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

M.D., F.F.A.R.C.S.ChairpersonDept. of Anaesthesiology, Pain and Perioperative MedicineSir Ganga Ram Hospital, New Delhi, INDIA.

LARYNGEAL MASK AIRWAY AND ITS VARIANTSDr. Jayashree Sood

IntroductionAirway management is one of the most important

skills in the field of anaesthesiology, and inability to securethe airway can lead to catastrophic results. Before 1990,only the face mask and the endotracheal tube (ETT) werethe available airway devices. Since then several supraglotticairway devices have been developed, of which the laryngealmask airway (LMA) is the most popular one.1,2

Laryngeal Mask Airway - ClassicThe LMA was conceived

and designed by Dr. Archie Brainin U.K. in 1981. Followingprolonged research, it was releasedin1988.1 At an early stage in itsdevelopment, the inventor realizedits potential in the management ofthe difficult airway. 1,3-6

Today, it has a clearlyestablished role as an airway

device in the elective setting where neither the procedurenor the patient requires tracheal intubation. It has nowbecome an established part of routine airway managementand has proved extremely useful in managing the difficultairway.

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 positionand degree of invasiveness. It is manufactured from medicalgrade silicone rubber and is reusable.

It consists of 3 main components (fig. 1) : An airwaytube, inflatable mask and mask inflation line. The airwaytube is slightly curved to match the oropharyngealanatomy, semirigid to facilitate atraumatic insertion andsemitransparent, so that condensation and regurgitatedmaterial is visible. A black line runs longitudinally alongits posterior curvature to aid in orientation. The distalaperture of the airway tube opens into the lumen of aninflatable mask and is protected by two flexible verticalrubber bars, called mask aperture bars (MAB), to preventthe epiglottis from entering and obstructing the airway.

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

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

The mask inflation line, which is attached to themost proximal portion of the cuff in the midline consists offour parts, the long narrow inflation line itself, the inflationindicator balloon (pilot balloon), a metallic valve and thesyringe port. The valve, which has a white coloured coreis made from polypropylene and has a stainless steel springvalve. The LMA is available in eight sizes (table 1), fromneonates to large adults, 1 to 6 and two half sizes 1.5 and2.5. The cuff, but not the tube, has identical proportionsamong sizes; it gets about 15% larger for each size.

Table - 1 : Classic LMA Specifications 4

Mask size Patient weight (kg) Maximum inflationvolume (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 theposterior pharyngeal wall.

The ideal final anatomic position occupied by theclassic LMA is as follows:

The distal cuff sits in the hypopharynx at the junctionof the upper oesophagus and respiratory tracts, where itforms a circumferential low pressure seal around the glottis.Superiorly, the upper part of the mask lies under the baseof the tongue, allowing the epiglottis to rest within the bowl

275

Fig. 1 : LMA - Classic

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of the mask at an angle probably determined by the extentto which passage of the mask has deflected it down-wards.When inflated, it lies with the tip resting against the upperesophageal sphincter, the sides facing the pyriform fossaewith the upper surface behind the base of the tongue and theepiglottis pointing upwards. The aperture of a properlypositioned LMA aligns itself anatomically with the laryngealinlet.

The tip of the LMA cuff lies at a variable depthbehind the cricoid cartilage; and the posterior surfaceimmediately anterior to the C2 to C7 cervical vertebrae.The laryngeal inlet can be tipped anteriorly by the inflatedLMA cuff when cricoid pressure is applied; this may explainwhy blind intubation via the LMA is more difficult withcricoid 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 ifthe problem is supraglottic in nature, since successfuluse of the LMA does not require the constellation offactors required for direct laryngoscopy andtracheal intubation.1,5,9 In 1996 it entered the AmericanSociety of Anesthesiologists’ difficult airwayalgorithm in five different places, both as a ventilatorydevice (airway) and a conduit for endotrachealintubation. 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 ofswallowing both in terms of the space it occupies and thetype of reflex response it elicits. The insertion techniquedoes not require the use of a laryngoscope or musclerelaxants and is designed to imitate the mechanism wherebythe food bolus is swallowed.

Preparation of the LMA and the patient is essentialfor successful placement. Lubrication of the mask shouldavoid the use of local anesthetics in order to preserveprotective reflexes against aspiration. A selection of LMAsizes should be available in addition to the one most likelyto fit because the anatomical features of the larynx cannotalways be predicted from the physical examination. Mostof the induction agents can be used to facilitate placement

of the LMA. The adequate depth of anaesthesia for LMAplacement is significantly less than that for trachealintubation.

Several insertion techniques have emerged tocomplement the original technique which was describedwhen the LMA was introduced. The standard techniqueinvolves a completely deflated LMA, held like a pen guidedinto the pharynx with the index finger of the operator at thejunction of the tube and the bowl, with the operator at thehead of the patient and the LMA aperture facing caudally.With the head extended and the neck flexed by using thehand under the occiput, under direct vision, the tip of thecuff is pressed upwards against the hard palate. The LMAis advanced into the hypopharynx till a resistance is felt.The cuff is then inflated with just enough air to seal, tointra cuff pressure around 60 cms H2O. A common alternativetechnique popular in children described by McNicol, consistsof inserting a partially inflated LMA into the pharynx abovethe epiglottis with the aperture facing cranially, the LMAis then turned 180 degrees before advancing it into its finalposition. 11

The LMA should then be secured after insertion insuch a way, so as to prevent rotation and movementcranially. If surgical access allows, a preferred way toconnect the LMA to the anaesthesia circuit is to direct thecircuit connection caudally and bring the circuit limbs downon the side of the patient’s neck and head.

Signs of correct LMA placement4,8,9

a. Slight outward movement of the tube upon LMAinflation.

b. Presence of a small oval swelling in the neck aroundthe 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 isinserted to stabilize the LMA and prevent tube occlusion.

Emergence techniqueRemoval of the LMA can be accomplished either

during deep anesthesia or after protective reflexes havereturned. 4,7,8

PathophysiologyPharyngeal microcirculation is unimpaired at low

to moderate cuff volumes for all LMA devices (exceptintubating LMA). The LMA is a relatively noninvasiveairway compared with a tracheal tube, and it causes minimaldisturbance of the cardiovascular and respiratory system.The incidence of sore throat is minimal because the cords

SOOD : LMA VARIANTS 277

are not penetrated. The haemodynamic stress response toLMA insertion is less pronounced than during trachealintubation during induction, maintenance and emergence fromanaesthesia. Less anaesthetic is required to tolerate theLMA once the device is insitu. 1,8

LMA and aspirationAlthough the correctly placed LMA tip lies against

the upper esophageal sphincter, the LMA does not isolatethe respiratory tract from the gastrointestinal tract anddoes not protect the lungs from regurgitated gastric contents.The glottic seal is usually lost at peak airway pressuresabove 20 cms H2O. 1,4 Incidence of aspiration with theLMA 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, thewidth and elasticity of the aperture bars, the angle at whichthe tube enters the bowl of the mask, anatomic alignmentof the LMA aperture with the glottis and the low pressureseal allowing synchronous patient ventilation.

However there are several problems associated withthis. The internal diameter of the airway tube is too smallto accommodate a normal sized tracheal tube, and it is toolong to ensure that a normal length tracheal tube willpenetrate the vocal cords. The mask aperture bars interferewith the passage of the tracheal tube. Removal of the LMAmay be difficult after successful intubation due to the lengthof the airway tube. Direct blind intubation has a successrate around 55%. Success is reduced by cricoid pressure,and is similar for normal and abnormal airways.

Fiberoptic guided intubation via the LMA has highersuccess rate and causes less trauma. It can be performeddirectly by inserting the tracheal tube over the fiberopticscope or indirectly using a guide first.

The manufacture’s warranty for LMA classsic is for40 uses, but deterioration in performance does not occuruntil 80-100 uses. Despite high capital costs, the LMA iscost effective compared to tracheal tube.8

LMA variantsAt present, variations include a reinforced/ flexible

LMA (LMA-Flexible), LMA specifically designed fortracheal 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. Theflexible LMA (fig. 2) was designed by Brain and released

in 1992 to prevent tube occlusion,improve surgical access and preventcuff displacement during head, neckand oropharyngeal surgery.4

It is made from medicalgrade silicone and rubber and isreusable. It consists of a ClassicLMA connected to a flexible, wirereinforced tube that is longer and

narrower than the Classic LMA. The wire reinforcementprevents kinking, the additional length allows the anaesthesiabreathing system to be connected further from the surgicalfield and the reduced diameter allows more room in themouth. It is preferable for intra-oral surgery especiallyadenotonsillectomy.

The cuff and inflation line are identical to the ClassicLMA. It is available in six sizes 2, 2.5, 3, 4, 5 and 6.

II. The intubating LMA - Fastrach2,5,8

Since the Classic LMAwas not ideally suited to aid (blind)tracheal intubation, the primarydesign goal for a new intubatingLMA was to produce an intubatingsystem that eliminated the needfor anatomical distortion and thatdid not require manipulation ofthe head and neck, and thusincreased its utility in patientswith cervical spine pathology. Itwas released in 1997.

It consists of three parts – the ILMA itself, thetracheal tube and a stabilizing rod.

The ILMA is a rigid, anatomically curved airwaytube made of stainless steel with a standard 15 mmconnector. The tube is wide enough to accommodate an 8.0ETT and short enough to ensure passage of the ETT beyondthe vocal cords. A rigid handle attached to the tube facilitatesone handed in sertion, removal, and most importantly,adjustment of the device’s position so that the aperturedirectly opposes the larynx. It has a single flap, the epiglotticelevating bar.

It is available in three sizes (3,4,5) that correspondto the cuff size of the original LMA. After adequatelubrication insertion of the ILMA may be easier than theoriginal LMA because the rigid tube follows the anatomiccurve of the palate and posterior pharyngeal wall and one’sindex finger does not have to enter the mouth. Oncepositioned correctly, the ILMA can be connected to a circuitand used as an airway device. There are several maneuvers

Fig. 3 : Intubating LMA

Fig. 2 : Flexible LMA

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

to facilitate ILMA guided intubation, of which the sealoptimization (Chandi’s maneuver) consists of two sequentialsteps: obtaining the best seal by moving the cuff in thepharynx in the sagittal plane, and then using the handle toslightly lift (and not tilt) the ILMA away from the posteriorpharyngeal wall.

It is recommended strongly that the special suppliedETT be used for intubation. This sili-cone tube is softtipped, straight, wire reinforced and cuffed. It exits theILMA at an angle that facilitates passage through the glottis.Tracheal tubes available are 7.0, 7.5 and 8 mm internaldiameter 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 theETT cuff remains inflated. Then swing the ILMA out of thepharynx and mouth while applying counter-pressure to theETT. To hold the ETT tube in place, the stabilizing rod (20cm) is opposed to its proximal end, which effectivelyincreases the length of the ETT and permits sliding of theILMA out of the mouth.

LMA C Trach 12

LMA C Trach is amodification on the “blindon blind” technique of theLMA Fastrach withintegrated fibreoptics.

It provides a directview of the larynx with realtime visualization of the

tracheal tube passing through the vocal cords. It has twointegrated fiberoptic channels – a light guide to transferlight to illuminate the larynx and a 10,000 pixel imageguide to transfer the image of the larynx to the viewer.

There is a modified epiglottic elevating bar whichoptimises the light source and enables uninteruppted imagetransmission to the viewer.

It is fully autoclavable unlike conventional endoscopesand is yet to be introduced in India.

III. The disposable LMA (UNIQUE)8 (fig. 5)It was synthesized and released

in 1998 for cardiopulmonaryresuscitation because the silicone basedClassic LMA was too expensive andneeded proper sterilization to preventcross infection for this rare indication.The disposable LMA is made of clearmedical grade polyvinyl chloride. Theairway tube is more rigid and the cuff

thicker. It is supplied sterile and for single use only. It iscurrently 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 thespecialized laryngeal mask devices. It was designed byArchie Brain in the late 1990s and released in 2000. Theprimary design goal was to construct a laryngeal mask withimproved ventilatory characteristics that also offeredprotection against regurgitation and gastric insufflation. Theprincipal 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 otherwith the gastrointestinal tract.

Concept and Design8,9,13

The ProSeal LMA is made from medical-gradesilicone and is reusable. The mask and inflation lines areidentical to the Classic LMA. The cuff has identicalproportions but different dimensions among sizes. The largerventral cuff is attached to a second cuff placed on thedorsal surface of the bowl.

Mask design is also unique. The bowl is deeper andhas no aperture bars and the inflatable portion extendsaround the back. When inflated, the mask is pushedanteriorly and the glottis becomes enveloped in the bowl,in contrast to the original design, in which the LMA andthe glottis opposed each other and the aperture bars preventedthe glottis from herniating into the bowl. There is a flexiblewire reinforced airway tube, and because of their concernfor gastric distention with positive pressure ventilation,ProSeal has an integral gastric access/venting port and atube which traverses through the PLMA bowl. When properlypositioned, the distal orifice of this drain tube lies in theupper esophagus. Sealed off from the glottis, the esophagusand stomach can be vented to air or a 14-F sump tube canbe passed through the drain tube and gastric contentsevacuated. There is a plastic supporting ring around thedistal drain tube to prevent the drain tube collapsing whenthe cuff is inflated.

A drain tube distal aperture that slopes anteriorlyallows the deflated tip to form a fine leading edge for

Fig. 4 : LMA C Trach

Fig. 5 : Disposable LMA

Fig. 7 : ProSeal LMA

SOOD : LMA VARIANTS 279

insertion. A rectangular depression in the proximal bowlfunctions as accessory ventilation channel tube. A built-inbite 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-offdevice that comprises a thin, curved, malleable, metal bladewith a guiding handle. Its inner surface and curved tip arecoated with a thin layer of transparent silicone to reducethe risk of trauma. The distal end fits into the locatingstrap, and the proximal end clips into the airway tubeabove the bite block, with the proximal drain tube restingto one side.

The locating strap (insertion strap) keeps the proximalcuff in the midline, provides an insertion slot for theintroducer tool and also prevents the finger slipping off thetube 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 andcan be either weight based (size 3 for adults and children,30-50 kg; size 4 for normal adults, 50-70 kg; and size 5 forlarge adults, 70-100 kg) or gender based (size 4 for femalepatients; size 5 for male patients).

Anatomy9,13

The anatomic position occupied by the ProSeal LMAis similar to but more extensive than the Classic LMA. Itforms a seal with and provides a conduit to the respiratoryand gastrointestinal tracts. The larger, conical shaped distalcuff fills the hypopharynx more completely, and the largerwedge shaped proximal cuff fills the proximal laryngopharynxmore completely, both to form a better seal with theirrespective tracts. The dorsal cuff may press the ventralcuff more firmly into the periglottic tissues and the parallel,narrower tubing may allow the base of the tongue to coverthe proximal cuff more effectively, enhancing itseffectiveness as a plug in the proximal pharynx. The internaldiameter of the ProSeal LMA airway tube is smaller thanthe Classic and Intubating LMA airway tubes, making itless suitable for passing instruments into the respiratory tract.

IndicationsIndications are similar to the Classic LMA, but the

ProSeal is preferable whenever a better seal, better airwayprotection, and access to the gastrointestinal tract arerequired. It may be a better alternative for any electivesurgery where Classic LMA is used with controlledventilation and also for cardiopulmonary resuscitation.13,14

ContraindicationsPatients at risk of aspiration before induction of

anaesthesia.8,13

InsertionThe principles of ProSeal LMA insertion are similar

to the Classic LMA. The semiflexible double tube is toofloppy to push the cuff around the oropharyngeal inlet intothe laryngopharynx but sufficiently stiff to push it into thehypopharynx once it has entered the laryngopharynx. Thelack of a backplate makes the cuff more likely to fold over.The bulkier deflated cuff reduces the space in the mouth fordigital manipulation and makes epiglottic downfolding morelikely.8,13

Insertion techniquesThere are three primary insertion techniques for the

ProSeal LMA: 1) digital insertion, which is similar to theClassic LMA, but a lateral approach is required morefrequently; 2) introducer-guided insertion, which allows theProSeal to be inserted like the intubating LMA, but thehead and neck are in the “sniffing” rather than the neutralposition; and 3) gum elastic bougie guided insertion, whichguides the ProSeal around the oropharyngeal inlet and intothe hypopharynx.8,9,13

Cuff inflation and fixationThe cuff volume required to form an effective seal

with the respiratory tract is lower for the ProSeal than theClassic LMA. The cuff should be inflated with at least25% of the maximum recommended volume to ensure aneffective seal with the gastrointestinal tract for preventionof aspiration and gastric insufflation. A properly placedPLMA can withstand peak inflation pressure of approximately35 cms H2O without leak as compared to 25 cms H2Ooffered by the LMA Classic.8,13

Signs of correct ProSeal placement8,13

a. Correct position of bite blockb. Chest expansion and capnographc. Seal pressure > 20 cms H2Od. Gel displacement test - a blob (1ml) of water soluble

lubricant jelly is placed over the proximal opening ofthe proSeal drain tube. Ejection of the gel from thedrain tube on gentle inflation of the bag indicatespresence of leak.

e. Gastric tube placementf. Fibreoptic examinationMalposition is easily recognised and corrected. Commonmalpositions are distal cuff in the laryngopharynx, glotticinlet or folded over, glottic compression or epiglotticdownfolding (incidence 5 to 15%).8,13

Emergence techniqueSuction and remove the gastric tube, and reverse

any neuromuscular blockade before beginning emergence.

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

Like the Classic LMA, remove when the patient obeyscommands.8,13

PhysiologyThe upper esophageal sphincter function is relatively

unimpaired. The drain tube provides easy access to thegastrointestinal tract for monitoring of cardiac output, gastricvolume / pH and core temperature. Cardiovascular responsesand peak airway pressures are similar to the Classic LMAand 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 andmovement when used in MRI.8

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

SterilizationThe LMAs and their accessories are supplied

unsterile, and must be cleaned by hand washing or automaticwashers and autoclaved at 135°C for 3-4 minutes(pre-vacuum and wrapped). The cuff should be fullydeflated and dry before autoclaving. ProSeal requires moreattention. A small pipe cleaner should be used to clean thedrain tube and deflation of the ProSeal cuff requires thedeflation tool since residual air can accumulate in thedorsal cuff.7,8

ConclusionClassic LMA along with its variants, flexible LMA,

ILMA, disposable LMA and ProSeal are now indispensablein the armamentarium of airway management devices.

References1. 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 difficultairway. In: The Upper Airway and Anesthesia. Anesthesiol Clin N AmDec. 2002; 20(4): 863-70.

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

7. Dorsch JA, Dorsch SE. (eds). Laryngeal Mask Airways. In UnderstandingAnesthesia 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. ParasMedical 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 withProSeal Laryngeal Mask Airway : A study of 200 consecutive patients.J Anaesth Clin Pharmacol 2004; 20(1): 51-57.

CONFERENCE CALENDER 2005 - 20061) 11th Annual Conference of Railway Forum of ISA

3rd - 4th September 2005Contact : Dr. R. A. PhadnisOrganizing Secretary and Sr. DMO (Anaesth)Central Railway Hospital, Opp. Rani Bagh,Byculla, Mumbai – 400027 (MS)Tel : 022-23717246 Ext.–444. 57575 Ext.–252-323-344Mobile : 09821638621, E-mail : rajaphadnis29@hotmail.com

2) 35th Annual Conference Orissa State & 15th EasternZonal Conference of ISA and WFSA-ISA CME-2005ISAJAC-200510th - 11th September 2005Contact : Dr. Nibedita Pani, Org. SecretaryDept. of Anaesthesiology, M.K.C.G. Medical College,Berhampur -760004, Orissa, Mobile: 9437004747Email : drnp@rediffmail.com

3) 3rd WISACON 2005 and 10th Raj ISACon - 20051st - 2nd October 2005Contact : Dr. Meenakshi Sharma, Org. Secretary13, Goverdhan Colony, New Sanganer Road, Jaipur.Tel : 0141-2290295, Mobile : 9828014135E-mail : meenaxi999@hotmail.com

4) 27th Annual Conference U. P. State Chapter,ISA,UPCONISA-20051st – 2nd October 2005Contact : Dr.Prof. Jaishri Bogra, Org. SecretaryDept. of Anaesthesia, King George’s Medical University, Lucknow-3Tel : 0522-2325323 (R), Mobile : 9839075895E-mail : kgmuisaupo5@rediffmail.com

5) XV Annual State Anaesthesia Conference (AP)I.S.A.-APCON-20058th – 10th October 2005Contact : Dr. D. Prasada Raju, Org. SecretaryK.I.M.S., Amalapuram, E.G.D.T. (AP) - 533201Phone : 08856-237998, Mobile : 9440148174

6) 38th Gujarat State Annual Conference of ISAGISACON – 200515th – 16th October 2005Contact : Dr. Chetan Shah, Org. SecretaryInmed Equipments Pvt. Ltd. 5, Firdosh Apartment,Opp. Petrol pump, Fatehgunj main road, Fatehgunj, Vadodara – 02Ph : 0265-2788833, 3096451, Mobile:- 098251 57999E-mail : gisacon2005@inmedequipments.com,

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