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

Users Online : 317242

AbstractMaterial and MethodsResultsDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

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 Dermatolgy,
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
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 : UC25 - UC28 Full Version

Assessment of Ease of Insertion of Laryngeal Mask Airway Comparing different Doses of Suxamethonium with Etomidate: A Comparative Randomised Double-blind Controlled Study


Published: June 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/56461.16472
Tumulu Rao Rajmohan, Shakti Swaroop, Raja Damarla, Tumulu Kumar Pranay, Garg Tanisha, Mohammed Amermohiuddin

1. Professor, Department of Anaesthesia, Malla Reddy Medical College for Women, Hyderabad, Telangana, India. 2. Assistant Professor, Department of Anaesthesia, Malla Reddy Medical College for Women, Hyderabad, Telangana, India. 3. Assistant Professor, Department of Anaesthesia, Malla Reddy Medical College for Women, Hyderabad, Telangana, India. 4. Student, Malla Reddy Medical College for Women, Hyderabad, Telangana, India. 5. Student, Malla Reddy Medical College for Women, Hyderabad, Telangana, India. 6. Student, Malla Reddy Medical College for Women, Hyderabad, Telangana, India.

Correspondence Address :
Dr. Tumulu Rao Rajmohan,
302-A, Usha Enclave, Srinagar Colony, Hyderabad, Telangana, India.
E-mail: rajmohanrao@yahoo.co.uk

Abstract

Introduction: Laryngeal mask airway (LMA) is used more often in today’s anaesthesia practice. Smooth and successful insertion needs proper mouth opening and minimal or no airway reflexes such as gagging, coughing, or laryngospasm. Induction agents like propofol and etomidate are known to blunt the laryngeal reflexes but often patient movement, coughing, and gagging create an unpleasant situation.

Aim: To assess the effects of suxamethonium 0.25 mg/kg, and 0.5 mg/kg, and placebo (normal saline) on the facilitation of laryngeal mask airway insertion along with etomidate as an induction agent in order to achieve haemodynamic stability and fewer complications.

Materials and Methods: This was a double-blind randomised controlled study, which included, a total of 90 adult patients, American Society of Anaesthesiologists (ASA) class I-II, scheduled for minor surgery under general anaesthesia and was conducted from December 2021 to February 2022, at Malla Reddy Medical College for Woman, Hyderabad, Telangana, India. The total participants were randomly allocated into three groups (Normal Saline (NS), S1 and S2). The group NS (placebo) received normal saline, and Group S1 and S2 received injections of suxamethonium 0.25 mg/kg, or 0.5 mg/kg, respectively. Induction of anaesthesia was performed with a bolus dose of etomidate 0.3 mg/kg. Study drugs were administered when the patient had lost consciousness. Laryngeal mask airway size 3 or 4 (as appropriate) was inserted. Relaxation of the jaw, coughing, gagging, laryngospasm, and any patient movements was observed during the insertion of LMA. The overall insertion conditions were graded according to modified scheme of Lund and Stovner. The statistical analysis was carried out by using Chi-square test, Fisher’s-Exact test and Bonferroni’s t-test.

Results: A total of 89 patients were analysed (group NS: n=29, group S1: n=30, group S2: n=30). Good jaw relaxation (absolutely relaxed with no muscle tone) was noted in 16 patients of group S2, 12 in group S1, and 2 in group NS (p<0.001). There was significant difference in coughing and gagging among the three groups (p=0.041). However, in the group NS, eight patients had mild movement and six had moderate movement during the insertion of LMA (p=0.002). Overall insertion conditions were better in suxamethonium groups (p=0.0001).

Conclusion: Etomidate as the sole induction agent for LMA insertion is not ideal. Concurrent use of a low dose of suxamethonium (0.5 mg/kg) might significantly obtund the airway reflexes in response to LMA insertion.

Keywords

Coughing, General anaesthesia, Laryngospasm, Low dose

The Laryngeal Mask Airway (LMA) is a non invasive supralaryngeal device that has allowed a radical change in the management of modern general anaesthesia. Smooth insertion of LMA requires attenuation of airway reflexes to avoid sequelae such as gagging, coughing, or laryngospasm. The most popular induction agent for LMA insertion continues to be propofol, as it best obtunds oropharyngeal reflexes (1),(2). With a standard induction dose (2-3 mg/kg) of propofol, the incidence of poor insertion conditions of LMA is 38-60% (3),(4). Dr. AIJ Brain introduced low-dose neuromuscular blocking drugs and used a small dose of alcuronium (0.2 mg/Kg) before LMA insertion. Korula S et al., in year 2010, described that relaxation was not essential for LMA insertion but the upper airway reflexes must be reduced for insertion to be successful (5). Later, other studies reported co-induction techniques using various induction agents with low doses of other agents, such as dexmedetomidine with propofol and fentanyl with propofol (6), ketamine with fentanyl and propofol with fentanyl (7),(8) neuromuscular blocking agents like atracurium and suxamethonim (9),(10) and thiopentone with lidocaine spray vs propofol (11). In the present study, etomidate was chosen as an induction agent for insertion of LMA, as it is known to have greater cardiovascular stability than the other intravenous induction agents, even in patients with cardiovascular risk factors (12). In the present study, a combination of etomidate 0.3 mg/kg with different low doses of suxamethonium was used, so as to obtain good LMA insertion conditions, whilst maintaining cardiovascular stability.

The primary objective was to find out, whether suxamethonium was useful along with etomidate to facilitate LMA insertion and compare the two different doses,0.25 mg/kg and 0.5 mg/kg of suxamethonium to obtain effective LMA insertion conditions. The secondary outcome was adverse events, if any.

Material and Methods

A double-blind randomised controlled study was conducted from December 2021 to February 2022 at Malla Reddy Medical College for Woman, Hyderabad, Telangana, India. After obtaining Ethical Committee approval (MRIMS/2021/IEC167) and written informed consent, a total of 90 American Society of Anaesthesiologists (ASA) class I and II (13) were studied.

Inclusion criteria: A total of 90 American Society of Anaesthesiologists (ASA) class I and II patients of either sex, aged 20-60 years scheduled for various elective minor surgeries under general anaesthesia were included in the study.

Exclusion criteria: Patients scheduled for emergency surgeries on anti-hypertensive medication or with a head injury, cardiac conduction defects, or on anti-arrhythmic drugs, were excluded from the study.

Sample size calculation: It was done based on the study by George LR et al., (4). A sample size of 25 in each group would be required to show a difference in the LMA insertion conditions (82.1% versus 84.9%). This was calculated assuming a 1% significance level, a value of 0.05 (2-sided), and 80% power. Considering a probable dropout rate of 10%, 30 patients were enrolled in each of the three groups. A computer block randomisation was used to divide the study population into three groups of 30 each. Group NS (placebo) received normal saline, group S1 received suxamethonium 0.25 mg/kg, and group S2 received suxamethonium 0.5 mg/kg.

Study Procedure

Upon arrival in the operating room electrocardiogram, pulse oximetry, and automated non invasive blood pressure monitors were connected and baseline values were noted. Peripheral intravenous access was secured using either an 18 or 20-gauge venous cannula. All patients were pre-oxygenated for 3 minutes with 100% oxygen. Fentanyl 2 μg/kg and Midazolam 1-2 mg were given intravenously. Induction of anaesthesia was performed with a bolus dose of etomidate 0.3 mg/kg. Study drugs were administered after confirmation that the patient had lost consciousness. The drugs were loaded in a 2 mL syringe- for group NS only normal saline, for group S1 suxamethonium 0.25 mg/kg, and for group S2 suxamethonium 0.5 mg/kg were diluted with normal saline to make it 2 mL. An appropriate size of LMA was inserted by an anaesthesiologist who was blinded to the drug administration. The same blinded anaesthesiologist administered the study drugs and LMA, and also assessed the insertion conditions. If jaw relaxation was found to be inadequate or the patient had a cough, a bolus dose of propofol 20 mg upto 0.5 mg/kg was given to deepen the plane of anaesthesia to facilitate the LMA insertion (14).

Heart rate (HR) and mean arterial blood pressure (MAP) were recorded at the end of pre-oxygenation, 30 seconds post-induction, and 60 seconds post-LMA insertion. Inhalational anaesthetic agents were not delivered to the patients until the variables are measured. Anaesthesia was then maintained with oxygen, nitrous oxide, sevoflurane, and fentanyl.

Jaw relaxation, coughing and gagging, and laryngospasm was graded according to the classification given by Young HAS et al., (15), and body movement (head or limbs) was graded on a four-point scale according to Nimmo SM et al., (16). Overall insertion conditions were graded according to a system modified by Lund I and Stovner J (17) (Table/Fig 1).

Statistical Analysis

Data were analysed using Statistical Package for Social Sciences (SPSS) software (version 19.0 for Windows; SPSS Inc., Chicago, IL, USA). The Shapiro-Wilk test was used to analyze the normality of the distribution of continuous variables. Differences in continuous variables were analysed using a one-way analysis of variance. Categorical variables were analysed using the Chi-square test or Fisher’s-Exact test, as deemed appropriate. Bonferroni’s t-test and Chi-square test were used to compare the three groups. Insertion conditions were assessed by Fisher’s-Eaxct test. A p-value of <0.05 was considered statistically significant.

Results

A total of 89 patients could be included in the final analysis as shown in the CONSORT flow diagram for the study (Table/Fig 2). Demographically, all three groups are comparable with respect to age, sex, and weight with a p-value of 0.820, 0.971, and 0.935 respectively (Table/Fig 3). The data were analysed using the one-way ANOVA (Analysis of Variance) test (Table/Fig 3).

Haemodynamic parameters of heart rate, and mean arterial pressure were recorded at pre-oxygenation, 30 sec post-induction, and one-minute post-LMA insertion. All the three groups were noted with similar changes in these parameters, which were statistically insignificant. The change across time as analysed using the one-way ANOVA test and Pearson’s Chi-square test is presented in (Table/Fig 4),(Table/Fig 5).

A significantly better jaw relaxation was noted in Group S2 than in Groups S1 and NS (p-value=0.0001). It was also noted that jaw relaxation was incomplete, ~60% in the NS (placebo) group and ~40% in Group S1. There was statistically significant difference (p-value 0.041) between the three groups for coughing and gagging; although clinically the incidence of mild cough was more in the placebo group. No coughing was seen in group S2 in response to LMA insertion. The patient movement was significantly more in the placebo group NS (p-value=0.002) compared in Groups S1 and S2.

Partial laryngospasm occurred in only 5 patients (17.2%) in the placebo group with p-value=0.004. No other patients in both Groups S1 and S2 had laryngospasm. Overall insertion conditions were significantly better in suxamethonium groups. Overall insertion conditions showed better results in Group S2 than in Group S1. Approximately, half the patients in the NS (placebo) group had excellent (10%) or good (40%) insertion conditions with a moderate patient response (Table/Fig 6).

Discussion

The laryngeal mask airway enables anaesthesiologists to keep both their hands free and obviates the need for tracheal intubation in some surgeries. However, the adverse response to the insertion of a laryngeal mask airway (such as gagging, coughing, and laryngospasm) may make correct positioning difficult or even impossible. Moreover, the popularity of a drug for LMA insertion does not preclude the uncertainty in the exact choice of the induction drug(s), the nature, doses, mode of administration, the optimal and guaranteed insertion procedure, the efficacy of the induction technique(s) used, and the recovery/respiratory onset after surgery.

Numerous pharmacological agents and combinations have been introduced to decrease the haemodynamic instability throughout anaesthesia. Etomidate is one of the Intravenous (i.v.)anaesthetics which are used alone or in combination with other anaesthetics for induction; it also has been used for anaesthesia maintenance in different contexts. However, it is mostly used in cardiac patients in whom the risk of cardiovascular instability following the administration of other i.v. anaesthetics such as propofol or thiopental cannot be underestimated. Etomidate is of rapid onset and emergence from anaesthesia and it is not associated with histamine release. In addition, it has sedative and hypnotic characteristics with no analgesic effects. The haemodynamic stability seen with etomidate may be partly caused by its unique lack of effect on both the sympathetic nervous system and baroreceptor function. Thus, it can be deliberated that the conditions and doses of the combination drugs chosen provide a viable and effective alternative for laryngeal mask airway insertion.

In 2004, a study was conducted by Liou CM et al., (18) using etomidate alone, and etomidate with fentanyl or suxamethonium, to assess improvement in the success rate of LMA insertion. They concluded that etomidate alone was far from perfect and succinylcholine with etomidate might provide better results in terms of shortened time for the LMA insertion, jaw relaxation, and the success rate of LMA insertion than that of fentanyl. In the present study, 60% of patients in the placebo group (etomidate alone) had incomplete jaw relaxation, and although statistically insignificant many had mild cough (15%). In the placebo group, patient movement (p-value=0.002), laryngospasm (p-value=0.004), and overall insertion condition (p-value=0.0001) were statistically significant.

George LR et al., compared different doses of suxamethonium and concluded that 0.25 mg/kg of suxamethonium facilitates the insertion of the LMA (4). But the present study found that 0.25 mg/kg
of suxamethonium (group S1) had an incomplete jaw relaxation in 40% of the patients, 20% had mild to moderate movement during LMA insertion, and overall insertion condition was poor in 10% of the patients. In the same year, Liao AH et al., (14) analysed data from 10 Randomised Clinical Trials (RCTs) comprising 625 participants. They concluded that low-dose suxamethonium (0.3 to 1 mg/kg) reduced the LMA insertion failure rate and its related coughing and gagging when compared with the mini dose (0.3 mg/kg). The low doses of suxamethonium only offered significant protection against coughing and gagging and did not provide significant improvement in mouth opening. Postoperative myalgia did not increase with the overall use, mini dose, or low dose of suxamethonium. No studies reported any severe complications such as malignant hyperthermia. The present study study used etomidate as an induction agent to observe, whether, this can be used as an induction agent of choice in emergency procedures in the elderly and patients with cardiovascular instability.

To summarise, a significant difference was observed in the incidence of patient response (coughing, gagging, patient movement) during LMA insertion in the NS (placebo) group versus the other two treatment groups. Jaw relaxation was found to be better in patients who received 0.5 mg/kg suxamethonium compared to the other two groups. The incidence of laryngospasm was highest in the NS (placebo) group when compared to the other groups. In the two groups, who received suxamethonium, the LMA insertion conditions were found to be better when compared to the saline group, but the overall optimal insertion conditions with fewer adverse events were observed in patients who received suxamethonium at a dose of 0.5 mg/kg.

Limitation(s)

The patients were not followed up for the known side effects of suxamethonium like myalgia, sore throat, hyperkalemia, and any other complications postoperatively. The type of LMA used in the study was not defined, so unable to compare the insertion conditions with different generations of LMAs.

Conclusion

Etomidate as the sole induction agent for LMA insertion is far from perfect. A low dose of suxamethonium when combined with etomidate, provides better conditions for LMA insertion than etomidate alone. Suxamethonium at a dose of 0.5 mg/kg produces better insertion conditions for the laryngeal mask airway than suxamethonium at 0.25 mg/kg given intravenously. Further prospective studies with larger sample size and different induction agents are required, to fully evaluate the dose-dependent effects of suxamethonium, for the safe insertion of LMA.

References

1.
Scanlon P, Carey M, Power M, Kirby F. Patient response to laryngeal mask insertion after induction of anaesthesia with propofol or thiopentone. Canadian Journal of Anaesthesia. 1993;40(9):816-18. [crossref] [PubMed]
2.
Brown GW, Ellis FR. Comparison of propofol and increased doses of thiopentone for laryngeal mask insertion. Acta Anaesthesiology Scandinavica. 1995;39(8):103-04. [crossref] [PubMed]
3.
Ang S, Cheong KF, Ng TI. Alfentanil co-induction for laryngeal mask insertion. Anaesthesia and Intensive Care. 1999;27(2):175-78. [crossref] [PubMed]
4.
George LR, Sahajanandan R, Ninan S. Low-dose succinylcholine to facilitate laryngeal mask airway insertion: A comparison of two doses. Anesth Essays Res. 2017;11(4):1051-56. Doi: 10.4103/aer.AER_98_17. [crossref] [PubMed]
5.
Korula S, Abraham V, Afzal L. Evaluation of low dose succinylcholine for insertion of laryngeal mask airway during thiopentone induction: A comparison with atracurium. J Anaesth Clin Pharmacol. 2010;26(3):355-59. [crossref]
6.
Choudhary J, Prabhudesai A, Datta C. Dexmedetomidine with propofol versus fentanyl with propofol for insertion of proseal laryngeal mask airway: A randomized, double-blinded clinical trial. J Anaesthesiol Clin Pharmacol. 2019;35(3):368-72. Doi: 10.4103/joacp.JOACP_104_18. PMID: 31543587; PMCID: PMC6748008. [crossref] [PubMed]
7.
Okeyemi A, Suleiman AZ, Oyedepo OO, Bolaji BO, Adegboye BM, Ige OA. Comparative study of haemodynamic effects of intravenous ketamine-fentanyl and propofol-fentanyl for laryngeal mask airway insertions in children undergoing herniotomy under general anaesthesia in a nigerian tertiary hospital. Niger Postgrad Med J. 2022;29(1):36-42. Doi: 10.4103/npmj.npmj_753_21. PMID: 35102948. [crossref] [PubMed]
8.
Nagalakshmi P, Leo S, Uthirapathi S. Use of butorphanol, fentanyl, and ketamine as co-induction agents with propofol for laryngeal mask airway insertion: A comparative study. Anesth Essays Res. 2018;12(3):729-34. Doi: 10.4103/aer.AER_104_18. PMID: 30283185; PMCID: PMC6157222. [crossref] [PubMed]
9.
Shetabi H, Jebelli E, Shafa A. Comparing the safety and efficacy of three different doses of atracurium in facilitating the insertion of laryngeal mask airway in patients undergoing phacoemulsification cataract surgery: A randomized clinical trial. Adv Biomed Res. 2020;9:28. Doi: 10.4103/abr.abr_61_19. PMID: 33072640; PMCID: PMC7532828. [crossref] [PubMed]
10.
Rao S, Modak A. Assessment of effect of low dose succinylcholine on facilitating insertion of laryngeal mask airway- A single-blind randomised study. J Clin of Diagn Res. 2020;14(10):UC01-04. https://www.doi.org/10.7860/JCDR/2020/44518/14081. [crossref]
11.
Belete E, W/Yahones M, Aweke Z, Dendir G, Mola S, Neme D, et al. Comparison of thiopentone with lidocaine spray vs propofol for laryngeal mask airway insertion at tikuranbessa specialized hospital. A prospective cohort study. Ann Med Surg (Lond). 2021;66:102436. Doi: 10.1016/j.amsu.2021.102436. PMID: 34141417; PMCID: PMC8187156. [crossref] [PubMed]
12.
Ostwald P, Doenicke AW. Etomidate revisited. Curr Opin Anaesthesiol. 1998;11(4):391-98. [crossref] [PubMed]
13.
American Society of Anaesthesiology. ASA physical status classification system. 2020. https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system.
14.
Liao AH, Lin YC, Bai CH, Chen CY. Optimal dose of succinylcholine for laryngeal mask airway insertion: Systematic review, meta-analysis and metaregression of randomised control trials. BMJ Open. 2017;7(8):e014274. Doi: 10.1136/bmjopen-2016-014274. PMID: 28780538; PMCID: PMC5724107. [crossref] [PubMed]
15.
Young HAS, Clark RSJ, Dundee JW. Intubating conditions with AH 8165 and suxamethonium. Anaesthesia. 1975;30(1):30-33. [crossref] [PubMed]
16.
Nimmo SM, McCann N, Broome IJ, Robb HM. Effectiveness and sequelae of very low-dose suxamethonium for nasal intubation. Br J Anaesth. 1995;74(1):31-34. [crossref] [PubMed]
17.
Lund I, Stovner J. Dose-response curves for tubocurarine, alcuronium and pancuronium. Acta Anaesth, Scand. 1970;37S:238-42. Doi: 10.1111/j.1399-6576.1970.tb00916.x. [crossref] [PubMed]
18.
Liou CM, Hung WT, Chen CC, Hsu SC, Lau HK. Improving the success rate of laryngeal mask airway insertion during etomidate induction by using fentanyl or succinylcholine. Acta Anaesthesiol Taiwan. 2004;42(4):209-13. PMID: 15679130.

DOI and Others

DOI: 10.7860/JCDR/2022/56461.16472

Date of Submission: Mar 22, 2022
Date of Peer Review: Apr 13, 2022
Date of Acceptance: May 05, 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. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Mar 24, 2022
• Manual Googling: Apr 29, 2022
• iThenticate Software: May 02, 2022 (24%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com