise in theft of unripened crops in July, Ryanggang Province's Farm Management Committee delivered a lecture to emphasize the illegality of stealing crops and ordered farm managers to strengthen prevention efforts.
Ryanggang Province's Farming Management Committee has continued to warn farmers from July of this year that the theft of even a handful of potatoes before the harvest season is equivalent to stealing "a straw bag" of potatoes, another source in Ryanggang Province said.
Despite warnings by the local authorities, farmers who have no food to eat have continued to steal what they can. Exasperated, the committee has put together a security force to combat the thefts.
The arrest of the farmer comes on the heels of these intensified efforts to identify and punish thieves. A member of a "Red Guard" unit at the farm witnessed the man stealing the potatoes and followed him home.
"After the man was caught, the farm's management decided that they had had enough of all the thefts and called in the farmers to the management committee office to berate them," the source told Daily NK. "A month later, the farmer in question was punished and sentenced to six months of forced labor."
The source added that the authorities decided to make an example out of him because most farmers and other people living near the farm who have stolen crops have not been caught and punished.
Please direct any comments or questions about this article to dailynkenglish@gmail.com.


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Sadr stressed that Russia has an active role in the humanitarian and service
by RamblerNash on Tue Jul 10, 2018 10:18 pm
The leader of the Sadrist movement, Moqtada al-Sadr, on Tuesday, that the next government must be a national patriotic government, pointing out that Russia should have an active role in the humanitarian and service.
"The Moqtada al-Sadr received the Ambassador of the Russian Federation to Iraq Maxime Maximov in Najaf," a statement from Sadr's office said. "The Russian ambassador offered his congratulations to Muqtada al-Sadr on the parliamentary elections and the victory of the National Alliance."
The statement added that "during the meeting, the relations between the two countries and the two friendly peoples of Iraq and Russia in various fields and means of upgrading them to serve the common interests, and discussed the internal and regional situation."
The statement quoted al-Sadr as saying that "the next government must be a patriotic national government to carry out the large tasks required by the current stage," calling for the need to "Russia has an active role in the humanitarian and service, especially the file of displaced people in the liberated areas, this field".
http://www.ikhnews.com/index.php?page=article&id=170669
Re: Sadr stressed that Russia has an active role in the humanitarian and service
by Terbo56 on Tue Jul 10, 2018 10:22 pm
An 'active' role? Why didn't Russia do this before ISIS bombed and burned the shit out of the country? I'd say too little, too late-If Sadr did anything to save Iraq, he'd be dangerous-
Terbo56
Location : Central Florida-