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

Users Online : 72146

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 : March | Volume : 16 | Issue : 3 | Page : UC01 - UC04 Full Version

Efficacy of Different Doses of Cisatracurium for Intubation for Surgeries under General Anaesthesia- A Randomised Clinical Study


Published: March 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/50991.16061
Sana Ahmed Shaikh, Arati Bhaskar Jadhav, Archita Rajaram Patil, Anupama Deepak Sahasrabudhe

1. Senior Resident, Department of Anaesthesiology, D. Y. Patil Medical College, Kolhapur, Maharashtra, India. 2. Assistant Professor, Department of Anaesthesiology, D. Y. Patil Medical College, Kolhapur, Maharashtra, India. 3. Associate Professor, Department of Anaesthesiology, D. Y. Patil Medical College, Kolhapur, Maharashtra, India. 4. Associate Professor, Department of Anaesthesiology, D. Y. Patil Medical College, Kolhapur, Maharashtra, India.

Correspondence Address :
Dr. Anupama Deepak Sahasrabudhe,
Indumati Road, 247/12, Shashi Bungalow ‘E’ Ward, Tarabai Park, Kolhapur, Maharashtra, India.
E-mail: dranuds@gmail.com

Abstract

Introduction: Cisatracurium is a new non depolarising, Neuromuscular Blocking Drug (NMBD) with fast onset and short duration of action. It is a stereoisomer of atracurium with a potency of approximately three to four times greater than that of atracurium. As it is devoid of histamine release, it reduces the chances of adverse effects during operative procedures. However, the optimum intubating dosage needs to be established in patients. This warrants the need for studies focusing on the efficacy of different doses of cisatracurium and their outcomes.

Aim: To study the efficacy of three different doses of cisatracurium {2x Effective dose (ED) 95, 4x ED95, and 6x ED95} for the time of onset of action, duration and haemodynamic stability offered for intubation.

Materials and Methods: A double-blind, randomised clinical study was conducted from December 2017 to July 2019 at a tertiary care hospital and research centre, Kolhapur, Maharashtra, India. Total 90 patients, undergoing surgeries under general anaesthesia were allocated into three groups, group A received 0.1 mg/kg, group B received 0.2 mg/kg and group C received 0.3 mg/kg of cisatracurium. Time taken for Train Of Four (TOF) to reach 0 was taken as the onset of action, and appearance of TOF two, three or patient’s attempt to breathe was taken as duration of action. Haemodynamic changes were also assessed preoperatively and postintubation immediately after confirmation of placement of ETT.

Results: Mean age 33.23±6.26 years in group A, 37.70±10.80 years in group B, 38.23±8.764 years in group C (p-value=0.06). Least time was required for the TOF to become zero by group C (5.10±1.01 minutes) as compared to groups A and B (9.91±1.39 and 7.48±1.45 minutes) which was statistically significant (p-value <0.001). The duration of action was also more in group C (49.83±5.33) compared to group A (27.23±6.97) and group B (36.17±7.62) (p-value=0.00001). Group C had better haemodynamic stability as the heart rate remained more stable than group A and group B.

Conclusion: Higher dose of cisatracurium provides faster onset, longer duration of action with better cardiovascular stability. This predictable recovery from non depolarising muscle relaxation makes it a good choice of muscle relaxant agent for intubation.

Keywords

Haemodynamic, Histamine release, Intubation, Muscle relaxant, Stereoisomerism

Muscle relaxants or neuromuscular blocking agents are used during surgery to keep the patient immobile during general anaesthesia. In recent years, muscle relaxation has become an inevitable part of anaesthesia, intensive and emergency care (1),(2). It is routinely being used for procedures like endotracheal intubation and during surgery thereby facilitating immobilisation of patients. When administered in optimal concentrations followed by regular top-ups or continuous infusion, it contributes to the safety of the patients as well (3).

The first neuromuscular blocking agent to be used was called curare. It was used in 1942 by Harold Griffiths and Enid Johnson for relaxation in abdominal surgeries. Following this, many neuromuscular blocking agents such as alcuronium, tubocurarine, and gallamine were discovered, but are no more used due to the adverse effects they produce (4). Atracurium was the first non depolarising muscle relaxant discovered. The duration of effect is limited by its metabolism by Hofmann’s degradation and not dependent on the liver or renal function as is the case with other depolarising agents. However, it is associated with adverse effects like flushing, erythema, bradycardia, bronchospasm, and dyspnoea resulting due to the release of histamine (5).

Cisatracurium is one of the 10 stereoisomers of atracurium, which is devoid of histamine release (6). It is an intermediate-acting, non depolarising NMBD, with minimal cardiovascular side-effects (3). It acts as a competitive antagonist to acetylcholine and binds to nicotinic cholinergic receptors at the muscle motor endplate. As acetylcholine cannot bind anymore on these receptors, end-plate potential cannot develop. The neuromuscular blocking potency of cisatracurium is proposed to be almost three times that of atracurium (7). It undergoes degradation by Hoffmann reaction, and the liver and kidneys play only minor roles in its metabolism and elimination.

Generally, the recommended dose of cisatracurium for induction ranges between 0.1-0.2 mg/kg, although it could vary in patients who are critically ill (8). Currently, studies comparing different ED of cisatracurium are scarce, and performed for a particular set of surgeries (9),(10). The present study aimed to study the efficacy of three different doses of cisatracurium for intubation during general anaesthesia, in different types of surgeries. The primary outcome was the time required for intubation (onset of action) and secondary outcomes were duration of action and haemodynamic stability.

Material and Methods

A double-blind, randomised clinical study was conducted from December 2017 to July 2019 at a D. Y. Patil Medical College, tertiary care hospital and research centre, Kolhapur, Maharashtra, India. Approval was obtained from the Institutional Ethics Committee (DMCK/129/2017). An informed consent letter was obtained from each patient.

Sample size calculation: The mean pulse rate recorded after one minute of intubation was 102.62 with SD of ±4.06 in group A and 99.57±3.35 and after five minutes 98.02 with SD of ±3.35.

Sample size n= (Zα/2 + Zβ)2×2×σ2 / d2

N1=30, so this is sample size of one group. In group A=30, group B=30 and group C=30. Total sample size=90.

Zα1/2=(?/2)th quantile of normal distribution

Zβ=(β)th quantile of normal distribution

D=difference in means

σ2=population variance

Sample size calculated is around 90 at 95% confidence interval. Sample size of 30 was taken in each group, so our total sample size=90 i.e 30 in each group A,B and C respectively.

Inclusion criteria: A total of 90 patients between 15-65 years, belonging to American Society of Anesthesiologists (ASA) grade I or II and requiring endotracheal intubation to undergo surgery under general anaesthesia were selected. Patients with Mallampati Class 1 and 2, thyromental distance >6.5 cm, adequate neck mobility were included in the study.

Exclusion criteria: Patients of ASA Grade 3 or more, Mallampati Class 3 or more, thyromental distance <6.5 cm, short neck, restricted neck mobility, and history of allergy were excluded from the study.

Patients were allocated randomly into three groups:

• Group A- 0.1 mg/kg
• Group B- 0.2 mg/kg
• Group C- 0.3 mg/kg

Randomisation was done using a computer-generated randomisation chart. Both the anaesthesiologist and patient were blinded. The preparation of medication according to the allocated group was done by a nurse, who was trained and qualified for such activity. The drug was prepared in 10 mL for all the groups (Table/Fig 1).

A day before the surgery, all patients were assessed for their clinical history, detailed clinical examination, and investigation. Clinical history was elicited to rule out symptoms of any cardiovascular, respiratory, hepatic, renal, or metabolic disease. Clinical examination included a general examination, systemic examination, and airway assessment to assess the functional status of the patients.

Study Procedure

All patients were kept nil by mouth for six hours before the surgery, in the operation theatre, intravenous access was secured for all patients. A baseline reading of pulse, blood pressure, and oxygen saturation were noted. Neuromuscular monitoring was carried out along with the use of clinical judgment. The adductor pollicis muscle of either hand was monitored for neuromuscular monitoring. Electrodes were applied on the volar side of the wrist. The distal electrode was placed 1 cm proximal to the point where the proximal flexion crease of the wrist traverses the radial side of the tendon extending towards the flexor carpi ulnaris muscle and the proximal electrode was positioned 3 cm proximal to the distal electrode. All patients received premedications consisting of injection glycopyrrolate -0.004 mg/kg Intravenous (i.v), injection ondansetron 0.1 mg/kg i.v., injection omeprazole 40 mg/kg i.v. in 500 mL Normal Saline (NS) over 30 minutes, injection metoclopramide 10 mg i.v., injection midazolam 0.05 mg/kg i.v. and injection fentanyl 2 mcg/kg i.v..

Anaesthesia was induced with injection propofol 2 mg/kg and after the patients were under anaesthesia as judged by the loss of eyelash reflex and could be ventilated well with, bag and mask ventilation. Inj. cisatracurium (CISATRA, Themis India, 2 mg/mL) was administered in the required dose according to the groups they belonged to group A, group B and group C. The investigator injected the drug prepared by the nurse according to the randomisation schedule and monitored the TOF. Inhalational agent sevoflurane was used to achieve a Minimum Alveolar Concentration (MAC) value of 1.0 until TOF, 0 was achieved, i.e., satisfactory intubating conditions were achieved to maintain the depth of anaesthesia. After 90 seconds of injection of cisatracurium, TOF was observed every 30 seconds until it reached 0 using the TOF watch Inmed device (Inmed Equipments Pvt. Ltd., Vadodara, Gujrat, India).

Once the TOF score reached 0, endotracheal intubation was performed. Laryngoscopy and endotracheal intubation was carried out using MacIntosh laryngoscope blade no. 3 by one of the senior investigators who was not a part of the study. Airway secured by using appropriate size cuffed portex endotracheal tube (males 8-8.5, females- 7-7.5) and secured with tape after confirmation of air entry by chest auscultation as bilaterally equal and end-tidal carbon dioxide monitoring. Vitals are recorded postintubation to assess the intubation response.

Anaesthesia was maintained with oxygen/air/sevoflurane. The TOF was assessed every five minutes after 20 minutes of intubation to find the duration of action of cisatracurium. The clinical duration of action of each patient was noted until the time of attempts to start breathing or a TOF score of 2 or 3 was seen. Patients were monitored clinically for any adverse effects of histamine release. The drug dose was not revealed to the investigator who conducted the intubations to avoid bias in the results.

Statistical Analysis

Descriptive data analysis was performed by R studio with version 1.2.5001 software. The categorical data were compared, and associations were calculated using the R-Studio, v1.2.5001. The p-value ≤0.05 were statistically significant. In the given study total 3 groups are comparatively studied and under each group total of 30 sample size was collected. Analysis of variance (ANOVA) and Kruskal-Wallis test was done for finding the significant mean difference in those three groups. Paired t-test was used to find the statistical difference between pre operative and postintubation vitals.

Results

The three groups A, B, and C had no difference based on the demographic parameters and Body Mass Index (BMI) (Table/Fig 2). The common surgeries that were performed were tonsillectomy (n=18, 20.00%), cholecystectomy (n=22, 24.44%), laparoscopic appendectomy (n=31, 34.44%) and diagnostic laparoscopy (n=10, 11.12%).

The time required for (onset of action) TOF to become 0 was assessed. Least time was taken by group C with a mean of 5.10±1.01 minutes as compared to group A and B, 9.91±1.39 minutes, and 7.48±1.45 minutes, respectively and was found to be statistically significant (p-value ≤0.05) (Table/Fig 3). Similarly, the duration of action was also found to be significantly different among groups. Group C had the longest duration of action with a mean of 36.17±7.62 minutes compared to group A with a mean of 27.23±6.97 minutes, and group B with a mean of 36.17±7.62 minutes (Table/Fig 3). The difference in duration was statistically significant as the p-value <0.001. There was good jaw relaxation and satisfactory intubating conditions in all the groups, irrespective of the dose. The mean heart rate varied significantly in groups A and B between the preoperative period and postintubation, the p-values being p-value <0.001 and p-values <0.001, respectively. No significant differences in heart rate was noted between the preoperative period and postintubation in group C (p-value <0.001 (Table/Fig 4). The Systolic Blood Pressure (SBP) varied significantly in preoperative and postintubation in all the groups, Diastolic Blood Pressure (DBP), varied significantly in group A and C , but not in group B (Table/Fig 4).

By using paired t-test it was found that SBP shows a significant difference between preoperative and postintubation vitals in groups A, B, and C, which is due to the pressor response to intubation. DBP also showed a significant difference between preoperative and postintubation vitals, in groups A and C only but group B showed better stability. HR shows a significant difference between preoperative vitals and postintubation in groups A and B respectively, but group C was more stable (Table/Fig 5). No adverse response nor other complications were noted in any of the patients, regardless of the dose used.

Discussion

Neuromuscular blocking agents are frequently used for the relaxation of the skeletal muscle during tracheal intubation in patients undergoing surgeries under general anaesthesia. An ideal anaesthetic agent should have a rapid onset, good muscle relaxation, predictable clinical duration of action, better haemodynamic stability, without residual paralysis, and without posing any complications (3),(11). Cisatracurium, a derivative of atracurium, has been proposed to be a molecule of choice and it is devoid of histamine release. Cis atracurium has been used in various types of surgeries like abdominal surgeries (12), laparoscopic surgeries, (13) gynaecological procedures (14), spine surgeries (15), and even in Intensive Care Unit (ICU) as well (8). This study evaluated three different doses of cisatracurium for the onset of action, duration of action, and haemodynamic stability offered. Three groups were matched regarding age and sex. Higher doses showed faster onset of action with a longer duration. Heart rate remained more stable during intubation with the higher dose of cisatracurium. SBP was increased in all three groups as a stress response to intubation. Group B had stable DBP compared to the other two groups. Overall haemodynamic stability offered was inconclusive.

Polovnikov EV et al., studied 24 women of class III and IV obesity posted for gynaecological procedures divided into two groups receiving 0.15 mg/kg according to real body weight and 0.15 mg/kg, ideal body weight. Patients who received doses related to ideal body weight showed better control (14). Dose-dependent prolongation of action was seen in patients who received dosing according to real body weight. This new isomer of atracurium has a wide range of intubating doses. The present study evaluated three different intubating doses of cisatracurium 2x ED95, 4x ED95, and 6x ED95.

Atef H et al., compared atracurium and three doses of cisatracurium for abdominal surgeries (12). They found two ED dose of Atracurium showed faster onset of action (3.24±0.55) than two ED dose of ci-atracurium (4.37±0.46), but four ED of cisatracurium dose showed faster onset of action (2.9±1.4) than atracurium (3.24±0.55). In this study, faster onset of action was found with a higher dose of cisatracurium, six ED dose had the fastest onset. Aswani B et al., compared between two doses 0.1 mg/kg (2×ED95) and 0.2 mg/kg (4×ED95) of cisatracurium for its intubating conditions, haemodynamic response and any untoward effects; and found that higher dose (4× times the ED95 dose) provides excellent intubating conditions and stable haemodynamic (6).

In the present study, the heart rate varied significantly among groups A, B, and C, corresponding to the different doses of cisatracurium (0.1 mg/kg, 0.2 mg/kg and 0.3 mg/kg). This the difference was more pronounced in postintubation vitals (p-value <0.0001) than the preoperative period. The lowest heart rate and closest to the preoperative value was reported in group C (0.3 mg/kg) suggests better maintenance of heart rate than groups A and B. Better muscle relaxation provided by a higher dose probably results in better heart rate stability. Cao Q et al., used three doses of cis atracurium (low dose- 0.15 mg/kg body weight, medium dose 0.2 mg/kg and high dose 0.3 mg/kg ) for radicle resection of lung cancer.They found better haemodynamic stability with the higher dose of cisatracurium, which is concurrent to the present study (10).

A similar trend of the higher dose of cisatracurium to provide a more stable heart rate has also been reported by Atef H et al., as well (12). It has been well suggested in previous studies that the SBP and DBP varied insignificantly between groups, both in the preoperative period and postintubation. The duration of action (minutes) for group A was 27.23 with an SD of 6.971and for group B was 36.17 with SD of 7.621 (0.1 mg/kg and 0.2 mg/kg, respectively) but increased significantly in group C to 49.83 with an SD of 5.331 (0.3 mg/kg). The duration of action here was however far shorter than in other studies. The reason for this difference may be related to the potency of the drug which is affected by inadequate maintenance in the cold chain during transport and storage of the drug. Likewise, Atef H et al., also reported a prolonged duration of action with increasing cisatracurium concentration (12).

No adverse events were reported in any of the cases, advocating the safety of the doses used for the study, similar to previous studies as cisatracurium is known to induce mast cell activation and pseudo-allergic reactions (5). Other important factors which are needed to be considered on deciding the cisatracurium dose for intubation is BMI (15), desired time of intubation and the anticipated length of surgery.

The principal advantage of cisatracurium is the lack of histamine release which provides better cardiovascular stability as compared to atracurium and other histamine-releasing NDMR. Also, faster onset, longer duration of action with larger doses of cisatracurium 4xED95 (0.2 mg/kg), which also provides better cardiovascular stability, thus making it a good muscle relaxant agent for endotracheal intubation in clinical practice. This study covers different types of surgeries under general anaesthesia, thereby ruling out surgery-specific deviations in the outcomes.

Limitation(s)

This was a single-centre study. Further studies in a target population with hepatorenal involvement are required to test the efficacy of the drug since this study was carried out among the general population. Authors used TOF for the onset and duration of action. Advanced monitors are available in the market which can give more precise readings.

Conclusion

The efficacy of cisatracurium is more at higher doses. It provides cardiovascular stability, predictable recovery from Non depolarising Neuromuscular Blockers, thus making it a good choice for a muscle relaxant agent during endotracheal intubation in clinical practices. It can be used in different types of surgeries in combination with anaesthetics in maintaining haemodynamic parameters.

References

1.
Tariq Hanifi M, Matthew Kynes J, Garfield JM. Monitoring of neuromuscular blockade. In: Essential Clinical Anaesthesia Review: Keywords, Questions, and Answers for the Boards. 2015. pp. 104-06. [crossref]
2.
Krizan S, Eche M, Wong A, Patel P, Stevens J. 1103: Impact of a standardized dosing and titration protocol on cisatracurium requirements for ARDS. Crit Care Med. 2020;48(1):531-31. [crossref]
3.
Petitpain N, Argoullon L, Masmoudi K, Fedrizzi S, Cottin J, Latarche C, et al. Neuromuscular blocking agents induced anaphylaxis: Results and trends of a French pharmacovigilance survey from 2000 to 2012. Allergy Eur J Allergy Clin Immunol. 2018;73(11):2224-33. [crossref] [PubMed]
4.
Gallamine. Meyler’s Side Eff Drugs. 2016;505. [crossref]
5.
Che D, Rui L, Cao J, Wang J, Zhang Y, Ding Y, et al. Cisatracurium induces mast cell activation and pseudo-allergic reactions via MRGPRX2. Int Immunopharmacol. 2018;62:244-50. [crossref] [PubMed]
6.
Aswani B, Kumar AA, Vijayakumar D, Balamurugan B. Comparison of efficacy of atracurium versus cisatracurium in patients undergoing surgeries under general anaesthesia. Ann Trop Med Public Heal. 2020;23(15). [crossref]
7.
Cisatracurium besilate. React Wkly. 2019;1775(1):126-26. [crossref]
8.
Liu X, Kruger PS, Weiss M, Roberts MS. The pharmacokinetics and pharmacodynamics of cisatracurium in critically ill patients with severe sepsis. Br J Clin Pharmacol. 2012;73(5):741-49. [crossref] [PubMed]
9.
Shrey S, Singam A. A comparative study of atracurium and cisatracurium in paediatric cleft lip and cleft palate surgeries. Res J Pharm Technol. 2020;13(2):867-70. [crossref]
10.
Cao Q, Tian X, Dong C, Bu H, Cheng Y. Effects of different doses of cisatracurium besilate on hemodynamics and postoperative cognitive function in patients undergoing radical resection of lung cancer. Oncol Lett. 2019;18(2):1761-66. [crossref] [PubMed]
11.
Maybauer DM, Geldner G, Blobner M, Pühringer F, Hofmockel R, Rex C, et al. Incidence and duration of residual paralysis at the end of surgery after multiple administrations of cisatracurium and rocuronium. Anaesthesia. 2007;62(1):12-17. [crossref] [PubMed]
12.
Atef H, Helmy A, El-Nasr Ma, El-Kasaby A. Cisatracurium in different doses versus atracurium during general anaesthesia for abdominal surgery. Saudi J Anaesth. 2010;4(3):152. [crossref] [PubMed]
13.
A Tank N. A Study of haemodynamic and pharmacodynamic effects of cisatracurium and vecuronium in patients undergoing laparoscopic. Indian J Anaesth Analg. 2020;7(3):829-34. [crossref]
14.
Polovnikov EV, Elizar’eva NL, Kolosov AN, Shmakov AN, Kokhno VN, Loktin EM. Cysatracurium dosing in gynecological laparoscopic surgery in obese patients. Kuban Sci Med Bull. 2020;27(4):62-71. [crossref]
15.
Hans P, Welter P, Dewandre PY, Brichant JF, Bonhomme V. Recovery from neuromuscular block after an intubation dose of cisatracurium and rocuronium in lumbar disc surgery. Acta Anaesthesiol Belg. 2004;55(2):129-33.

DOI and Others

DOI: 10.7860/JCDR/2022/50991.16061

Date of Submission: Jun 21, 2021
Date of Peer Review: Sep 25, 2021
Date of Acceptance: Dec 01, 2021
Date of Publishing: Mar 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: Aug 08, 2021
• Manual Googling: Nov 16, 2021
• iThenticate Software: Jan 06, 2022 (10%)

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