Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


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

Important Notice

Original article / research
Year : 2010 | Month : December | Volume : 4 | Issue : 6 | Page : 3337 - 3343

A Comparative Study on the Effects of Adding Fentanyl and Buprenorphine to Local Anaesthetics In Brachial Plexus Block

DHRUBAJYOTI SARKAR*, GURJEET KHURANA**,AMIT CHAUDHARY***, J P SHARMA****

*Resident, Dept. of Anaesthesiology, Himalayan Institute of Medical Sciences, Jolly Grant, Dehradun, (U.K.), India; **Professor, Dept. of Anaesthesiology, Himalayan Institute of Medical Sciences, Jolly Grant, Dehradun, (U.K.), India; ***Assistant Professor, Dept. of Anaesthesiology, Himalayan Institute of Medical Sciences, Jolly Grant, Dehradun, (U.K.), India;; ****Professor and Head, Dept. of Anaesthesiology, Himalayan Institute of Medical Sciences, Jolly Grant, Dehradun, (U.K.), India

Correspondence Address :
Dr Gurjeet Khurana
Department of Anaesthesia
Himalayan Institute of Medical Sciences
Jolly Grant Dehradun
ph.- 9410539190
e-mail id.- khurana_gj@yahoo.co.in

Abstract

Objective: To evaluate the efficacy of fentanyl and buprenorphine in improving the blockade characteristics when used as an additives in supraclavicular block.
Study Design: Prospective, randomized, double blind trial conducted over a period of twelve months (July 09- June 10).
Material and Methods: A total 75 adult patients of either sex with ASA health status I-III, who were selected for elective upper limb surgery under supraclavicular brachial plexus block were randomly divided into three equal Groups A, B and C. Group A received a mixture of lignocaine (2%) with adrenaline (1:2,00,000) 10ml + bupivacaine (0.5%) 20 ml + distilled water 10 ml, to make a total volume of 40 ml. Group B received 1 ml (0.3 mg) buprenorphine and Group C received 1ml (50 µgm) fentanyl in addition to the above local anaesthetics in the same volumes and concentrations. The onset time of the sensory and motor blocks; the time required for complete sensory and motor blocks; the total duration of analgesia, the haemodynamic changes and side effects were noted and compared in both the groups.
Results: The onset time of the sensory and motor blocks was delayed in the fentanyl group (4.4 ± 1.41 min and 3.04 ± 1.31 min respectively), with no significant benefits on the duration of analgesia. In group C, buprenorphine, when added to local anaesthetics, prolonged the duration of analgesia by more than 1.5 times as compared to group A. Addition of fentanyl and buprinorphine to local anaesthetics in the brachial plexus block had no significant effects on the respiratory and haemodynamic parameters, except with minimal incidence (5.33%) of nausea and vomiting with the use of buprenorphine.
Conclusion: We conclude that the addition of buprenorphine to local anaesthetics provides long lasting analgesia without any significant increase in complications and recommend its incorporation in the routine anaesthesia practice.

Keywords

Peripheral nerve block (PNB), Supraclavicular brachial plexus block, fentanyl, buprenorphine

Introduction
It has been suggested since long, that peripheral nerves possess opioid receptors, and this has tempted clinicians to add narcotics to local anaesthetics to prolong the analgesic effects of these solutions. To date, the results of studies evaluating the efficacy of opioids and local anaesthetic combinations in the brachial plexus are inconclusive (1)(2)(3)(4). However, over the past 20 years, several studies have suggested that the addition of certain opiates to the local anaesthetics which are used for brachial block may provide effective, long-lasting postoperative analgesia (3),(4). Some studies have indicated that the agonist-antagonist, buprenorphine, when added to bupivacaine, provided a longer period of postoperative analgesia than the traditional opiates. This practice can be of particular benefit to patients undergoing ambulatory upper extremity surgery, by providing prolonged analgesia after discharge from the hospital. (5)(6)(7)(8)
This study was conducted to compare the effects of adding fentanyl and buprenorphine to local anaesthetics in the supraclavicular brachial plexus block (SBPB) by using nerve stimulators. The features of the blockade which were observed were the onset time of the sensory and motor blocks, the time of complete sensory and motor blocks and the duration of analgesia and motor blocks, along with any side effects or complications.

Material and Methods

The study was conducted in our institute in 75 patients who were undergoing elective upper limb surgery over a period of one year (July 2009- June 2010), with prior permission from the institute’s ethics committee. Patients aged18 years and above, of both sexes and with ASA physical status I to III, were enrolled for the study after taking their written informed consent. The exclusion criteria included patient refusal, infection at the proposed site of injection, history / findings of allergy to local anaesthetics, medical disorders like diabetic neuropathy, psychiatric illness, coagulopathy and bleeding disorders or any other contraindication to PNB.
The patients were randomly divided into 3 equal groups by drawing out any one of the three labelled cards (A, B and C) from a sealed opaque envelope. The anaesthetist performing the randomization and preparation of the drug solution was not involved in the process of performing blocks or in the evaluation and recording of the study parameters and thus, the study was double blinded. The composition of the drugs in the various groups included:

Group A: 10ml of lignocaine (2%) with adrenaline (1:2,00,000) + 20 ml of 0.5% bupivacaine diluted with 10 ml distilled water.

Group B: 10ml of lignocaine (2%) with adrenaline (1:2,00,000) + 20 ml of 0.5% bupivacaine + buprenorphine (0.3 mg) 1 ml diluted with 9 ml distilled water.

Group C: 10ml of lignocaine (2%) with adrenaline (1:2,00,000) + 20 ml of 0.5% bupivacaine + fentanyl 50µg 1 ml diluted with 9 ml distilled water.

Thus, the total volume of the drug solutions which were prepared in all the three groups was 40 ml, to ensure their blinding from the investigator who was performing the block.

On the day of surgery, the Visual Analogue Scale (VAS) was explained in detail to the patients, but not the process of Bromage evaluation.

In the operating room (OR), after achieving asepsis, the site of stimuplex needle insertion was identified and marked as per surface anatomical landmarks (Table/Fig 1) : Anaesthetist-2 performing the block procedure

The stimuplex needle was connected with the Nerve stimulator, with the current output set at 1.0 mA and repeat twitch mode selected by the assistant under the guidance of an anaesthetist. On needle insertion, a twitch of the upper trunk (shoulder) was considered as the evidence of the needle approaching the brachial plexus. Wrist flexion and extension of the fingers were taken as acceptable responses and the current was gradually reduced between 0.2 to 0.5 mA, whereby maintaining the visible twitches. As per the card of the randomization process, the total volume of the anaesthetic solution was injected at an incremental dose of 5ml each, preceded by negative aspiration in each group.

Following completion of the LA injection, the sensory block was evaluated by a Hollmen scale Score (1) = Normal sensation of pinprick; (2) = Weaker sensation of pin prick felt as compared with other upper limb; (3) = Pin prick recognized as touch with blunt object; (4) = No perception of pin prick. The findings were recorded at an interval of 2 min till a complete sensory block was achieved i.e Hollmen Score=4 (10).

The onset time of the sensory block (OTSB) was taken as the time interval in minutes from time-0 till the sensory block started appearing i.e Hollmen score > 1, while the time for the complete sensory block (TCSB) was taken from time-0 till the complete sensory block was achieved i.e Hollmen Score=4. The total duration of the Sensory Block (TDSB) was taken as the duration of the time in minutes between TCSB till the time when the Hollmen score reached <4 in the postoperative period.
The motor block was evaluated by using the Modified Bromage Scale (MBS) for the upper extremity and the finding was recorded from time-0 till the complete loss of the motor power was achieved i.e MBS Score=3(11). The onset time of the motor block (OTMB) i.e MBS score=1 and the time for complete motor block (TCMB) i.e MBS score=3 were also recorded in all cases.

The adequacy of the block was evaluated by asking the patients whether they felt any discomfort when pressure was applied with the Allis clamp at the area of the surgical field. The block was considered to have failed if complete sensory and motor block was not achieved after 30 min and the failed block was converted to GA and it was recorded. Intra-operative complications, if any, including vessel injury, haematoma, nausea and vomiting, dyspnea, fall in respiratory rate or oxygen saturation, any symptom/sign of LA toxicity, ECG changes, Horner’s syndrome, sedation, etc were recorded, with their respective management.

Postoperatively, on complaint of pain (i.e. VAS>4), systemic analgesics were supplemented as per the individual requirement and the total time of the sensory block was recorded. VAS scale consisted of a 10 cm line, where the patients were asked to mark the pain intensity on the line in between 0 (no pain) to 10 (worst possible pain).

Statistical analysis: The results were presented as Mean ± Standard Deviation (SD) for parametric data and as percentage for non-parametric data. The data were analyzed by using Microsoft Office Excel 2007 and SPSS version 14 software (Chicago ltd). The difference between the two groups was analysed by using the unpaired t-test and one way ANOVA and between the three groups by using the Kruskal-Wallis test. A P-value <0.05 was considered to be significant

Results

There was no significant difference in the demographic data or the duration of surgery in all the three groups.
(Table/Fig 2). Demographic data of all patients

The onset time of the sensory block (OTSB) and the onset time of the motor block (OTMB) were the earliest in Group A>B>C when compared among the groups (2.88>3.28>4.4 min respectively) (Table/Fig 3). Intergroup comparison showed a non-significant difference (P >0.05) between Groups A and B, a significant difference (P < 0.05) between Groups B and C and a highly significant (P <0.001) difference between Groups A and C. OTMB was earlier and significant (P <0.05) in Group A than in Groups B or C and non significant (P >0.05) between Group A vs. C and Group B vs. Group C. The time for the complete sensory block (TCSB) and the complete motor block (TCMB) were the earliest in Group A>B>C. TCSB, when compared between Groups A and B, showed a non-significant difference, but it was significantly delayed (P <0.001) in Group C as compared to Group A or B. The time for complete motor block (TCMB) was significantly less (P <0.05) when compared between Groups A and B and highly significant (P <0.001) between Group A vs. C and Group B vs. C (Table/Fig 3).

(Table/Fig 3): Time of onset and achievement of complete sensory and motor blockade in groups A, B & C.

*: Onset Time of Sensory Block (OTSB); +: Onset Time of Motor Block (OTMB); §: Time required for Complete Sensory Block (TCSB); €: Time required for Complete Motor Block (TCMB)

The total duration of the Sensory and motor blocks (TDSB and TDMB) and Analgesia (TDA) were all significantly prolonged in Group B as compared to the other groups (Table/Fig 4). TDSB and TDMB were statistically non significant (P >0.05) between Groups A and C.


(Table/Fig 4): Total Duration of Sensory & Motor Block (TDSB & TDMB) and Total Duration of Analgesia (TDA) in all the 3 groups.
*: Values expressed in Mean ± SD

Out of 75 patients, 5 (6.7%) patients had vessel injury, of which 1 (4%) was in Group-B and 2 (8%) were in Groups A and C (1 in each). They were managed by a little withdrawal and repositioning of the needle and antiseptic pressure dressing after completion of the block. Four (5.33%) cases, all from Group-B, complained of nausea and vomiting in the postoperative period and were managed with injection ondensetron 4 mg intravenously. No serious complication was observed in the perioperative period in any of the groups.

Discussion

We designed this prospective randomized double blind study to identify the outcome of adding fentanyl and buprenorphine to local anaesthetics in the brachial plexus block. We observed a 100% success rate in our study and none of our patients were supplemented with general anaesthesia. This is comparable to the study by Jeon DG et al, wherein they concluded that the elicitation of a twitch on the fingers was more effective in increasing the success rate (93.7% versus 75.0%) and reducing the onset time (14.4% ± 6.0 min versus 15.3 ± 6.7 min) than the elicitation of a proximal response (arm or elbow) (19). In Borgeat et al's study, the success rates were 97% when a distal response was elicited and 44% when a proximal response was observed in the infraclavicular block (20).
In our study, adjuvants to the local anaesthetics which were used were buprenorphine, which is a lipid soluble opioid agonist- antagonist and fentanyl, which is a pure agonist. The onset time of LA is greatly influenced by the relative amounts of the ionized and the non ionized forms of the drugs which are present in the solution.
In our study, the onset time of the sensory and the motor blocks was delayed in the fentanyl group, they being 4.4 ± 1.41 min and 3.04 ± 1.31 min, respectively. The time required for the complete sensory and the motor blocks were 11.44 ± 1.47 min and 14.16 ± 1.40 min, respectively. This does not correlate with the study done by Kardash K et al, who achieved the onset of the sensory and the motor blocks at 2.9 ± 1.9 min and 4.0 ± 3.1 min, respectively and the complete sensory and the motor blocks at 18.2 ± 7.5 min and 13.5 ± 7.3 min, respectively (21). As compared to the study done by Nishikawa K et al (22), who used100 gm of fentanyl in 40 ml of 1.5% lidocaine with 1:2,00,000 epinephrine in the brachial plexus block by the axillary approach, we found a similar delay in the time which was required for the complete sensory block. They concluded that the decrease in pH of lignocaine from 6.2 to 5.2 by the addition of 100 gm of fentanyl may have reduced the rate of nerve penetration of lidocaine, thus resulting in a slower onset of analgesia.
Jadon A .et al (10) examined the benefit of adding buprenorphine to 30 ml of 0.3% bupivacaine in the supraclavicular block. In their study, the onset time of the motor block (4.05 ± 0.94 min) was significantly faster than the onset of the sensory block (6.65 ± 1.18 min), which does not correlate with those found in our study. This can be explained by the “core and mantle concept” of Winnie (23). The earlier time to achieve the complete sensory and motor blocks in our study, as compared to theirs, can be attributed to the mixture of local anaesthetics which were used.
Sahu DK et al, in their study on supraclavicular brachial plexus block, used a mixture of 15 ml of 1.5% lignocaine and 15 ml of 0.325% bupivacaine and found that the average time for complete analgesia was 7.61 ± 2.82 min and that for motor loss was 11.70±2.50 min (24). Similarly, in our study, the time for the onset of complete sensory block was faster than that required for complete motor block in all the three groups, with the earliest sensory and motor block onset times being observed in Group A i.e 8.88 ± 2.59 min and 11.04 ± 1.93 min, respectively. A similar sequence i.e sensory onset time faster than motor onset time was also observed by Misiolek HD et al (25). Klein SM et al, in their study, observed that the mean onset time for both the motor and sensory blockade was < 6 min when 30 ml of 0.5% bupivacaine, 0.5% ropivacaine and 0.75% ropivacaine was used in 3 different groups in the interscalene block. They premedicated their patients with IV midazolam (1-5 mg) and fentanyl (50-250 µgm), which probably enhanced the onset of the block, which does not correlate with our study (26).
(Table/Fig 5): Duration of analgesia in other studies on Brachial Plexus Block by adding Fentanyl or Buprenorphine (Buprenor.)with LA
Bupiv: Bupivacaine; Ligno: Lignocaine; Buprenor: Buprenorphine; Adr: Adrenalinez


In our study, the duration of analgesia was maximum in the buprenorphine group (698.64 ± 189.48 min), as compared to that in Group-A (448.32±147.69 min), which was 1.5 times that found in Group-A, whereas the fentanyl group did not show any significant prolongation of analgesia.

Jadon A et al (10) noted that the total duration of motor block with buprenorphine was 329.2 ± 28.4 min, whereas in our study, it was 328.32 ± 47.94 min, which is comparable. This can be explained by the fact that bupivacaine, a long acting LA, was used and buprenorphine as such, does not have effect on the motor block.
From the above findings, we can suggest that opioids can be safely and effectively used in the brachial plexus block for post operative analgesia even in day care surgery. The more lipophilic the opioid (buprenorphine>fentanyl,) the longer the effect seems to last.
A limitation of our study was that a larger sample size could have added more precision to our results. Secondly, the incorporation of an ultrasound guided block localization technique could have drastically decreased the total volume of the local anaesthetics which were administered and this could have added new dimensions to our study. Future trials can explore the minimal safe doses of newer opioid additives by using an ultrasound guided method of nerve localization in the brachial plexus block.

Conclusion

We conclude that the addition of buprenorphine to local anaesthetics provides a significantly longer duration of analgesia by more than 1.5 times than when local anaesthetics are used alone in the supraclavicular block. The addition of opioids to local anaesthetics in the brachial plexus block has no significant adverse effect on the respiratory and haemodynamic parameters when used in prescribed doses and has a minimal incidence of nausea and vomiting or other minor side effects.

Acknowledgement

Note On the Request of all Authors Order of Authors was amended in the article on the 13th of June 2011.

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