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Dr Mohan Z Mani

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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."



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




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"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 : UC62 - UC66 Full Version

Comparative Evaluation of the Effect of Clonidine and Dexmedetomidine as Adjuncts to Lignocaine in Intravenous Regional Anaesthesia in Forearm and Hand Surgeries- A Randomised Clinical Study


Published: June 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/56280.16514
S Krishnendu, Aruna Chandak, Vijay Chandak, Neeta Verma, Sanjot Ninave, Vivek Chakole, Karuna Taksande

1. Junior Resident, Department of Anaesthesia, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India. 2. Professor, Department of Anaesthesia, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India. 3. Assistant Professor, Department of Anaesthesia, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India. 4. Professor, Department of Anaesthesia, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India. 5. Professor, Department of Anaesthesia, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India. 6. Professor and Head, Department of Anaesthesia, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India. 7. Professor, Department of Anaesthesia, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India.

Correspondence Address :
Dr. S Krishnendu,
Junior Resident, Department of Anaesthesia, Acharya Vinoba Bhave Rural Hospital, Sawangi (Meghe), Wardha, Maharashtra, India.
E-mail: krish22nendu@gmail.com

Abstract

Introduction: Intravenous regional anaesthesia for forearm and hand surgeries, which is one of the safe, cost-effective and rapid onset anaesthesia is less popular nowadays, because of its lesser postoperative analgaesia and tourniquet pain.

Aim: To compare dexmedetomidine and clonidine as an adjuvant to 0.5% lignocaine to study block characteristics, tourniquet pain and postoperative analgaesia in forearm and hand surgeries.

Materials and Methods: This randomised clinical trial was conducted in Acharya Vinoba Bhave Rural Hospital (Tertiary Care Hospital), Wardha, Maharashtra, India, from September 2019 to September 2021 on 70 patients posted for forearm and hand surgeries. The patients were divided into two groups of 35 each. Group C received clonidine 1 mcg /kg with 40 mL of 0.5% lignocaine preservative free. Group D received dexmedetomidine 1 mcg /kg with 40 mL of 0.5% lignocaine preservative free. Independent samples t-test was used for evaluation of demographic data, haemodynamic data, block characteristics, duration of surgery and tourniquet, onset of tourniquet pain, duration of analgaesia and intraoperative and postoperative analgesic requirement.

Results: Onset of sensory and motor block was faster with dexmedetomidine group (1.60±0.60 min and 2.77±0.81 min) when compared to clonidine group (3.57±0.74 min and 6.40±1.26 min). Duration of analgaesia was significantly longer in group D (345.23±44.52 min) compared to group C (205.14±37.76 min), sensory and motor regression was delayed with group D (7.69±0.72 min) as compared to group C (6.40±0.85 min). There was no significant adverse effect noted in both the groups.

Conclusion: Dexmedetomidine is an excellent adjuvant when added to lignocaine for Intravenous Regional Anaesthesia (IVRA) in terms of block quality, postoperative analgaesia, and adverse effects.

Keywords

Adjuvant, Motor block, Postoperative analgaesia, Sensory block

For any forearm and hand surgeries we have various options of anaesthesia to provide, like general anaesthesia, peripheral nerve block, intravenous regional anaesthesia (1). Advantages of general anaesthesia include greater acceptance by patients, duration can be prolonged for more than 2 hours, greater muscle relaxation and secured airway, this is even acceptable in haemodynamically unstable patients. However, there are associated complications like airway instrumentation, respiratory complications, at risk of barotrauma, deep vein thrombosis, pulmonary embolism and it also comes with postoperative discomfort (2).

Peripheral nerve block has been commonly used nowadays for surgeries of extremities. Advantages of this technique include longer duration of analgaesia with least effect of haemodynamics. Disadvantages are chances of nerve injury, it being time consuming as technical expertise is needed, and requirement of equipment like nerve stimulator or ultrasound machine (2).

August Karl Gustav Bier, a German surgeon in 1908, described Intravenous Regional Anaesthesia (IVRA) (Bier’s block) for the first time. Even though it was effective, because of the advent of the brachial plexus block, IVRA lost its popularity. Then in the 1960s Charles Holmes made IVRA popular by improving the technique and substituting lidocaine for prilocaine. Now even after 100 yrs it remains popular for short procedures of extremities (3). The exact mechanism of action of IVRA is not known. When a local anaesthetic is injected it diffuses into the small nerves in the skin blocking conduction (2).

The benefits of IVRA is that it allows us to get a bloodless anesthetic field with less procedural skill. It is considered as safe, less time consuming, cost effective, and reliable with rapid onset of analgaesia. It has a high success rate of 94% to 98%. It is popular because of rapid recovery of function which aids for rapid ambulation after surgery (3).

There are certain disadvantages of IVRA includes application of a pneumatic tourniquet throughout the procedure can cause tourniquet pain, the duration of surgery is limited by time during which the tourniquet could be safely inflated, minimal postoperative analgaesia, and the chance of local anesthetic toxicity is high if tourniquet is not inflated properly (3).

To overcome these disadvantages few advancements have been made, mainly aimed to improve the quality of intra operative and postoperative analgaesia to improve tourniquet tolerance.Various modalities have been adopted like altering the concentration and volume of local anesthetics. Different local anesthetics (ropivacaine and chlorprocaine) have been tried and modification of tourniquet techniques. To mitigate tourniquet pain and to improve intra operative and post operative analgaesia various drugs has been used. Alpha 2 adrenergic receptor agonist is the focus of interest to improve the quality of analgaesia perioperatively (4). Clonidine, an alpha 2 adrenergic receptor agonist, has sympatholytic, sedative and cardiovascular stabilizing effects. This as an adjuvant to local anesthetic and it has shown to prolong the duration of analgaesia and also improves tourniquet pain by blocking selectively A Δ and C fibers (5).

Dexmedetomidine, a powerful alpha 2 receptor agonist, is more selective than clonidine for alpha2 receptors. Other than the sympatholytic effect of dexmedetomidine it has antihypertensive, anxiolytic, sedative and analgesic effects (6).

The aim of the study was to compare the effects of adding clonidine or dexmedetomidine to lignocaine for IVRA in forearm and hand procedures as an adjuvant to intravenous (i.v) lignocaine 0.5%.The primary outcome measures were to compare and study the duration of analgaesia when clonidine and dexmedetomidine were added as adjuvant to i.v. lignocaine 0.5% in IVRA. The secondary outcome measures were to compare and study the onset of sensory and motor block, incidence of tourniquet pain, haemodynamic changes, post operative analgaesia and adverse effects.

Material and Methods

This randomised clinical trial was conducted in Acharya Vinoba Bhave Rural Hospital (Tertiary Care Hospital), Wardha, Maharashtra, India, from September 2019 to September 2021 on 70 patients posted for forearm and hand surgeries. Institutional Ethical Committee clearance obtained (Ref Number: DMIMS (DU)/IEC/SEPT/8372). Informed consent were obtained from the patients.

Sample size calculation: Sample size was calculated using the open epi app. The sample size was calculated from values of previous study (4). Using α level of 0.05 and β level of 0.90 to produce a desired power of 90% using two-sample mean test (Satterthwaite's t-test) assuming unequal variance. Enrollment of 32 patients in each group was required according to the calculation. Considering possible dropouts 35 patients in each group and a total of 70 were taken up in the study (Table/Fig 1).

Inclusion criteria: Age group 20 to 60 years of both sex, surgeries lasting for less than 1 to 1.5 hrs, American Society of Anaesthesia (ASA) grade I and II, patient undergoing forearm and hand surgery, both elective and emergency were included in the study.

Exclusion criteria: Patients with peripheral vascular disease, hypersensitivity to local anesthetic agents, coagulation disorder, patients with sickle cell trait or any haemolytic diseases, local infection, haemodynamically unstable patients, any neurological diseases, anticipated difficult airway patients were excluded from the study.

There were 70 patients, 35 in each group -

• Group C: Clonidine 1 mcg /kg with 40 mL of 0.5% lignocaine preservative free
• Group D: Dexmedetomidine 1 mcg /kg with 40 mL of 0.5% lignocaine preservative free.
Data collection: Independent samples t-test was used for evaluation of demographic data, haemodynamic data, block characteristics,. duration of surgery and tourniquet, onset of tourniquet pain, duration of analgaesia and intraoperative analgesic requirement.

A thorough preoperative evaluation was done in preoperative visit and the nature of procedure along with its complications was explained and written informed consent was obtained. Visual Analogue Scale (VAS) scoring system was explained before the surgery 0 as ‘no pain’ and 10 as ‘worst pain’.

Procedure

Lignocaine 0.5% was constituted by adding 30 mL normal saline to 10 mL of 2% preservative-free lignocaine.

On the day of surgery, 8 hours of NBM was confirmed, antibiotic was given before shifting the patient to the Operation Theater (OT). In OT patients baseline non invasive blood pressure, pulse rate, Electrocardiogram (ECG) was recorded. A 22-gauge i.v. cannula was secured into the distal vein of the operating limb (12). One more i.v. cannula was secured in non operating hand to administer drug or fluids, if needed in case of emergency. Two tourniquets were tied over the cotton pad in the arm of operating limb (Table/Fig 2).

Operating arm was exsanguinated using the Esmarch bandage and the arm was kept elevated for 2 minutes (Table/Fig 3). Proximal tourniquet inflated to 100-150 mmHg above the patient’s systolic blood pressure. Pulse oximetry was used for radial artery pulsation confirmation. A 40 mL of test solution was injected slowly over 180 sec by an anesthesiologist who was blinded to the study drug (7). The sensory block was assessed by pinprick every 30 sec and sensory onset was evaluated in dermatomal distribution. Motor onset was checked by asking the patient to do some voluntary movements. Sensory and motor onset was noted. Onset of sensory block was noted from administering study drug to absence of pinprick sensation in required dermatome. And onset of motor block was noted from injection of drug to absence of motor movements. After achieving sensory and motor block distal cuff was inflated and then proximal cuff was deflated.

Parameters monitored: Basic haemodynamic parameters were monitored before induction like Mean Arterial Pressure (MAP), Heart Rate (HR), it was monitored before tourniquet inflation and also at 5, 10, 15, 20 and 40 min after the injection of study drugs. Hypotension was treated with i.v. ephedrine and bradycardia (>20% decrease from baseline) was treated with i.v. atropine 0.6 mg.

Tourniquet pain scores: The Tourniquet pain scores was assessed by:

• VAS between 0 and 10 (0 - “no pain” and 10 - “worst pain imaginable”) (8).
• Sedation by Modified Ramsay sedation score (9) before tourniquet application and after the injection of anesthetic drug.

Intraoperatively, intravenous inj.paracetamol 15 mg/kg was given for tourniquet pain if needed. The tourniquet was not inflated for more than 1hr 30 mins and it was not deflated before 30 mins, even if the procedure was short. Sensory and motor recovery time was recorded. The VAS score was recorded 30 min after tourniquet deflation and at frequent intervals for 24 hrs. Patients were given 15 mg/Kg i.v paracetamol once they complained of pain in the postanaesthesia care unit. The duration of analgaesia was taken as the time between tourniquet release and first rescue analgaesia. If there was no usage of inj.paracetamol for 24 hrs, then duration of analgaesia was considered as 1440 min (3).

Patient and surgeon satisfaction: This was Patient and surgeon satisfaction was also recorded as:

• Very satisfied-5
• Satisfied-4
• Neutral-3
• Dissatisfied-2
• Very dissatisfied-1.

All the measurements were performed by an anesthesiologist who was blinded to the medication administered. All complications and adverse effect were recorded.

Statistical Analysis

Data were entered in Microsoft excel software and analyzed using STATA software version 12.0 (manufactured by Stata Corp LP, College station, Texas). Independent samples t-test was used for evaluation of demographic data, haemodynamic data, block characteristics, duration of surgery and tourniquet, onset of tourniquet pain, duration of analgaesia and intraoperative analgesic requirement. For all the statistical interpretation p-value <0.05 was considered as significant.

Results

With respect to the basic demographic parameters of both the groups were comparable (Table/Fig 4).

The mean time required for onset of sensory block (min) was faster in group C compared to group D.Time required for the regression of sensory and motor block was faster in group C (Table/Fig 5).

The duration of surgery, tourniquet pain and duration of tourniquet time was statistically not significant. However, the total duration of analgaesia in group D was significantly longer than group C (Table/Fig 6).

The difference observed in pulse rate and MAP among the both groups at various time intervals was not statistically significant (Table/Fig 7). After distal tourniquet deflation, there was a slight drop in mean pulse rate and MAP in group D which was statistically significant when compared with group C, but not significant enough that it required treatment.

The pain experienced by the group C (205.14±37.76 mins) patients was early as compared to group D (345±44.52 mins). While studying the complications it was observed that among the group C one patient had hypotension and from group D one had bradycardia. There were no sedation, dry mouth, nausea, vomiting or urinary retention in any of the patients.

The patient’s satisfaction was more among group D (62.86% were satisfied) as compared to group C (34.29% were satisfied). The Surgeon’s satisfaction score was better in the group D (88.57% were satisfied) as compared to group C (82.86% were satisfied) but the difference observed was not statistically significant (Table/Fig 8).

Discussion

The technique of IVRA has been significantly improved and simplified since August Bier's historical "Venous Anaesthesia" was published. It's great for ambulatory or short operative surgeries on the extremities that need only a few minutes of surgery. The inability to administer postoperative analgaesia is a disadvantage of this approach (10).

Thakur A et al., studied different doses of dexmedetomidine (0.5 mcg/kg and 1 mcg/kg) in axillary brachial plexus block. They found that mean duration of analgaesia was more with 1 mcg/kg than 0.5 mcg/kg without any significant side effects. So, 1 μg/kg as a dose for dexmedetomidine was considered (11).

To improve the quality of anaesthesia by IVRA and postoperative analgaesia various additives like opioids, muscle relaxants, NSAIDs, ketamine and lornoxicam have been studied but satisfactory results appear to be less (12),(13).

This study was carried out to find the action of dexmedetomidine and clonidine with respect to duration of analgaesia, onset of sensory and motor, regression of sensory and motor and its side-effects. It was found that onset of sensory and motor was faster and duration of analgaesia was prolonged with dexmedetomidine with minimal side-effects.

In group C, only two patients had onset of sensory block within 2 mins , 33 patients had onset of sensory block between 3-5 mins.Whereas in group D only two patients had onset of sensory block between 3-5 mins all other patients had onset within 3 mins.The mean time required for onset of sensory block (min) among group D patients was earlier compared to group C. About 29 patients from group D had faster onset of motor block within 1-3 mins but none in group C. In group C all patients had onset of motor block from 5-8 mins. Time required for the onset of motor block in group D was shorter compared to group C.

Sardesai SP et al., conducted a similar study comparing clonidine 1 μg/kg and dexmedetomidine 1 μg/kg as adjuncts to 0.5% lignocaine in biers block. They found that onset of sensory block in dexmedetomidine group was earlier (4.28±1.23 min) compared to clonidine group ( 6.18±1.07 min). Similarly, onset of motor block was 11.27±1.66 min in group C and 8.63±1.86 min in group D, suggesting that onset of motor block was faster in dexmedetomidine group than in clonidine group. In this study, onset of motor block was much earlier i.e within 1-3 mins. But study showed faster onset of sensory and motor in dexmedetomidine group (3). Hence, results of this study correlates with the present study findings.

Rayan AA and El Sayed AA, investigated the efficacy of dexmedetomidine in IVRA by giving it as an adjuvant to LA (0.5 mcg/kg) and intravenous systemic infusion (1 mcg/kg). Onset of sensory block when dexmedetomidine added as adjuvant was faster compared to plain lignocaine group and dexmedetomidine infusion group. They found that there was faster onset of motor block (12.3±3.5 min vs 14.6±4.9 min) when dexmedetomidine was added as an adjuvant to LA as compared to systemic infusion. The result coincides with the findings of this study (13).

In group D, only one patient complained of tourniquet pain, in group C, five patients complained of tourniquet pain, even though group D showed less tourniquet pain compared to the other, it was statistically not significant in the present study. In group C almost 17 patients had regression of sensory block within 5 mins, rest of the patients also had regression within 7 mins. Whereas, in group D only two patients had regression of sensory block within 5 mins. It was seen that the time required for regression of sensory blocks was more in group D as compared to group C and the difference observed was statistically significant. None of the patients in group D and C had regression of motor block within 5 mins. Total 34 patients in group D regression within 7-9 mins, but only 15 patients from group C had regression of motor block within 7-9 mins.

So, the time required for regression of motor block was more in group D as compared to group C and the difference observed was statistically significant. These findings were similar to the study conducted by Sardesai SP et al., (3).

Abdelkader AA et al., studied and evaluated the addition of dexmedetomidine 0.5 mcg/kg to lidocaine in IVRA and found that regression time for sensory block was 5.3±0.7 min in group L and 7.65±1.3 min in group LD showing prolonged effect in dexmedetomidine group. Mean while, regression time of motor block was 3.8±0.8 min in lidocaine group vs 6±0.7min in dexmedetomidine group suggesting prolonged regression time of motor block in dexmedetomidine group, where p-value <0.05, which is statistically significant. Hence, their results are consistent with the findings of the present study (14).

There was no significant change in mean pulse rate and mean arterial pressure among the group C and group D patients. After the deflation of distal tourniquet there was a slight drop in MAP in group D which was statistically significant when compared with group C, but not significant enough that it required treatment, which resolved on its own (Table/Fig 7).

Tourniquet pain was assessed by using Visual Analogue Scale (VAS) of 0-10. A score of 0 was given for no pain and 10 for intolerable pain (15). Rescue analgaesia was given when VAS ≥3. In group C (6.31±15.75) patients experienced pain compared to group D (1.31±7.78). It was observed that pain experienced by the group C patients was early as compared to group D and the difference observed in pain on VAS was statistically significant in the present study.

Nasr YM and Waly SH, studied haemodynamic changes following administration of dexmedetomidine to lignocaine in IVRA, found that there was fall in blood pressure and heart rate with dexmedetomidine group after the release of tourniquet, which was similar to the present findings (16).

Subramanya V et al., studied dexmedetomidine 0.5 mcg/kg with lignocaine for IVRA, they used VAS score for assessing the postoperative pain. In their study they found that patients in the dexmedetomidine group had less pain in the first 6 hours after deflation of tourniquet compared to only lignocaine group which was consistent with the current study. The total duration of analgaesia was considered from deflation of distal tourniquet to patient receiving rescue analgaesic (17).

The average total duration of analgaesia among the group C patients was more among group D patients when compared to group C and the difference observed was statistically significant (Table/Fig 5) which was similar to the study conducted by Sardesai SP et al., (3).

Dexmedetomidine and clonidine have been compared in various other studies. Kasirajan G, studied the effect of clonidine 1 mcg/kg and dexmedetomidine 1 mcg/kg as adjuncts to ropivacaine in caudal analgaesia found that the dexmedetomidine group had a longer duration of postoperative analgaesia (18). Swami SS et al., compared dexmedetomidine 1 mcg/kg and clonidine 1 mcg/kg as an adjunct to local anaesthesia in supraclavicular nerve blocks. They found that the duration of analgaesia was more in group D compared to group C, which was consistent with the current study (19).

Patient satisfaction score and surgeon satisfaction score was more among group D compared to group C in the present study. Sardesai SP et al., in their study they found that patient satisfaction was significantly higher in Group D, which showed similar results like the present study (3).

Complications: The expected complications were hypotension, bradycardia, sedation, dry mouth, nausea, vomiting and urinary retention .While studying the complications it was observed that among group C one patient had hypotension and one had bradycardia from group D.

According to the study by Sardesai SP et al., they did not observe any side-effects like sedation, hypotension or bradycardia in both clonidine and dexmedetomidine group (3). Chatrath V et al., compared clonidine 1 mcg/kg and dexmedetomidine 1 mcg/kg in IVRA, they observed that haemodynamic parameters were stable and no side-effects were noted which was similar to this study (20).

Limitation(s)

In this study patients requiring tourniquet for more than 90 minutes were not included. The efficacy of α receptor agonists was not compared with other group of drugs like opioid, NSAIDs, muscle relaxants.

Conclusion

Dexmedetomidine is an excellent adjuvant when added to lignocaine for IVRA, in view of their block quality which includes both sensory and motor onset and regression, postoperative analgaesia and it also has minimal side effects. Hence, it is recommended to use dexmedetomidine as an effective adjunct to lignocaine for IVRA.

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DOI and Others

DOI: 10.7860/JCDR/2022/56280.16514

Date of Submission: Mar 11, 2022
Date of Peer Review: Apr 21, 2022
Date of Acceptance: May 09, 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. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Mar 21, 2022
• Manual Googling: May 05, 2022
• iThenticate Software: May 07, 2022 (17%)

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