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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Effect of Dexmedetomidine versus Propofol on Sevoflurane related Emergence Agitation in Paediatric Patients: A Randomised Clinical Study
Correspondence Address :
Dr. Rekha Krishnankutty,
Professor, Department of Anaesthesiology, Government Medical College, Kozhikode-673008, Kerala, India.
E-mail: drrekhakrish@gmail.com
Introduction: Postoperative Emergence Agitation (EA) is a troublesome side-effect of sevoflurane anaesthesia. Drugs like dexmedetomidine and propofol offer significant benefits in reducing the incidence and severity of sevoflurane-related postoperative EA in paediatric patients.
Aim: To compare the efficacy of intravenous dexmedetomidine and propofol in reducing the incidence and severity of EA associated with sevoflurane anaesthesia in paediatric patients.
Materials and Methods: A randomised clinical study was conducted on 140 patients, belonging to American Society of Anaesthesiologists Physical Status (ASA PS) classes I and II, aged between 2-6 years, undergoing infraumbilical surgery lasting more than one hour. The patients were divided into two equal groups receiving dexmedetomidine 0.3 μg/kg (Group SD) and propofol 1 mg/kg (Group SP) at the start of skin closure, administered over 10 minutes. The incidence of EA in the Post Anaesthesia Care Unit (PACU) was evaluated using the Watcha scale, and the severity of EA was assessed using the Paediatric Anaesthesia Emergence Delirium (PAED) scale. A Watcha score of 3 or 4 indicated the presence of EA, while a PAED score of ≥12 was deemed significant. Statistical analysis of the data was performed using International Business Machines (IBM) Statistical Package for Social Sciences (SPSS) version 22.0, with an Independent sample t-test for comparing normally distributed quantitative parameters, and the Chi-square test for comparing categorical outcomes between the study groups.
Results: The mean age of the patients in group SD was 4.19±0.78 years, and in group SP was 4.03±0.71 years. Both study groups were found to be comparable in terms of patient characteristics such as age, sex, weight, and duration of surgery (p-value >0.05). The incidence of postoperative EA, as measured by the Watcha scale, was higher in group SP compared to group SD upon arrival and up to 30 minutes in the PACU (p-value <0.001). The severity of EA, assessed using the PAED score, was greater in group SP compared to group SD at 0, 5, 10,15 and 20 minutes in the PACU (p-value <0.001).
Conclusion: Dexmedetomidine 0.3 μg/kg was more effective than propofol 1 mg/kg in reducing the incidence and severity of EA associated with sevoflurane anaesthesia, with minimal haemodynamic effects and no clinically relevant severe adverse effects in both the groups. The significantly prolonged extubation times observed in the propofol group did not result in significantly longer stays in the PACU.
Children, Delirium, Extubation, Restlessness, Sedative hypnotic
Postoperative EA is a common phenomenon in children undergoing sevoflurane anaesthesia (1),(2),(3). EA is characterised by agitation, restlessness, persistent crying, confusion, delusions, hallucinations, and cognitive shifts, including memory loss. The incidence ranges from 10-67% (4). Many possible aetiologies have been proposed, including rapid awakening in unfamiliar settings, pain, noisy environment, stress during induction, hypoxemia, the child’s personality, and the duration and type of anaesthesia (4),(5),(6),(7). There are numerous pharmacological and non pharmacological therapies available for treating postoperative EA (8),(9),(10). Sevoflurane is a commonly used inhalational anaesthetic agent in the paediatric population due to its non pungency, smooth and rapid induction properties. Its low blood gas partition coefficient ensures prompt induction and recovery following sevoflurane discontinuation. Sevoflurane also induces bronchodilation and causes the least airway irritation among currently available volatile anaesthetics. Postoperative EA is a troublesome side-effect of sevoflurane anaesthesia. Various drugs have been utilised to facilitate smooth emergence from sevoflurane anaesthesia, such as dexmedetomidine, propofol, midazolam, clonidine, ketorolac, and fentanyl (8),(9),(10). While there have been numerous studies on the use of propofol or dexmedetomidine to reduce sevoflurane-related EA, there are only a few studies comparing these two drugs in the published literature (11),(12).
Dexmedetomidine is a selective α-2 agonist with 1600 times more affinity to α-2 than α-1. It possesses sedative, anxiolytic, and analgesic properties due to its central sympatholytic effects, making it suitable for use in intensive care and operating room settings (13),(14). It has been proven that dexmedetomidine reduces EA following sevoflurane anaesthesia in paediatric surgery and non surgical procedures (15). Propofol is an intravenous anaesthetic agent administered as a 1% solution. It is believed to exert its sedative-hypnotic effects through γ-Aminobutyric acid type A (GABA A) receptor interaction. The quick recovery without residual sedation and low incidence of nausea and vomiting make propofol suitable for ambulatory conscious sedation techniques. Propofol also reduces postoperative sevoflurane-related EA (16),(17).
Authors hypothesised that dexmedetomidine was more effective than propofol in reducing sevoflurane-related EA in children. The aim of this study was to compare the efficacy of intravenous dexmedetomidine and propofol in reducing the incidence and severity of EA in paediatric patients undergoing sevoflurane anaesthesia.
This randomised clinical study was conducted at Government Medical College, Kozhikode, Kerala, India from January 2018 to December 2019 after obtaining institutional review and ethical committee approval (Ref No. GMCKKD/RP2017/IEC/236), clinical trial registration (CTRI/2018/09/015838), and written informed consent from parents of children belonging to both genders undergoing urological surgeries or other infraumbilical surgeries.
Inclusion criteria: One hundred and forty-eight children aged between 2 to 6 years, scheduled for elective urological surgery and infraumbilical surgeries lasting for more than one hour, belonging to ASA PS I-II, and weighing between 10 to 25 kg, were included in the study.
Exclusion criteria: Children with developmental delay, spinal anomaly or neurological disease, psychiatric illness, cardiac disease, difficult airway, and those with a known allergy to the study drug. Based on these criteria, eight children were excluded from the study (Table/Fig 1).
Sample size: The sample size was calculated based on the incidence of EA from the randomised study by Ali MA and Abdellatif AA (11). With an alpha error set at 0.05 and 90% power, it was estimated that 70 patients were required per group to achieve statistical significance (p-value <0.05).
After selection, the patients were randomised into two equal groups of 70 each using a random number table. Group SD included patients who received dexmedetomidine 0.3 μg/kg, and Group SP received propofol 1 mg/kg (11). All patients underwent a detailed preanaesthetic check-up, including history, physical examination, and laboratory investigations. All children were kept nil per oral before surgery (8 hours for solid food, 6 hours for semisolid food, 2 hours for clear fluids). On the day of surgery, children were brought to the premedication room, and baseline HR, blood pressure, SpO2, and respiratory rate were recorded. Subsequently, they received oral midazolam 0.5 mg/kg approximately half an hour before separation from parents.
In the operating room, after attaching all standard ASA non invasive monitors, which included an electrocardiogram, pulse oximeter, and non invasive blood pressure monitor, anaesthesia was induced with 8% sevoflurane and 66% nitrous oxide in oxygen via a face mask. Following the establishment of intravenous access under adequate anaesthetic depth, atracurium 0.5 mg/kg was administered intravenously, and oral endotracheal intubation was performed. Heart rate, blood pressure, end-tidal carbon dioxide, and oxygen saturation using a pulse oximeter were monitored throughout the procedure. Anaesthesia was maintained with 1.5% to 2% sevoflurane in 66% nitrous oxide in oxygen throughout the operation. Atropine 0.02 mg/kg was given during the procedure if the heart rate decreased to more than 30% of baseline values. For intraoperative and postoperative pain relief, all children received intravenous paracetamol 15 mg/kg, and a caudal epidural block with 0.25% bupivacaine was performed immediately after intubation. At the start of skin closure, group SD received dexmedetomidine 0.3 μg/kg diluted in 10 mL of normal saline, while group SP received 1 mg/kg of propofol intravenously over 10 minutes using a syringe pump. Sevoflurane, dexmedetomidine, and propofol were discontinued upon completion of skin closure. With the onset of spontaneous ventilation, residual muscle relaxation was reversed with Neostigmine 0.05 mg/kg and atropine 0.02 mg/kg intravenously. Extubation was performed after restoration of the child’s gag reflex, regular respiration, and adequate muscle tone, and the children were transferred to PACU. The incidence and severity of EA were assessed using the Watcha scale, PAED score at various follow-up intervals, and the time of extubation were considered as primary outcome variables, while haemodynamic parameters such as Heart Rate (HR), Mean Blood Pressure (MAP), and the occurrence of various adverse effects were considered as secondary outcome variables [18-20].
HR, peripheral capillary oxygen saturation (SpO2), and blood pressure were recorded after induction, at the start of the operation, just before loading of study drugs, after the end of the operation, and in the PACU. Since EA is more common within 30 minutes of PACU arrival, the incidence and severity of EA were measured upon arrival (T0) and then every five minutes (T5, T10, T15, T20, T25, T30) for up to 30 minutes in the PACU. This assessment was conducted by an anaesthesiologist who was blinded to the study intervention used. Watcha scores and PAED scores were employed as primary outcome measures for comparing the incidence and severity of EA, respectively. A score of 3 or 4 on the Watcha scale was considered indicative of EA (19). The severity of EA was determined using the PAED scale (20), where a score of ≥12 was considered significant. Children were classified as severely agitated if their PAED score was 15/20 or higher, and these severely agitated children were administered 0.5 mg/kg fentanyl intravenously (11). Children were discharged to the ward when the modified Aldrete score was above 9.
Statistical Analysis
All the raw data were entered into a Microsoft Excel spreadsheet, and the statistical analysis of the data was performed using IBM SPSS version 22.0 The study group (Group SP vs. Group SD) was regarded as the primary explanatory variable, with age and gender serving as other explanatory variables. For normally distributed quantitative parameters, mean values were compared between study groups using an unpaired t-test. Categorical outcomes were compared between study groups using the Chi-square test. Data are presented as mean±standard deviation, median (Interquartile Range), or as the number of patients and percentages. A p-value of <0.05 was considered statistically significant.
Both study groups were found to be comparable in terms of patient characteristics, including age, sex, weight, and duration of surgery (Table/Fig 2). The incidence of EA was higher in group SP compared to group SD (p-value <0.001) (Table/Fig 3). The severity of EA, as indicated by the PAED score, was significantly higher in group SP compared to group SD, except at 25 minutes and 30 minutes in the PACU (p-value >0.05) (Table/Fig 4). The time of extubation between the two groups was statistically significant, with group SD exhibiting shorter extubation times (p-value <0.001) (Table/Fig 5).
Group SD demonstrated lower heart rates at various follow-up intervals compared to group SP, a difference that was statistically significant (p-value <0.001) (Table/Fig 6). The MAP was comparable upon arrival in the PACU and after 30 minutes between group SD and group SP (p-value >0.05) (Table/Fig 7). The few episodes of bradycardia and hypotension recorded in both groups were not clinically relevant and resolved without treatment (Table/Fig 8). Respiratory rates and SpO2 recorded at various time intervals were found to be comparable, except at 20 minutes when group SP exhibited lower respiratory rates (p-value=0.03); however, this was not deemed clinically relevant (Table/Fig 9).
The EA is a common adverse effect of sevoflurane anaesthesia in children. Although it often resolves within 30 minutes, agitated children may inadvertently harm themselves by bumping into objects, pulling off tubes, drains, and wound dressings. This situation can be distressing for parents and caregivers. With multifactorial origins, numerous pharmacological and non pharmacological measures have been proposed to mitigate sevoflurane EA (3).
In the current study, the efficacy of dexmedetomidine and propofol was compaared in preventing EA associated with sevoflurane anaesthesia in the paediatric population. Present study analysed the incidence and severity of EA, extubation time, haemodynamic changes, and side-effects. Zhu M et al., evaluated the effect of dexmedetomidine in various doses and routes for sevoflurane-related EA, encompassing a total of 1,364 patients (696 in the dexmedetomidine group and 668 in the placebo, fentanyl, and midazolam group) from 20 prospective Randomised Controlled Trial (RCT) in their meta-analysis. They reported a reduced incidence of EA with prolonged extubation times (WMD 0.61, 95% CI, 0.27-0.95) compared to placebo, and a similar incidence of EA, comparable extubation times, and less nausea and vomiting compared to opioids. The results of the current study align with these findings (8). Another meta-analysis by Yang X et al., yielded similar results (21).
In the present study, the incidence and severity of EA were lower in the group that received dexmedetomidine compared to patients who received propofol. The difference in the incidence of EA in the initial 30 minutes in the PACU between the two groups was statistically significant (p-value <0.05), with the dexmedetomidine group exhibiting a lower incidence. group SD showed an increasing trend in the incidence of EA during the first 30 minutes in the PACU. This result in group SD contrasted with the study conducted by Ali MA and Abdellatif AA (11). This difference may be attributed to the fact that their study population included children undergoing adenotonsillectomy, a surgery known for a high propensity for EA. group SD showed the highest incidence of EA at 25 and 30 minutes (14.2%). group SP exhibited the highest incidence within the first 15 minutes in the PACU, with the peak incidence (62.8%) occurring at five minutes in the PACU. This result reported in group SP in present study was consistent with the findings of the study by Ali MA and Abdellatif AA (11). They observed that the incidence and severity of EA were high within the first 15 minutes in the control group, propofol group, and dexmedetomidine group in the PACU. The control group displayed a higher incidence of EA compared to the other two groups. The dexmedetomidine group exhibited the lowest incidence of EA compared to propofol, which aligns with our results.
The time of extubation between the two groups was statistically significant, with group SD having lower extubation times (p-value <0.001). The side-effects and duration of PACU stay between the two groups were comparable (p-values 0.595 and 0.382, respectively). These results were consistent with the study report by Ali MA and Abdellatif AA (p-value ≥0.05) (11). Wu et al., found lower extubation times (11.35±3.17) with propofol 2 mg/kg i.v. compared to saline placebo (21.41±4.62) (p-value <0.001) given towards the end of surgery. They correlated this positively with lower PAED scores in the propofol group (17).
Ibacache ME et al., compared dexmedetomidine in two doses (0.15 g/kg, 0.3 μ/kg) with saline placebo given i.v. soon after sevoflurane induction in infraumbilical surgeries. They reported a lower incidence of EA, along with stable haemodynamics with dexmedetomidine (15). Abu Shahwan I had similar results with propofol (1 mg/kg) given i.v. at the completion of an Magnetic Resonance Imaging (MRI) procedure in children under sevoflurane anaesthesia. There were no significant changes in heart rates or mean arterial pressure when compared to saline placebo (16).
The present study also found comparable results with the above-mentioned studies in terms of haemodynamic parameters. The HR and MAP showed lower values in the dexmedetomidine group, exhibiting a significant difference at various time intervals compared to the propofol group, but neither of these differences were clinically relevant to warrant treatment. In a study by Kim NY et al., on the effect of dexmedetomidine in sevoflurane-related EA, it was found that intraoperative infusion of dexmedetomidine (1 μg/kg followed by 0.1 μg/kg/hour) reduced sevoflurane requirements and EA without delaying discharge in children. In their study, the mean arterial blood pressure and heart rate were significantly lower in the dexmedetomidine group compared to the saline group (22). This difference may be attributed to the higher dose of dexmedetomidine administered. Costi D et al., in their Cochrane review, suggested combining effective interventions as a multimodal approach to further reduce the risk of EA (3).
Limitation(s)
Postoperative pain, which may be an independent correlate of EA, was not assessed in the present study.
Dexmedetomidine 0.3 μg/kg reduces the incidence and severity of EA more effectively than propofol 1 mg/kg when administered 10 minutes before the end of surgery in paediatric infraumbilical surgery under sevoflurane anaesthesia. Although the extubation time was significantly longer with propofol, it was not found to associate with significantly longer PACU stays. Lower MAP and HR were documented with dexmedetomidine, showing a significant difference between the groups. Both propofol and dexmedetomidine did not produce any clinically relevant changes in haemodynamic parameters or any adverse effects that warranted treatment. Thus, it can be concluded that the administration of dexmedetomidine is safe and more effective in reducing sevoflurane-related EA. Further research may explore alternate routes and doses or multimodal approaches to prevent EA.
DOI: 10.7860/JCDR/2024/68717.19374
Date of Submission: Nov 22, 2023
Date of Peer Review: Jan 11, 2024
Date of Acceptance: Mar 11, 2024
Date of Publishing: May 01, 2024
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
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