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

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On Aug 2018




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




Dr. Mamta Gupta,
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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.
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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.
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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

Important Notice

Case report
Year : 2012 | Month : May | Volume : 6 | Issue : 3 | Page : 488 - 489 Full Version

Intra-operative Bronchospasm in a Patient Who was Scheduled for Emergency Caesarean Section under Spinal Anaesthesia


Published: May 1, 2012 | DOI: https://doi.org/10.7860/JCDR/2012/.2072
R. Mudaraddi, S. Kinthala, U. Byadarahalli Ramachandra

1. Senior registrar, Department of Anesthesiology and Surgical Intensive Care, Queen Elizabeth Hospital Barbados. 2. Senior registrar, Department of Anesthesiology and Surgical Intensive Care, Queen Elizabeth Hospital Barbados. 3. Senior registrar, Department of Anesthesiology and Surgical Intensive Care, Queen Elizabeth Hospital Barbados.

Correspondence Address :
Rajashekar Mudaraddi MD., Senior Registrar,
Department of Anesthesiology and Surgical Intensive care.
Queen Elizabeth Hospital Barbados.
E-mail: raj123doc@yahooo.co.in
Fax: +12464274423

Abstract

An asthmatic attack during spinal anaesthesia is uncommon. It is a known fact that regional anaesthesia is the best option for asthmatic patients. The incidence of bronchospasm under spinal anaesthesia is high, during high spinal anaesthesia, which is infrequent. The incidence of episodes of bronchospasm are relatively higher in general anaesthesia than in spinal anaesthesia. The episodes of asthmatic attack during anaesthesia are decreasing due to the improved medical care. The prompt recognition of the episode and the timely treatment prevents the life threatening complications. Here, we are describing a case of an asthmatic attack during caesarean section under spinal anaesthesia.

Keywords

Bronchospam, Fentanyl, Spinal Anaesthesia

Introduction
Bronchospasm, the clinical feature of exacerbated, underlying airway hyperreactivity, has the potential to become an anaesthetic disaster if it is not recognized (1). Whatever the clinical circumstances, different triggers are identified in the peri-operative bronchospasm with asthma, among which a chronic inflammation of the airway is frequently involved. Spinal anaesthesia is the choice in caesarean section due to its decreased risk of failed intubation, avoidance of the gastric contents, avoidance of the depressant effects of the drugs on the foetus and the ability of the mother to remain awake and to enjoy the birthing experience. The use of spinal anaesthesia has dramatically increased in view of all these advantages, as compared to general anaesthesia (2). It has been studied that intra-thecal fentanyl provides a good quality of anaesthesia when it is used with Hyperbaric Bupivacaine 0.5%, without causing respiratory depression. Here, we are reporting a case of bronchospasm which was caused by a high sensory blockade due to intra-thecal fentanyl with a review of the literature.

Case Report

A 20-year primigravida who had completed 41 weeks of pregnancy, who was a known case of asthma, presented for emergency caesarean section due to failure to progress and post datism. She received oxytocin infusion in the labour room for augmentation. The patient was a known case bronchial asthma from the past 2 years and the last episode of the asthmatic attack was 1year back. She had a history of allergy to dust. She was prescribed the mixture of Budenoside and Formeterol inhaler after asthma was diagnosed by the physician. The systemic examination was unremarkable. The laboratory reports showed a haemoglobin value of 12.2g/dl. The patient received a dose of inj. pantoprazole 40mg and metoclopromide 10mg before she was shifted to the operating room. The decision to induce the patient with spinal anaesthesia was made after explaining the procedure to the patient. In the operating room, standard anaesthesia monitoring was initiated after checking the electrocardiogram (ECG), non invasive blood pressure (NIBP), and the pulseoximetry (SpO2) reports. The blood pressure was 130/74 mmHg and the heart rate was 90/min. The oxygen saturation was 98% on room air. The patient already had an 18G intrvenous access with 500ml normal saline infusion. She was preloaded with the same 500ml saline. Spinal anaesthesia with a mixture of 10mg 0f bupivacaine 0.5% and 25mcg fentanyl was given in the L2-L3 space by using a 27G Whitacre needle, by taking aseptic precautions, with the patient in the sitting position. The total volume of the drug was 2.5ml. After achieving a sensory level upto T4, the caesarean section was started. The patient received inj. cefazolin 1gm and metronidazole 500mg as prophylactic antibiotics. The hypotension which was caused by the spinal anaesthesia was treated with inj.ephedrine 5mg IV. A live male baby was delivered, which was uneventful. An infusion of 40 units of oxytocin in a litre of normal saline was started after the delivery. The duration of the procedure from the skin incision to the delivery was 25 minutes.10 min after the delivery, the patient started complaining of shortness of breath, her heart rate went upto 130/min, her oxygen saturation was 99%, and her lowest blood pressure which was recorded was 84/40 mmHg. Auscultation of the chest revealed bilateral extensive wheezes. The diagnosis of an asthmatic attack was made. The patient received 100% oxygen by mask and 12mg of inj.dexamethasone intravenously. Then, the patient was started on nebulization with a mixture of Ipratropium bromide 0.5mg and salbutomol 3.01 mg by using a venturi mask. The patient was relieved of the asthmatic attack after 15min. Her blood pressure and her oxygen saturation were normal. The physical examination of the skin and the mucosa was normal. The arterial blood gas was normal.(PH-7.415, Pco2-26.6, Po2-156.9, HCO3-16.7,BE--6.1,O2saturation-99.5%). The surgery lasted for 1 hour and the patient was shifted to the recovery room. The patient was comfortable and she was advised to continue using her inhaler. A chest X-ray which was done post operatively wasnormal. The consent for the publication of this article was obtained from the patient.

Discussion

The sudden onset of bronchospasm in a patient with a history of asthma during general anaesthesia is an anticipated problem at any stage of an anaesthetic course, but a prompt recognition and treatment are crucial for an uneventful outcome (1).The onset of an asthmatic attack or bronchospasm is a rare event under spinal anaesthesia, as there is no airway manipulation. The incidence of asthma is increasing worldwide and the mortality is decreasing because of improved medical care (3). Although the incidence of severe peri-operative bronchospasm is relatively low in asthmatics, when it does occur, it may be life threatening (3).

The bronchospasm which is encountered during the peri-operative period under spinal anaesthesia has various causes to be ruled out before its diagnosis is established. In our patient, an allergic reaction to the drugs which were administered was ruled out, as there were no features of skin erythema, hypotension or oxygen desaturation (3). The bronchospasm which could be caused by an anaphylactic reaction to oxytocin was unlikely, as the patient had labour augmentation with oxytocin prior to the surgery (4). The event which occurred after the delivery of the baby coincided with the peak action of the spinal anaesthesia. The triggering factors for the asthmatic attack in our patient could have been anxiety or sensory blockade upto T4, which could have been caused by by the spinal anaesthesia. The patient was comfortable after the delivery and anxiety was unlikely. The addition of intra-thecal fentanyl to hyperbaric bupivacaine in parturients who underwent caesarean section was found to improve the quality of the anaesthesia, without producing significant side effects, but the level of the sensory blockade which was produced by intra-thecal fentanyl was significantly higher than that which was seen in the control group (5).

The autonomic nervous system controls the normal calibre of the bronchi (6). The principal function of the sympathetic (T2-T4) supply to the lung is bronchodilation, while the vagi act as stretch recep-tors (7). An asthmatic patient will have an abnormal autonomic nervous system, which is resposible for the airway hyper reactivity. The stimulation of the para-sympathetic nervous system is implicated in the pathogenesis of asthma (8). A thoracic sympathetic blockade which is made by spinal anaesthesia might trigger an asthmatic attack by influencing the cholinergic ganglia of the lung and thepulmonary blood flow (9) and by releasing inflammatory mediators. In our case, even though the patient had no asthmatic attack in the past 1 year, she became susceptible to the bronchospasm under spinal anaesthesia. Spinal anaesthesia is considered to be the safest form of anaesthesia in patients with hyperreactive airways, but still the patients can get asthmatic attack due to various causes which have been described above. It is always better to anticipate the problem, especially when the sensory blockade under spinal anaesthesia is between T2-T4 in the susceptible patients. The treatment includes the supplementation of oxygen and intravenous steroids and nebulization with bronchodilators. The prophylactic administration of moisturized oxygen and intravenous steroids was shown to be beneficial in preventing asthmatic attacks during surgery (10). In conclusion, even though intra-thecal fentanyl is safe, we should always keep in mind the high sensory level which is caused by this additive and we should be vigilent in order to anticipate complications in susceptible asthmatic patients.

References

1.
Dewachter P, Mouton-Favivre C, Emla C W., Beloucif S. Case scenario: bronchospasm during anesthetic induction. Anesthesiology 2011; 114(5):1200-10.
2.
Birnbach DJ, Browne IM. Anesthesia for Obstetrics. In: Miller RD, Miller’s Anesthesia 7th ed. Philadelphia: Elsevier Churchill Livingstone, 2009;2219.
3.
Woods BD, Sladen RN. Peri-operative considerations for patients with asthma and bronchospasm. British Journal of Anaesthesia 2009;103(12):57-658.
4.
Pant D, Vohra VK, Pandey SS, Sood J. Pulseless electrical activity during caesarean delivery under spinal anaesthesia: a case report of a severe anaphylactic reaction to Syntocinon. Int J Obstet Anesth 2009;18(1):85-88.
5.
Obara M, Sawamura S, Satoh Y, Chinzei M, Sekiyama H, Tamai H, et al. The effect of intra-thecal fentanyl which was added to hyperbaric bupivacaine for caesarean section. Masui 2003;52(4): 378-82.
6.
Kumar M, Verma NS, Tiwari S, Pandey US. Sympathetic hyperactivity in bronchial asthma. Indian Journal of Physiology and Pharmacology. 2005;49(1):89-94.
7.
Harold Ellis. Lungs: blood supply, lymphatic drainage and nerve supply. Anaesthesia and Intensive Care Medicine 2008; 9(11):462-64.
8.
Lewis MJ, Short AL, Lewis KE. Autonomic nervous system control of the cardiovascular and the respiratory system in asthma. Respiratory Medicine 2006;100(10) :1688-705
9.
Kawabata KM. Two cases of asthmatic attack which were caused by spinal anaesthesia. (Article in Japanese). Masui 1996 ;45(1):102-6.
10.
Ochiai N, Okutani R, Yoshimura Y, Fu K. Peri-operative management of a patient who had a severe bronchial asthma attack. (Article in Japanese) Masui 1995;44(8):1124.

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