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

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On Sep 2018




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Chairman, Research Group, Charutar Arogya Mandal, Karamsad
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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."



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Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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C.S. Ramesh Babu,
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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
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

Original article / research
Year : 2022 | Month : June | Volume : 16 | Issue : 6 | Page : UC10 - UC14 Full Version

Comparison of Effect of Clonidine and Magnesium Sulphate on Attenuation of Haemodynamic Response to CO2 Pneumoperitoneum in Patients Undergoing Laparoscopic Surgeries- A Randomised Clinical Study


Published: June 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/56354.16447
Aparna Bagle, Krusha Suresh Shah, Spoorti Pujari, Tanya Gulia, Chandrakala Singh

1. Professor, Department of Anaesthesiology, Dr D.Y. Patil Medical College Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India. 2. Junior Resident, Department of Anaesthesiology, Dr D.Y. Patil Medical College Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India. 3. Junior Resident, Department of Anaesthesiology, Dr D.Y. Patil Medical College Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India. 4. Senior Resident, Department of AnaesthesioloGy, Dr D.Y. Patil Medical College Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India. 5. Junior Resident, Department of Anaesthesiology, Dr D.Y. Patil Medical College Hospital And Research Centre, Dr. D.Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India.

Correspondence Address :
Dr. Krusha Suresh Shah,
Junior Resident, Department of Anaesthesiology, Dr. D.Y. Patil Medical College Hospital and Research Centre, Pune, Maharashtra, India.
E-mail: shahkrusha07@gmail.com

Abstract

Introduction: Laparoscopy, a minimally invasive technique causes several physiological fluctuations. There can be deleterious sympathetic responses during carbon dioxide insufflation, which is done to create a pneumoperitoneum.

Aim: To assess the impact of clonidine and magnesium sulphate on sympathetic response to carbon dioxide insufflation in patients undergoing laparoscopic surgeries.

Materials and Methods: A double-blinded randomised clinical study was conducted in Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune, Maharshtra, India, from June 2020 to September 2021, included 52 patients, posted for elective laparoscopic surgeries. Patients were randomized into two groups i.e, group M (n=26) received 30 mg/kg of magnesium sulphate and group C (n=26) received 1 μg/kg of clonidine after premedication. The vital parameters like heart rate, systolic, diastolic and mean arterial pressure, end tidal carbon dioxide, saturation were observed and noted at predetermined interval in perioperative period. Also, Visual Analogue Score (VAS) and sedation score were recorded in the recovery room. The statistical software SPSS version 16 was used. The p-value <0.05 was considered as significant.

Results: The mean age in group C and group M was 35.46± 8.5 years and 35.38±9.02 years (p-value=0.751). Both groups were compared for change in heart rate, systolic, diastolic and mean blood pressure changes after pneumoperitoneum and showed no significant variations in both groups at different time intervals (p-value >0.05). Also, both groups showed less than 20% variation from the baseline parameters, thus, effectively attenuating the pressor response. The VAS and sedation score were comparable in both the groups and showed no significant variations in both groups at different time intervals.

Conclusion: Intravenous administration of clonidine 1 μg/kg, or magnesium sulfate 30 mg/kg prior to pneumoperitoneum was effective in suppressing the pressor response during laparoscopic procedures. At the above used dosages, groups C and M showed insignificant difference in the measured parameters, thus proving to be equally effective in blunting the pressor response.

Keywords

Carbon dioxide insufflation, Haemodynamic surge, Pressor response, Visual analogue score

French gynaecologist Mouret was the first to perform laparoscopic cholecystectomy (1). The demand for laparoscopic surgeries is on the surge due to minimal incision which results in less pain, early ambulation and thus short stay in the hospital (2),(3).

Creation of pneumoperitoneum is essential for laparoscopic procedures. For this the surgeons insufflate gases, like carbon dioxide, which causes several physiological fluctuations. There is a rise in the abdominal pressure which leads to elevation of the diaphragm, thus, compressing both small and big blood vessels. Compression of inferior vena cava leads to decreased venous return as well as pooling of blood in the legs which ultimately causes decreased cardiac output by approximately 50%. Positioning, like reverse Trendelenburg or patients with compromised cardiovascular reserve are at a higher risk. Moreover, there is a rise in the intrathoracic pressure. Carbon dioxide insufflation creates a state of hypercarbia which causes vasopressor effects due to release of catecholamines and vasopressin, leading to raised blood pressure and heart rate.

Pharmacological agents like nitroglycerine, alpha blockers, β blockers, opioids etc. help in attenuation of heart rate and blood pressure thereby enabling better outcome during the surgeries (4),(5).

Clonidine, being a selective α-2 adrenergic receptor agonist, causes bradycardia and hypotension accompanied with a fall in systemic vascular resistance and decreased cardiac output; thereby blunting the haemodynamic response (6).

Magnesium sulphate deters the release of catecholamines from adrenal gland as well as adrenergic terminals. By action on blood vessels it leads to vasodilatation, whereas, at higher doses it can attenuate the release of vasopressin thereby causing further vasodilation (7),(8).

In various studies like the one conducted by Kalra NK et al., used a higher doses like 1.5 μg/kg clonidine and 50 mg/kg magnesium sulfate (9). There was evidence of delayed response to command which was statistically significant. In a study conducted by Mallick et al., used infusion of magnesium sulfate with a loading dose of 30 mg/kg followed by 10 mg/kg/hr infusion and compared this to dexmedetomidine 1 μg/kg followed by infusion of 0.5 μg/kg/hour (10). They concluded that both these drugs attenuated the haemodynamic surge. Seth et al., compared 50 mg/kg magnesium sulfate and 1.5 μg/kg clonidine and concluded that sedation score was higher in the postoperative room (11).

In the previous studies magnesium sulfate was used in the dose of 50 mg/kg and clonidine 1.5 μg/kg. These doses were associated with increased sedation score. So, this study was designed to find the minimum effective dosage of 30 mg/kg of magnesium sulphate and 1 μg/kg of clonidine drugs with least side effects. The primary outcome measures were change in heart rate, systolic, diastolic and mean arterial blood pressure after carbon dioxide insufflation. The secondary objectives of the study were to rule out any side effects of the study drugs like bradycardia, hypotension, postoperative Visual Analogue Score (VAS) and sedation.

Material and Methods

The double-blinded randomised clinical study was conducted in Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune, Maharshtra, India, from June 2020 to September 2021. The approval from the Institution Ethics Committee (Research Protocol No. IESC/PGS/2019/153) was obtained. Total 52 patients, undergoing laparoscopic surgeries, were included. Written informed consent was taken from all patients.

Sample size calculation: In a study conducted by Paul S et al., the mean and standard deviation of heart rate after pneumoperitoneum among two groups was 79.4±10.6 and 90.2±10.4. Considering the difference in the mean heart rate in this study, WINPEPI software was used, with confidence interval 95% and power of study 95% (12). Total sample size calculated was 52 (26 in each group). The patients were then randomly allocated to respective groups of 26, using lottery method.

Inclusion criteria: All patients of either gender aged between 18-65 years and physical status American Society of Anesthesiologists (ASA) status I and II were included in the study.

Exclusion criteria: Patients with cardiovascular, neurological, renal and respiratory co-morbidities, allergies to any drug used in the study and hypermagnesemia were excluded from the study.

• Group M received 30 mg/kg of magnesium sulfate in 20 mL normal saline over a period of 10 minutes.
• Group C received 1 μg/kg of clonidine diluted in 20 mL normal saline over a period of 10 mins.

The study drug preparation was done by an anaesthesiologist who was not involved in administration of anaesthesia and patient care. Patient care, monitoring and data collection was done by another anaesthesiologist who was not involved in the study (Table/Fig 1).

Procedure

After a thorough pre anaesthetic check-up, patients were taken inside the operation theatre. Preoperative pulse, non invasive blood pressure, Electrocardiogram (ECG) and oxygen saturation were noted. Peripheral venous access was established and intravenous (iv) fluid (ringer’s lactate) was given at 10 mL/kg. All patients received premedication with injection midazolam 0.02 mg/kg, injection fentanyl 2 μg/kg, and injection glycopyrrolate 4 μg/kg body weight intravenously. After premedication study drug was given. Patients were pre-oxygenated with 100% O2 for 3 minutes before induction. Induction was done in both the groups with inj. propofol 2 mg/kg body weight i.v and injection vecuronium 0.1 mg/kg iv to facilitate endotracheal intubation. After intubation bilateral air entry was confirmed by auscultation, End tidal Carbon Dioxide (EtCO2) reading was noted and the endotracheal tube was firmly secured using adhesive tape. Anaesthesia was maintained with oxygen and air mixture 50:50, sevoflurane1.5 to 2.5% and vecuronium 0.1mg/kg intermittent boluses. During surgery ringer lactate was infused in accordance with deficit, maintenance and blood loss. Carbon dioxide pneumoperitoneum was created and intra-abdominal pressure was maintained between 12-14 mmHg. Patients were ventilated with Intermittent Positive Pressure Ventilation (IPPV). Tidal volume and respiratory rate were adjusted to maintain EtCO2 between 35-45 mmHg.

Monitoring of Heart Rate (HR), Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Mean Arterial Pressure (MAP), Oxygen saturation (SpO2) and EtCO2 was done on a multichannel monitor and noted at baseline, after premedication, after study drug, at one, three and five minutes ,after creation of pneumoperitoneum at 5, 10, 20, 30, 50, 70, 90, 120 mins till the end of the surgery. All patients were given injection ondanseteron 4 mg, injection diclofenac sodium 75 mg intravenously 30 mins prior to the end of surgery. Also local infiltration with 0.125% bupivacaine was given at the port site for postoperative analgesia.

After completion of surgery100% oxygen was administered. Residual neuromuscular blockade was reversed with injection neostigmine 0.05 mg/kg and injection glycopyrrolate 8 μg/kg. A patient was then extubated. In recovery room, all patients were observed for vital parameters. Pain and sedation score was assessed on arrival and after 30 mins, 1 hour, 2 hours, 3 hours, and 4 hours in the recovery room with the help of VAS and Ramsay sedation score, respectively. Also all patients were observed for any other side effects such as nausea, vomiting and shivering.

Statistical Analysis

Variables like age, weight, heart rate, mean arterial pressure and Saturation (SpO2), VAS and sedation score are expressed as Mean ± Standard Deviation, and compared across the groups using unpaired t test. The statistical software Statistical Package for Social Sciences (SPSS) version 16.0 was used. The p-value <0.05 was considered as significant.

Results

The demographic profile like age, sex and factors like the type and duration of surgeries were comparable in both the groups (Table/Fig 2).

The MAP, SBP, DBP, and HR were comparable between the two groups (Table/Fig 3), (Table/Fig 4), (Table/Fig 6). The VAS score, as shown in (Table/Fig 7), shows no clinical significance in the both the compared groups at all time intervals. Sedation score, as mentioned in (Table/Fig 8), showed no significant difference and was comparable at all time intervals.

Discussion

Laparoscopic surgeries are minimally invasive, less painful and thus shorten the hospital stay. Pneumoperitoneum can cause increase in heart rate, rise in blood pressure accompanied with positional changes, anaesthesia and retention of CO2 due to insufflation. This has increased the challenge to maintain haemodynamic stability for the anaesthetist.

Clonidine is a selective α-2 adrenergic receptor agonist. It causes fall in heart rate and blood pressure along with decrease in systemic vascular resistance. It also reduces the cardiac output. These effects help to reduce a surge in the haemodynamic response during creation of pneumoperitoneum. Magnesium sulfate decreases release of catecholamines. It causes vasodilatation and can suppress the release of vasopressin at higher doses thereby causing further vasodilation. This will help in attenuation of haemodynamic response during laparoscopy.

Paul S et al., compared 30 mg/kg magnesium sulfate with a placebo group and observed a significant attenuation of pressor response in the former group for pneumoperitoneum (12). Pareek A et al., compared 50 mg/kg magnesium sulfate, 1 μg/kg clonidine and normal saline to attenuate the haemodynamic response due to pneumoperitoneum in laparoscopic cholecystectomy. The study concluded that at these doses clonidine and magnesium were better at blunting the response as compared to normal saline whereas both these drugs were equally effective when compared to each other. So the lowest dose of magnesium sulfate (30 mg/kg) and clonidine (1 μg/kg) which was effective in previous studies was chosen for this study to minimise the side effects (13).

Haemodynamic parameters: In the present study, on comparing the mean heart rate, systolic and diastolic blood pressure, mean arterial pressure it was concluded that amidst both the groups there was insignificant variance in the two groups during the perioperative period.

Kalra et al., studied patients, who received 1.5 μg/kg clonidine or 50 mg/kg magnesium sulfate. They concluded that heart rate showed insignificant difference between the two groups. There was a measurable decrease in systolic blood pressure in the group administered with 1.5 μg/kg clonidine at an interval of 10 and 30 minutes post pneumoperitoneum as compared to group that received 50 mg/kg magnesium. The 30 and 40 minutes post pneumoperitoneum the diastolic blood pressure was significantly lesser in the group which received clonidine as compared to those who received 50 mg/kg magnesium sulfate (9). Statistically significant difference in the time required to respond to commands like eye opening between the two groups was observed. There was no significant difference in both systolic and diastolic blood pressures in both the groups in our study. Also there was no delay in response as compared with the above study.

Kamble NK et al., compared 30 patients each in group C (clonidine 1 μg/kg), group M (magnesium sulfate 50 mg/kg), and group NS (normal saline 10 mL). Heart rate was significantly lower in magnesium group and systolic blood pressure was significantly higher in normal saline group as compared to magnesium and clonidine group. Between the later groups systolic pressure was, at 5 minutes post pneumoperitoneum, significantly reduced in magnesium group as compared to clonidine group (14). Thus, concluding that clonidine and magnesium sulfate were both effective in attenuation of pressor response. This is similar to present study.

Reddy JS et al., in their research compared the efficacy of single intravenous dose of magnesium sulphate (50 mg/kg) and clonidine (1 μg/kg) for suppression of sympathetic response. They concluded that MgSO4 attenuated the heart rate better than those who received clonidine and diastolic pressure was significantly reduced in the magnesium group at 5,10,20 minutes after the pneumoperitoneum and even postoperatively (15).

Pareek A et al., group C, group M, group Normal Saline (NS) which received 50 mg/kg magnesium sulphate, 1 μg/kg clonidine and normal saline, respectively. They concluded that there was significant bradycardia amidst groups C and M . In group NS the heart rate was significantly higher than the other two groups. There was insignificant difference in systolic blood pressure and MAP. On comparing these groups with normal saline showed a significant reduction in blood pressure as a result of pneumoperitoneum was noted in groups C and M (13).

Paul S et al., compared 30 mg/kg magnesium sulfate with placebo group. Preoperatively and prior to pneumoperitoneum MAP in both groups was comparable. This was followed by a statistically significant reduction in MAP during the entire course of surgery and even post extubation (12). Thus, study concluded that magnesium sulfate was effective in lowering MAP during pneumoperitoneum (12).

Tripathi et al., observed a significant drop in diastolic blood pressure occurred in the patients that were administered 2 μg/kg clonidine, as compared to placebo 20 minutes after pneumoperitoneum (16). Dutta PL, piloted a study to observe the effectiveness of 50 mg/kg magnesium sulfate with placebo to attenuate the arterial blood pressure in abdominal laparoscopic surgeries and observed a surge in diastolic as well as systolic blood pressure in control group (17). Observing the results in both these studies, clonidine and magnesium sulfate proved to attenuate the elevation of blood pressure to pneumoperitoneum as compared to placebo group.

In this study, the VAS and sedation score was comparable in both the study groups and all patients were calm and alert. A recent study by Shafiq T et al., used 50 mg/kg magnesium sulfate versus placebo for haemodynamic surge prevention in patients undergoing laparoscopic cholecystectomy. They concluded that there was significant reduction in the haemodynamic surge due to pneumoperitoneum in patients that received magnesium sulfate (18).

Nand K et al., concluded that magnesium 50 mg/kg and clonidine 1.5 mcg/kg blunted the haemodynamic stress response (9). Sheth PP et al., concluded that the sedation score was significantly higher in group M (50 mg/kg) as compared to group C (1.5 μg/kg) in the first two hours in the postoperative period (11). Increase in the sedation score can be attributed to the higher doses they have used in their studies. In the present study the sedation score was comparable in both the groups without significant delay in recovery.

Monitoring of all the patients in recovery for the adverse effects like decrease in heart rate, fall in blood pressure, postoperative nausea and vomiting, shivering was done. There was no such adverse event seen in either group M or group C. Studies by Kalra et al., and Sheth PP et al., concluded a delayed response and increased sedation score (9),(11).

Limitation(s)

This study was conducted on American Society of Anesthesiologists (ASA) grades I and II patients and a small sample size. Hence, it is not possible to extrapolate the results to all patient populations. So, further studies on elderly patients and those with compromised cardiac function are required to recommend its use in such high risk patients.

Conclusion

Intravenous administration of clonidine 1 μg/kg and magnesium sulfate 30 mg/kg prior to pneumoperitoneum was effective in suppressing the pressor response during laparoscopic procedures. However, at the above used dosages, 1 μg/kg of clonidine and 30 mg/kg of magnesium sulphate showed insignificant difference in the measured factors thus proving to be equally effective in blunting the pressor response.

References

1.
Nicholson ML, Elwell R, Kaushik M, Bagul A, Hosgood SA. Health-related quality of life after living donor nephrectomy: a randomized controlled trial of laparoscopic versus open nephrectomy. Transplantation. 2011;91;457-461. [crossref] [PubMed]
2.
Pither S, Bayonne Manou LS, Mandji Lawson JM, Tchantchou TD, Tchoua R, et al. Surgical approaches to hysterectomy. Sante. 2011;21:79-81. [crossref] [PubMed]
3.
Hatakeyama T, Nakanishi M, Murayama Y, Komatsu S, Shiozaki A, Kuriu Y, et al. Laparoscopic resection for colorectal cancer improves short-term outcomes in very elderly colorectal cancer patients. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. 2013;23:532-35. [crossref] [PubMed]
4.
Maskuri S, Nagarjuna CN, Venkateshwarlu G. A study to compare the efficacy of dexmedetomidine with esmolol on hemodynamic response during laparoscopic cholecystectomy. IAIM, 2018;5:17-29.
5.
Koh V, Ali S, Hassan MH, Mokhtar AM, Yaacob MNM, Mazlan MZ. Comparison of Esmolol and Dexmedetomidine Infusion in Attenuating Haemodynamic and Blood Glucose Response to Laryngoscopy and Intubation: A Single Blinded Study. Malays J Med Sci. 2021;28:46-55. [crossref] [PubMed]
6.
Hines RL, Marschall KE. Anaesthesia and co-existing disease. 5th edition. Churchill Livingstone. 2008.
7.
De Baaij JH, Hoenderop JG, Bindels RJ. Magnesium in man: implications for health and disease. Physiol Rev. 2015;95:01-46. [crossref] [PubMed]
8.
Diamant M, Benumof JL, Saidman LJ. Hemodynamics of increased intra-abdominal pressure: Interaction with hypovolemia and halothane anesthesia. Anesthesiology. 1978;48:23-27. [crossref] [PubMed]
9.
Kalra NK, Verma A, Agarwal A, Pandey H. Comparative study of intravenously administered clonidine and magnesium sulfate on hemodynamic responses during laparoscopic cholecystectomy. J Anaesthesiol Clin Pharmacol. 2011;27:344-48. [crossref] [PubMed]
10.
Mallick S, Sawika S, Chakraborty S, Ghosh S, Choudhuri R. A Comparative Study Of Infusion Dexmedetomidine And Infusion Magnesium Sulphate On Attenuation Of Blood Pressure Surge In Laparoscopic Surgery Under General Anaesthesia. Journal of Evolution of Medical and Dental Sciences. 2019;8:1695-700. [crossref]
11.
Sheth PP, Soni B, Kapadia K. Comparative study of intravenous infusion of clonidine and/or magnesium sulphate on haemodynamic stress response to tracheal intubation and pneumoperitoneum during laproscopic surgery. National Journal of Medical Research. 2017;7:22-25.
12.
Paul S, Biswas P, Bhattacharjee DP, Sengupta J. Effects of magnesium sulfate on hemodynamic response to carbon dioxide pneumoperitoneum in patients undergoing laparoscopic cholecystectomy. Anesth Essays Res. 2013;7:228-31. [crossref] [PubMed]
13.
Pareek A, Baid J, Manthan K, Sharma A. A comparative study of magnesium sulphate and clonidine in attenuating hemodynamic response to pneumoperitoneum in laparoscopic cholecystectomy. JMSCR. 2020:04:505-11.
14.
Kamble SP, Bevinaguddaiah Y, Nagaraja DC, Pujar VS, Anandaswamy TC. Effect of Magnesium Sulfate and Clonidine in Attenuating Hemodynamic Response to Pneumoperitoneum in Laparoscopic Cholecystectomy. Anesth Essays Res. 2017;11:67-71. [crossref] [PubMed]
15.
Reddy JS. Compare the efficacy of pre-anaesthetic single IV dose of magnesium sulphate versus clonidine for suppression of sympathetic response to pneumoperitoneum in patients undergoing elective laparoscopic cholecystectomy. IJMA. 2020;3:177-83. [crossref]
16.
Tripathi DC, Shah KS, Dubey SR, Doshi SM, Raval PV. Hemodynamic stress response during laparoscopic cholecystectomy: Effect of two different doses of intravenous clonidine premedication. J Anaesthesiol Clin Pharmacol. 2011;27:475-80. [crossref] [PubMed]
17.
Dutta PK. A Prospective Randomized Study of Effect of Magnesium Sulfate In Attenuating Artirial Blood Pressure In Elective Laparoscopic Abdominal Surgeries. IOSR-JDMS. 2018;17:13-17.
18.
Shafiq T, Rana MA, Nisar A. Comparison of Hemodynamic Response after Pneumoperitoneum with Versus without Pre-Emptive Magnesium Sulphate in Patients Undergoing Laparoscopic Cholecystectomy. Pakistan Journal of Medical & Health Sciences. 2022;16:267. [crossref]

DOI and Others

DOI: 10.7860/JCDR/2022/56354.16447

Date of Submission: Mar 15, 2022
Date of Peer Review: Apr 13, 2022
Date of Acceptance: May 02, 2022
Date of Publishing: Jun 01, 2022

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. No

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Mar 23, 2022
• Manual Googling: Apr 11, 2022
• iThenticate Software: Apr 18, 2022 (16%)

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