laryngeal mask airway and its variants - MedIND

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Oct 2, 2005 - mask airway (LMA) is the most popular one.1,2. Laryngeal Mask ... with the upper surface behind the base of the tongue and the epiglottis ...
SOOD LMA VARIANTS Indian J.: Anaesth. 2005; 49 (4) : 275 - 280

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LARYNGEAL MASK AIRWAY AND ITS VARIANTS Dr. Jayashree Sood Introduction Airway management is one of the most important skills in the field of anaesthesiology, and inability to secure the airway can lead to catastrophic results. Before 1990, only the face mask and the endotracheal tube (ETT) were the available airway devices. Since then several supraglottic airway devices have been developed, of which the laryngeal mask airway (LMA) is the most popular one.1,2

The inflatable mask is oval shaped with a broad, round proximal end and a narrower, more pointed distal end. It has an inflatable cuff and a semirigid, concave, shield like backplate. The cuff is attached to the outer rim of the backplate.

Laryngeal Mask Airway - Classic The LMA was conceived and designed by Dr. Archie Brain in U.K. in 1981. Following prolonged research, it was released in1988.1 At an early stage in its development, the inventor realized its potential in the management of the difficult airway. 1,3-6

The mask inflation line, which is attached to the most proximal portion of the cuff in the midline consists of four parts, the long narrow inflation line itself, the inflation indicator balloon (pilot balloon), a metallic valve and the syringe port. The valve, which has a white coloured core is made from polypropylene and has a stainless steel spring valve. The LMA is available in eight sizes (table 1), from neonates to large adults, 1 to 6 and two half sizes 1.5 and 2.5. The cuff, but not the tube, has identical proportions among sizes; it gets about 15% larger for each size.

Today, it has a clearly established role as an airway device in the elective setting where neither the procedure nor the patient requires tracheal intubation. It has now become an established part of routine airway management and has proved extremely useful in managing the difficult airway. Fig. 1 : LMA - Classic

Concept and design1,4,7,8 The LMA fills a niche between the face mask (FM) and tracheal tube (TT) in terms of both anatomical position and degree of invasiveness. It is manufactured from medical grade silicone rubber and is reusable. It consists of 3 main components (fig. 1) : An airway tube, inflatable mask and mask inflation line. The airway tube is slightly curved to match the oropharyngeal anatomy, semirigid to facilitate atraumatic insertion and semitransparent, so that condensation and regurgitated material is visible. A black line runs longitudinally along its posterior curvature to aid in orientation. The distal aperture of the airway tube opens into the lumen of an inflatable mask and is protected by two flexible vertical rubber bars, called mask aperture bars (MAB), to prevent the epiglottis from entering and obstructing the airway. M.D., F.F.A.R.C.S. Chairperson Dept. of Anaesthesiology, Pain and Perioperative Medicine Sir Ganga Ram Hospital, New Delhi, INDIA.

The inner aspect of the mask is called the bowl, which is comprised of the distal aperture, mask aperture bars, backplate and the inner aspect of the inflatable cuff.

Table - 1 : Classic LMA Specifications Mask size

Patient weight (kg)

4

Maximum inflation volume (mg)

1

< 5

4

1.5

5 – 10

7

2

10 – 20

10

2.5

20 – 30

14

3

30 – 50

20

4

50 – 70

30

5

70 – 100

40

6

> 100

Anatomy1,8 The cuff is pressed aganist several structures in sequence – the hard palate, the soft palate, the naso/ oropharyngeal and then the hypopharyngeal portion of the posterior pharyngeal wall. The ideal final anatomic position occupied by the classic LMA is as follows: The distal cuff sits in the hypopharynx at the junction of the upper oesophagus and respiratory tracts, where it forms a circumferential low pressure seal around the glottis. Superiorly, the upper part of the mask lies under the base of the tongue, allowing the epiglottis to rest within the bowl

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of the mask at an angle probably determined by the extent to which passage of the mask has deflected it down-wards. When inflated, it lies with the tip resting against the upper esophageal sphincter, the sides facing the pyriform fossae with the upper surface behind the base of the tongue and the epiglottis pointing upwards. The aperture of a properly positioned LMA aligns itself anatomically with the laryngeal inlet. The tip of the LMA cuff lies at a variable depth behind the cricoid cartilage; and the posterior surface immediately anterior to the C2 to C7 cervical vertebrae. The laryngeal inlet can be tipped anteriorly by the inflated LMA cuff when cricoid pressure is applied; this may explain why blind intubation via the LMA is more difficult with cricoid pressure applied. Indications • Elective short surgical procedures under general anaesthesia excluding head and neck surgery • Rescue airway in “cannot intubate – can ventilate” and “cannot intubate, cannot ventilate” scenario if the problem is supraglottic in nature, since successful use of the LMA does not require the constellation of factors required for direct laryngoscopy and tracheal intubation.1,5,9 In 1996 it entered the American Society of Anesthesiologists’ difficult airway algorithm in five different places, both as a ventilatory device (airway) and a conduit for endotracheal intubation. 1,2,8,9 • Cardiopulmonary resuscitation1,7,8 Contraindications2,4 • Mouth opening less than 1.5 cm • Poor lung compliance • Airway pressure more than 20 cm of H2O • Non fasting patients

INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005

of the LMA. The adequate depth of anaesthesia for LMA placement is significantly less than that for tracheal intubation. Several insertion techniques have emerged to complement the original technique which was described when the LMA was introduced. The standard technique involves a completely deflated LMA, held like a pen guided into the pharynx with the index finger of the operator at the junction of the tube and the bowl, with the operator at the head of the patient and the LMA aperture facing caudally. With the head extended and the neck flexed by using the hand under the occiput, under direct vision, the tip of the cuff is pressed upwards against the hard palate. The LMA is advanced into the hypopharynx till a resistance is felt. The cuff is then inflated with just enough air to seal, to intra cuff pressure around 60 cms H2O. A common alternative technique popular in children described by McNicol, consists of inserting a partially inflated LMA into the pharynx above the epiglottis with the aperture facing cranially, the LMA is then turned 180 degrees before advancing it into its final position. 11 The LMA should then be secured after insertion in such a way, so as to prevent rotation and movement cranially. If surgical access allows, a preferred way to connect the LMA to the anaesthesia circuit is to direct the circuit connection caudally and bring the circuit limbs down on the side of the patient’s neck and head. Signs of correct LMA placement4,8,9 a. Slight outward movement of the tube upon LMA inflation. b. Presence of a small oval swelling in the neck around the thyroid and cricoid area. c. No cuff visible in the oral cavity. d. Expansion of chest wall on bag compression

Insertion technique1,2,4,7,9,10 LMA insertion can be considered in the context of swallowing both in terms of the space it occupies and the type of reflex response it elicits. The insertion technique does not require the use of a laryngoscope or muscle relaxants and is designed to imitate the mechanism whereby the food bolus is swallowed.

Before taping the LMA in place, a bite block is inserted to stabilize the LMA and prevent tube occlusion.

Preparation of the LMA and the patient is essential for successful placement. Lubrication of the mask should avoid the use of local anesthetics in order to preserve protective reflexes against aspiration. A selection of LMA sizes should be available in addition to the one most likely to fit because the anatomical features of the larynx cannot always be predicted from the physical examination. Most of the induction agents can be used to facilitate placement

Pathophysiology Pharyngeal microcirculation is unimpaired at low to moderate cuff volumes for all LMA devices (except intubating LMA). The LMA is a relatively noninvasive airway compared with a tracheal tube, and it causes minimal disturbance of the cardiovascular and respiratory system. The incidence of sore throat is minimal because the cords

Emergence technique Removal of the LMA can be accomplished either during deep anesthesia or after protective reflexes have returned. 4,7,8

SOOD : LMA VARIANTS

are not penetrated. The haemodynamic stress response to LMA insertion is less pronounced than during tracheal intubation during induction, maintenance and emergence from anaesthesia. Less anaesthetic is required to tolerate the LMA once the device is insitu. 1,8 LMA and aspiration Although the correctly placed LMA tip lies against the upper esophageal sphincter, the LMA does not isolate the respiratory tract from the gastrointestinal tract and does not protect the lungs from regurgitated gastric contents. The glottic seal is usually lost at peak airway pressures above 20 cms H2O. 1,4 Incidence of aspiration with the LMA is 2 per 10,000. 1 LMA and the difficult airway1,2,7,8 Several design features make possible its use as an airway intubator, like the wide bore of the LMA tube, the width and elasticity of the aperture bars, the angle at which the tube enters the bowl of the mask, anatomic alignment of the LMA aperture with the glottis and the low pressure seal allowing synchronous patient ventilation. However there are several problems associated with this. The internal diameter of the airway tube is too small to accommodate a normal sized tracheal tube, and it is too long to ensure that a normal length tracheal tube will penetrate the vocal cords. The mask aperture bars interfere with the passage of the tracheal tube. Removal of the LMA may be difficult after successful intubation due to the length of the airway tube. Direct blind intubation has a success rate around 55%. Success is reduced by cricoid pressure, and is similar for normal and abnormal airways. Fiberoptic guided intubation via the LMA has higher success rate and causes less trauma. It can be performed directly by inserting the tracheal tube over the fiberoptic scope or indirectly using a guide first. The manufacture’s warranty for LMA classsic is for 40 uses, but deterioration in performance does not occur until 80-100 uses. Despite high capital costs, the LMA is cost effective compared to tracheal tube.8 LMA variants At present, variations include a reinforced/ flexible LMA (LMA-Flexible), LMA specifically designed for tracheal intu-bation (LMA-Fastrach), single-use LMA (LMA-Unique) and LMA with an integral gastric access/ venting port (LMA-ProSeal). I. Flexible laryngeal mask airway (reinforced LMA) 2,7,8 In 1990, two reports appeared in the journal ‘Anaesthesia’ describing kinking of the LMA tube. The flexible LMA (fig. 2) was designed by Brain and released

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in 1992 to prevent tube occlusion, improve surgical access and prevent cuff displacement during head, neck and oropharyngeal surgery.4 It is made from medical grade silicone and rubber and is reusable. It consists of a Classic Fig. 2 : Flexible LMA LMA connected to a flexible, wire reinforced tube that is longer and narrower than the Classic LMA. The wire reinforcement prevents kinking, the additional length allows the anaesthesia breathing system to be connected further from the surgical field and the reduced diameter allows more room in the mouth. It is preferable for intra-oral surgery especially adenotonsillectomy. The cuff and inflation line are identical to the Classic LMA. It is available in six sizes 2, 2.5, 3, 4, 5 and 6. II. The intubating LMA - Fastrach2,5,8 Since the Classic LMA was not ideally suited to aid (blind) tracheal intubation, the primary design goal for a new intubating LMA was to produce an intubating system that eliminated the need for anatomical distortion and that did not require manipulation of the head and neck, and thus increased its utility in patients Fig. 3 : Intubating LMA with cervical spine pathology. It was released in 1997. It consists of three parts – the ILMA itself, the tracheal tube and a stabilizing rod. The ILMA is a rigid, anatomically curved airway tube made of stainless steel with a standard 15 mm connector. The tube is wide enough to accommodate an 8.0 ETT and short enough to ensure passage of the ETT beyond the vocal cords. A rigid handle attached to the tube facilitates one handed in sertion, removal, and most importantly, adjustment of the device’s position so that the aperture directly opposes the larynx. It has a single flap, the epiglottic elevating bar. It is available in three sizes (3,4,5) that correspond to the cuff size of the original LMA. After adequate lubrication insertion of the ILMA may be easier than the original LMA because the rigid tube follows the anatomic curve of the palate and posterior pharyngeal wall and one’s index finger does not have to enter the mouth. Once positioned correctly, the ILMA can be connected to a circuit and used as an airway device. There are several maneuvers

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to facilitate ILMA guided intubation, of which the seal optimization (Chandi’s maneuver) consists of two sequential steps: obtaining the best seal by moving the cuff in the pharynx in the sagittal plane, and then using the handle to slightly lift (and not tilt) the ILMA away from the posterior pharyngeal wall. It is recommended strongly that the special supplied ETT be used for intubation. This sili-cone tube is soft tipped, straight, wire reinforced and cuffed. It exits the ILMA at an angle that facilitates passage through the glottis. Tracheal tubes available are 7.0, 7.5 and 8 mm internal diameter and each fits through each of the three ILMA. To remove the ILMA once the trachea is intubated, one should remove the 15-mm ETT connector while the ETT cuff remains inflated. Then swing the ILMA out of the pharynx and mouth while applying counter-pressure to the ETT. To hold the ETT tube in place, the stabilizing rod (20 cm) is opposed to its proximal end, which effectively increases the length of the ETT and permits sliding of the ILMA out of the mouth.

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thicker. It is supplied sterile and for single use only. It is currently available in sizes similar to the Classic LMA.9 IV. ProSeal Laryngeal mask airway (LMA ProSeal)4,5,8,9,13 The ProSeal LMA is the most complex of the specialized laryngeal mask devices. It was designed by Archie Brain in the late 1990s and released in 2000. The primary design goal was to construct a laryngeal mask with improved ventilatory characteristics that also offered protection against regurgitation and gastric insufflation. The principal new features are a modified cuff and a drain tube. The ProSeal LMA is a double mask, forming two end-toend junctions: one with the respiratory tract and the other with the gastrointestinal tract.

LMA C Trach 12 LMA C Trach is a modification on the “blind on blind” technique of the LMA Fastrach with integrated fibreoptics. It provides a direct view of the larynx with real Fig. 4 : LMA C Trach time visualization of the tracheal tube passing through the vocal cords. It has two integrated fiberoptic channels – a light guide to transfer light to illuminate the larynx and a 10,000 pixel image guide to transfer the image of the larynx to the viewer. There is a modified epiglottic elevating bar which optimises the light source and enables uninteruppted image transmission to the viewer. It is fully autoclavable unlike conventional endoscopes and is yet to be introduced in India. III. The disposable LMA (UNIQUE)8 (fig. 5) It was synthesized and released in 1998 for cardiopulmonary resuscitation because the silicone based Classic LMA was too expensive and needed proper sterilization to prevent cross infection for this rare indication. The disposable LMA is made of clear medical grade polyvinyl chloride. The Fig. 5 : Disposable LMA airway tube is more rigid and the cuff

Fig. 7 : ProSeal LMA

Concept and Design8,9,13 The ProSeal LMA is made from medical-grade silicone and is reusable. The mask and inflation lines are identical to the Classic LMA. The cuff has identical proportions but different dimensions among sizes. The larger ventral cuff is attached to a second cuff placed on the dorsal surface of the bowl. Mask design is also unique. The bowl is deeper and has no aperture bars and the inflatable portion extends around the back. When inflated, the mask is pushed anteriorly and the glottis becomes enveloped in the bowl, in contrast to the original design, in which the LMA and the glottis opposed each other and the aperture bars prevented the glottis from herniating into the bowl. There is a flexible wire reinforced airway tube, and because of their concern for gastric distention with positive pressure ventilation, ProSeal has an integral gastric access/venting port and a tube which traverses through the PLMA bowl. When properly positioned, the distal orifice of this drain tube lies in the upper esophagus. Sealed off from the glottis, the esophagus and stomach can be vented to air or a 14-F sump tube can be passed through the drain tube and gastric contents evacuated. There is a plastic supporting ring around the distal drain tube to prevent the drain tube collapsing when the cuff is inflated. A drain tube distal aperture that slopes anteriorly allows the deflated tip to form a fine leading edge for

SOOD : LMA VARIANTS

insertion. A rectangular depression in the proximal bowl functions as accessory ventilation channel tube. A built-in bite block helps to fuse the airway and drain tubes together, prevents airway obstruction and damage to the device during biting and provides information about depth of insertion. The introducer tool is a reusable clip-on/clip-off device that comprises a thin, curved, malleable, metal blade with a guiding handle. Its inner surface and curved tip are coated with a thin layer of transparent silicone to reduce the risk of trauma. The distal end fits into the locating strap, and the proximal end clips into the airway tube above the bite block, with the proximal drain tube resting to one side. The locating strap (insertion strap) keeps the proximal cuff in the midline, provides an insertion slot for the introducer tool and also prevents the finger slipping off the tube during insertion. It is currently available in six sizes: 1.5, 2, 2.5, 3, 4 and 5. Size selection is similar to the Classic LMA and can be either weight based (size 3 for adults and children, 30-50 kg; size 4 for normal adults, 50-70 kg; and size 5 for large adults, 70-100 kg) or gender based (size 4 for female patients; size 5 for male patients). Anatomy9,13 The anatomic position occupied by the ProSeal LMA is similar to but more extensive than the Classic LMA. It forms a seal with and provides a conduit to the respiratory and gastrointestinal tracts. The larger, conical shaped distal cuff fills the hypopharynx more completely, and the larger wedge shaped proximal cuff fills the proximal laryngopharynx more completely, both to form a better seal with their respective tracts. The dorsal cuff may press the ventral cuff more firmly into the periglottic tissues and the parallel, narrower tubing may allow the base of the tongue to cover the proximal cuff more effectively, enhancing its effectiveness as a plug in the proximal pharynx. The internal diameter of the ProSeal LMA airway tube is smaller than the Classic and Intubating LMA airway tubes, making it less suitable for passing instruments into the respiratory tract. Indications Indications are similar to the Classic LMA, but the ProSeal is preferable whenever a better seal, better airway protection, and access to the gastrointestinal tract are required. It may be a better alternative for any elective surgery where Classic LMA is used with controlled ventilation and also for cardiopulmonary resuscitation.13,14 Contraindications Patients at risk of aspiration before induction of anaesthesia.8,13

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Insertion The principles of ProSeal LMA insertion are similar to the Classic LMA. The semiflexible double tube is too floppy to push the cuff around the oropharyngeal inlet into the laryngopharynx but sufficiently stiff to push it into the hypopharynx once it has entered the laryngopharynx. The lack of a backplate makes the cuff more likely to fold over. The bulkier deflated cuff reduces the space in the mouth for digital manipulation and makes epiglottic downfolding more likely.8,13 Insertion techniques There are three primary insertion techniques for the ProSeal LMA: 1) digital insertion, which is similar to the Classic LMA, but a lateral approach is required more frequently; 2) introducer-guided insertion, which allows the ProSeal to be inserted like the intubating LMA, but the head and neck are in the “sniffing” rather than the neutral position; and 3) gum elastic bougie guided insertion, which guides the ProSeal around the oropharyngeal inlet and into the hypopharynx.8,9,13 Cuff inflation and fixation The cuff volume required to form an effective seal with the respiratory tract is lower for the ProSeal than the Classic LMA. The cuff should be inflated with at least 25% of the maximum recommended volume to ensure an effective seal with the gastrointestinal tract for prevention of aspiration and gastric insufflation. A properly placed PLMA can withstand peak inflation pressure of approximately 35 cms H2O without leak as compared to 25 cms H2O offered by the LMA Classic.8,13 Signs of correct ProSeal placement8,13 a. Correct position of bite block b. Chest expansion and capnograph c. Seal pressure > 20 cms H2O d. Gel displacement test - a blob (1ml) of water soluble lubricant jelly is placed over the proximal opening of the proSeal drain tube. Ejection of the gel from the drain tube on gentle inflation of the bag indicates presence of leak. e. Gastric tube placement f. Fibreoptic examination Malposition is easily recognised and corrected. Common malpositions are distal cuff in the laryngopharynx, glottic inlet or folded over, glottic compression or epiglottic downfolding (incidence 5 to 15%).8,13 Emergence technique Suction and remove the gastric tube, and reverse any neuromuscular blockade before beginning emergence.

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Like the Classic LMA, remove when the patient obeys commands.8,13 Physiology The upper esophageal sphincter function is relatively unimpaired. The drain tube provides easy access to the gastrointestinal tract for monitoring of cardiac output, gastric volume / pH and core temperature. Cardiovascular responses and peak airway pressures are similar to the Classic LMA and are unaffected by cuff volume or tidal volume.8,13 Caution • The ferromagnetic material present in LMAs can reduce image quality and even cause heating and movement when used in MRI.8 •

N2O rapidly diffuses into the air filled cuff, causing a doubling of intra cuff pressure within 1-2 hours.8

Sterilization The LMAs and their accessories are supplied unsterile, and must be cleaned by hand washing or automatic washers and autoclaved at 135°C for 3-4 minutes (pre-vacuum and wrapped). The cuff should be fully deflated and dry before autoclaving. ProSeal requires more attention. A small pipe cleaner should be used to clean the drain tube and deflation of the ProSeal cuff requires the deflation tool since residual air can accumulate in the dorsal cuff.7,8 Conclusion Classic LMA along with its variants, flexible LMA, ILMA, disposable LMA and ProSeal are now indispensable in the armamentarium of airway management devices.

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References 1.

Brimacombe JR., Berry AM. The Laryngeal Mask Airway. In: The Difficult Airway I. Anesthesiol Clin N Am June 1995; 13(2): 411-37.

2.

Rasanen J. The laryngeal mask airway – First class on Difficult Airways. Finnanest 2000; 33(3): 302-05.

3.

Pollard BJ, Norton ML. Principles of Airway Management, In: Wylie and Churchill – Davidson’s (ed), A Practice of Anesthesia (7th Edn), 2003; 28: 445-46.

4.

Rosenblatt WH. Airway Management. In: Barash PG, Cullen BF, Stoelting RK. (eds) Clinical Anesthesia (4th Edn) 2001; 23: 599-605.

5.

Bogetz MS. Using the laryngeal mask airway to manage the difficult airway. In: The Upper Airway and Anesthesia. Anesthesiol Clin N Am Dec. 2002; 20(4): 863-70.

6.

Verghese C, Brimacombe JR. Survey of laryngeal mask airway Usage in 11, 910 patients: Safety and efficacy for conventional and nonconventional usage. Anesth Analg 1996; 82: 129-33.

7.

Dorsch JA, Dorsch SE. (eds). Laryngeal Mask Airways. In Understanding Anesthesia Equipment (4thEdn), Williams and Wilkins 1999; 15: 463-504.

8.

Brimacombe JR. In: Laryngeal Mask Anesthesia - Principles and Practice (2nd Edn), Saunders, Philadelphia 2005.

9.

Khan RM(ed). Supraglottic airway devices. In: Airway Management – Made Easy. A manual for Clinical Practitioners and Examinees. Paras Medical Publishers, Hyderabad, 2005; 12: 82-95.

10. Ovassapian A, Meyer RM. Airway Management. In: Longnecker DE, Tinker JH (eds) Principles and Practice of Anesthesiology (2nd Edn), Mosby : Philadelphia, 1998; 49: 1076-78. 11. McNicol LR. Insertion of the laryngeal mask airway in children. Anaesthesia 1991; 46: 330. 12. http://www.LMACO.com. Instruction manual for LMA. 13. Brimacombe J, Keller C. The ProSeal laryngeal mask airway. In: The Upper Airway and Anesthesia. Anesthesiol Clin N Am Dec. 2002; 20: 871-91. 14. Sharma B, Sahai C, Bhattacharya A, Kumra VP. Our experience with ProSeal Laryngeal Mask Airway : A study of 200 consecutive patients. J Anaesth Clin Pharmacol 2004; 20(1): 51-57.

CONFERENCE CALENDER 2005 - 2006 1) 11th Annual Conference of Railway Forum of ISA 3rd - 4th September 2005 Contact : Dr. R. A. Phadnis Organizing Secretary and Sr. DMO (Anaesth) Central Railway Hospital, Opp. Rani Bagh, Byculla, Mumbai – 400027 (MS) Tel : 022-23717246 Ext.–444. 57575 Ext.–252-323-344 Mobile : 09821638621, E-mail : [email protected] 2) 35 th Annual Conference Orissa State & 15 th Eastern Zonal Conference of ISA and WFSA-ISA CME-2005 ISAJAC-2005 10th - 11th September 2005 Contact : Dr. Nibedita Pani, Org. Secretary Dept. of Anaesthesiology, M.K.C.G. Medical College, Berhampur -760004, Orissa, Mobile: 9437004747 Email : [email protected] 3) 3 rd WISACON 2005 and 10 th Raj ISACon - 2005 1st - 2nd October 2005 Contact : Dr. Meenakshi Sharma, Org. Secretary 13, Goverdhan Colony, New Sanganer Road, Jaipur. Tel : 0141-2290295, Mobile : 9828014135 E-mail : [email protected]

4) 27 th Annual Conference U. P. State Chapter, ISA,UPCONISA-2005 1st – 2nd October 2005 Contact : Dr.Prof. Jaishri Bogra, Org. Secretary Dept. of Anaesthesia, King George’s Medical University, Lucknow-3 Tel : 0522-2325323 (R), Mobile : 9839075895 E-mail : [email protected] 5 ) XV Annual State Anaesthesia Conference (AP) I.S.A.-APCON-2005 8th – 10th October 2005 Contact : Dr. D. Prasada Raju, Org. Secretary K.I.M.S., Amalapuram, E.G.D.T. (AP) - 533201 Phone : 08856-237998, Mobile : 9440148174 6) 38th Gujarat State Annual Conference of ISA GISACON – 2005 15th – 16th October 2005 Contact : Dr. Chetan Shah, Org. Secretary Inmed Equipments Pvt. Ltd. 5, Firdosh Apartment, Opp. Petrol pump, Fatehgunj main road, Fatehgunj, Vadodara – 02 Ph : 0265-2788833, 3096451, Mobile:- 098251 57999 E-mail : [email protected],

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