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SOOD : LMA VARIANTS 275Indian J. Anaesth. 2005; 49 (4) : 275 - 280

M.D., F.F.A.R.C.S.

Chairperson

Dept. of Anaesthesiology, Pain and Perioperative Medicine

Sir Ganga Ram Hospital, New Delhi, INDIA.

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

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

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.

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.

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.

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.

The mask inflation line, which is attached to the

most proximal portion of the cuff in the midline consists offour 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.

Table - 1 : Classic LMA Specifications 4

Mask size Patient weight (kg) 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 insequence 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

275

Fig. 1 : LMA - Classic

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INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005276 PG ISSUE : AIRWAY MANAGEMENT

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 fossaewith 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

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 techniquedoes not require the use of a laryngoscope or muscle

relaxants and is designed to imitate the mechanism whereby

the food bolus is swallowed.

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

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 alternativetechnique 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 patients 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

Before taping the LMA in place, a bite block is

inserted to stabilize the LMA and prevent tube occlusion.

Emergence technique

Removal of the LMA can be accomplished either

during deep anesthesia or after protective reflexes have

returned. 4,7,8

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

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SOOD : LMA VARIANTS 277

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 theLMA 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 anairway 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 lengthof 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 manufactures 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

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

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 thusincreased its utility in patients

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 devices 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 ones

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

Fig. 3 : Intubating LMA

Fig. 2 : Flexible LMA

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INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005278 PG ISSUE : AIRWAY MANAGEMENT

to facilitate ILMA guided intubation, of which the seal

optimization (Chandis 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 toslightly 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 thepharynx 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.

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

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

airway tube is more rigid and the cuff

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-to-

end junctions: one with the respiratory tract and the other

with the gastrointestinal tract.

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 identicalproportions 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

Fig. 4 : LMA C Trach

Fig. 5 : Disposable LMA

Fig. 7 : ProSeal LMA

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SOOD : LMA VARIANTS 279

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 duringbiting 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 theintroducer 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 respiratoryand 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

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 intothe 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 theProSeal 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 H

2O

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 indicatespresence 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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INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005280 PG ISSUE : AIRWAY MANAGEMENT

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 135C 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.

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 Davidsons (ed), A Practice of Anesthesia (7 th Edn),

2003; 28: 445-46.

4. Rosenbla tt 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 (2 nd 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 withProSeal 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)

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2) 35th Annual Conference Orissa State & 15 th Eastern

Zonal Conference of ISA and WFSA-ISA CME-2005

ISAJAC-2005

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Contact : Dr. Nibedita Pani, Org. Secretary

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Email : drnp@rediffmail.com

3) 3rd WISACON 2005 and 10 th Raj ISACon - 2005

1st - 2ndOctober 2005

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4) 27th Annual Conference U. P. State Chapter,

ISA,UPCONISA-2005

1st 2nd October 2005

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Tel : 0522-2325323 (R), Mobile : 9839075895

E-mail : kgmuisaupo5@rediffmail.com

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

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