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On Sep 2018

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"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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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.
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Dr. Mamta Gupta
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Aug 2018

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"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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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.
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Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
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.
On April 2011

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
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : May | Volume : 16 | Issue : 5 | Page : UC05 - UC08 Full Version

Comparison between Haemodynamic Responses of Propofol Induction between BIS Guided Dose and Sleep Dose: A Randomised Control Trial

Published: May 1, 2022 | DOI:
Sentila Shangne, Kasomhung Soreingam, Sinam Neetu Devi, Keisham Upendra Singh, Laishram Rani Devi, Kalpana Thongram, Bishakha Keishab, Rakesh Nongthombam

1. Post Graduate Trainee, Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India. 2. Assistant Professor, Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India. 3. Senior Resident, Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India. 4. Professor, Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India. 5. Post Graduate Trainee, Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India. 6. Post Graduate Trainee, Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India. 7. Post Graduate Trainee, Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Institute of Medical Sciences, Imphal, M

Correspondence Address :
Dr. Rakesh Nongthombam,
Associate Professor, Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Institute of Medical Sciences, Porompat-795001, Imphal, Manipur, India.


Introduction: Propofol contributes largely in the rapid evolution of day care surgery due to its superior recovery characteristics. However, it is associated with dose-dependent systemic arterial hypotension which increases morbidity and mortality. Bispectral index or BIS is an Electroencephalographic (EEG) derived parameter used to assess the depth of anaesthesia. Titrating drugs to a specific BIS value during general anaesthesia allows to adjust the dose of anaesthetic needed by the patient thereby, reducing the dose related side-effects.

Aim: To determine whether the dose of propofol guided BIS values causes less arterial hypotension than the commonly used sleep dose method.

Materials and Methods: The present study was a randomised control trail conducted on 92 patients of American Society of Anesthesiologists (ASA) I and II physical status, aged 18-60 years, of both genders, scheduled for elective surgeries under general anaesthesia and were randomly divided into group A and B (46 in each). For induction of anaesthesia, Group A received propofol till the BIS values reached 50±1 for 30 seconds, while Group B received sleep dose of propofol without BIS monitoring. Haemodynamic effects Heart Rate (HR), Diastolic Blood Pressure (DBP), Systolic Blood Pressure (SBP) and Mean Arterial Pressure (MAP) were recorded at baseline, during induction and at 1, 5, 10 and 15 minutes after intubation. Total propofol consumption and secondarily, level of sedation after extubation using Ramsay Sedation Scale were also measured in both the groups.

Results: The total dose requirement of propofol was reduced significantly in group A compared to group B (p<0.005). Blood pressure decreased from the baseline in both the groups following induction with propofol but was insignificant. HR increased by 2.2% in group A while it decreased by 8.5% in group B but was insignificant (p>0.005). On arrival to Post Anesthesia Care Unit (PACU), group A were more co-operative, oriented patients compared to group B (67.4% vs 32.6% respectively).

Conclusion: BIS monitoring significantly reduces the consumption of propofol for induction of anaesthesia while the incidence of hypotension was similar in both the groups. Lower sedation level with comparatively better extubation score with the use of BIS helps in fast tracking.


Day care surgery, Extubation, General anaesthesia, Sedation

Ambulatory or day-care surgery has gained wide popularity throughout the globe. The fast pace of life, need of early return to work and the potential benefits of shorter hospital stay, lower procedural cost, shorter surgical waiting list has led to its widespread acceptance (1). Rapid and satisfactory procedural outcome owing to advancements in anaesthesia technique, availability of newer drugs like propofol and sophisticated monitors like BIS monitors have contributed immensely to the progress of day-care surgeries. Studies have shown that ambulatory surgery provides better respiratory and cardiovascular outcomes, facilitating early post-operative recovery with fewer complications (2),(3).

Propofol, a hypnotic inducing agent contributes largely in the rapid evolution of day-care surgery due to its rapid onset, adequate depth of anaesthesia and rapid recovery (4),(5). However, it causes dose dependent systemic arterial hypotension and bradycardia due to reduced systemic vascular resistance.

BIS is and EEG derived parameter which is used to assess the depth of anaesthesia/sedation. It can be used to reflect propofol concentration in the blood. Titrating drugs to a specific BIS value during general anaesthesia allows to adjust the dose required by the patient, thereby reducing the dose related side-effects of the drug (6),(7). It is known that propofol, when used as an induction agent during general anaesthesia, causes intraoperative hypotension. This can be prevented by targeting a clinical end point during induction either with BIS guided or sleep dose. This may in addition provide a favourable outcome during extubation and postoperative period. Therefore, it was hypothesised that BIS guided dose adjustment of intravenous propofol provide a stable haemodynamic profile, smooth extubation and alertness during postoperative period.

As one of the most commonly used induction agents in general anaesthesia, propofol dose optimisation is required to avoid haemodynamic instability. The present study aimed to determine whether the dose of propofol guided by BIS values causes less arterial hypotension than the commonly used sleep dose method. The primary outcome was to compare the haemodynamic responses of propofol during induction in terms of SBP, DBP, MAP and HR between BIS guided dose and sleep dose method. The secondary outcome was to compare the extubation score and sedation after extubation using Ramsay Sedation Scale (8).

Material and Methods

This randomised control trail was conducted from September 2020 - January 2022 at Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India. The Institutional Ethical Committee (IEC) had approved the study (vide protocol no.183/6/PGT-2019).

Inclusion criteria: Consenting male and female patients, between 18-60 years, with ASA physical status I and II undergoing elective surgeries under general anaesthesia.

Exclusion criteria: Patients with history of cardiac diseases, pregnancy or any serious medical condition that would interfere with Cardio Vascular System (CVS) response, history of allergy to any general anaesthesia drugs and cases lasting less than 30 minutes.

Sample size: Sample size of 92 with 46 in each group was calculated with proportion of occurrence of a hypothesis among manually guided at 47% and among BIS guided at 17% with α=5%, β=10%, 90% power and 95% confidence limit (9).

The patients were randomised into two groups, group A (BIS group) and group B (non-BIS group), based on computer generated random number tables (Table/Fig 1).

All patients received Tab. ranitidine 150 mg and Tab. alprazolam 0.25 mg the night before surgery. After shifting to operating room, intravenous drip was started with Ringer’s lactate (5ml/hr/hr) after intravenous access. Standard monitors were attached and the baseline HR, SBP, DBP and MAP were recorded. BIS electrodes were attached and connected to a BIS monitor in group A. As per protocol, all patients were pre-medicated with Inj. ondasetron 4 mg IV, Inj. fentanyl 2 mg/kg prior to induction along with pre-oxygenation using 100% O2 for 3 minutes.

For induction of anaesthesia, group A received propofol till BIS value reached 50±1 for 30 seconds while group B received sleep dose of propofol without BIS monitoring. Both the groups were intubated using succinylcholine 1.5mg/kg. Sevoflurane, N2O and vecuronium were used for maintenance of anaesthesia. HR, SBP, DBP and MAP were recorded at baseline, during induction, and at 1,5,10,15 minutes after intubation. All intraoperative complications were treated appropriately. Patients were extubated using reversal agent after extubation criteria were met. Total propofol consumption, haemodynamic changes and level of sedation after extubation using Ramsay Sedation Scale (8) were compared in both the groups.

Statistical Analysis

Data was analysed using Statistical Package for the Social Sciences (SPSS) software (21.0 version) and presented as mean±Standard Deviation (SD). Chi-square test and Fischer’s exact test were used to find out association between categorical variables. All the test were considered significant at p<0.05.


Demographic data like age, sex, weight, duration of surgery and anaesthesia were comparable in both the groups (p>0.05) (Table/Fig 2).

Total dose requirement of propofol: The mean dose of propofol for induction was more in Group B compared to Group A and was statistically significant (1.94 vs 1.64 mg/kg respectively, p=0.017). Females required lower dose of propofol for induction as compared to males in both the groups but was insignificant (p>0.05). On comparing among males of the two groups, lower doses of propofol was observed in group A compared to group B and was statistically significant (p=0.001) (Table/Fig 3).

Mean HR: The baseline mean HR were comparable in both the groups (p=0.060). Immediately after induction, HR decreased by 8.5% in Group B while it increased by 2.2% in Group A from the baseline (p>0.05). At 1 min, 5 mins, 10 mins and 15 mins interval after intubation, mean HR was comparable in both the groups. Maximum increase in HR was seen in both the groups after extubation but was insignificant.

B#BMAP, SBP, DBP:B?B Baseline MAP, SBP, and DBP between group A and B were comparable. More fall in MAP from the baseline immediately after induction was seen in group B compared to group A but was insignificant (13.47% vs 11.05%. 1 min after intubation, rise in MAP from the baseline was more in group A compared to group B but was statistically insignificant (5.7% vs 2.08%). SBP, DBP and MAP at 5 mins, 10 mins and 15 mins after intubation and 5 mins after extubation were comparable between the two groups. In group A 67.4% were cooperative, oriented and tranquil post extubation compared to 32.6% in group B. There was no cough/strain in 63% of patients in group A during extubation compared to 34.8% in group B (Table/Fig 6).


Propofol reduces systemic vascular resistance, cardiac contractility and preload. Several studies have shown reduction in SBP, DBP and MAP when propofol was given as IV bolus (10). In this study, there was a decreased SBP (11.2%), DBP (8.7%) and MAP (13.47%) from the baseline during induction in Group B compared to Group A i.e. SBP (11.5%), DBP (10.7%) and MAP (11.05%) respectively but was insignificant. This was similar to a study by Riisch D et al., where they demonstrated that the maximal drop in MAP from the baseline between the BIS guided, manually-administered propofol and the dose based on weight were comparable (33% vs 30%, respectively) (10). Puri GD et al., demonstrated that BIS had no co-relation with MAP and that decrease in MAP were comparable even when the BIS value was significantly different between the group manually guided by BIS and BIS guided by closed-loop administration of propofol during induction (11). However, another study by Shah NK et al., demonstrated a decrease in SBP by 20%, DBP by 16% and MAP by 19%, 2 minutes following induction of propofol at 2 mg/kg IV bolus using BIS (12). Another study by Möller Petrun A and Kamenik M showed that propofol caused significant hypotension even when doses were given with BIS guided protocol for induction (13). Haemodynamic instability caused by propofol even with the use of BIS was demonstrated by Lui N et al., (7). In contrast, some studies found that BIS cannot predict haemodynamic responses to intubation during anaesthesia induction with propofol and fentanyl (4),(14).

In this study, there was an increase in HR from the baseline by 2.2% in group A while in group B, it decreased by 8.5% during induction with propofol but was insignificant. This reduction in HR may be due to the dose dependent inhibition of baroreflexes and sympathetic activity by propofol (2). Some studies found increase in HR following propofol induction (3). Increase in HR is due to reflex increase in the sympathetic activity due to hypotension induced by propofol (12).

Previous studies were conducted in the dose requirement and side-effects of propofol using clinical end points such as loss of eyelash reflex (7),(15),(16),(17). However, this method can cause underdosing or overdosing of propofol. BIS monitoring is increasingly preferred in routine clinical practice for achieving adequate anaesthesia and reducing the dose of propofol by titration of the drug to a desired hypnotic level. Accordingly, it was assumed that the incidence of unintended side-effects such as arterial hypotension would be minimised with the decrease in propofol consumption. Many studies have demonstrated that propofol target concentration correlates with BIS values and predicts the level of sedation and loss of consciousness accurately (18),(19),(20).

In this study, there was significant reduction in the dose of propofol in group A compared to group B (1.64 mg/kg vs 1.94 mg/kg, respectively, p=0.017). The dose reduction of propofol when BIS guided monitoring was used to guide induction and maintenance of manually controlled administration as well as closed loop delivery have been demonstrated in several studies (7),(12),(21). Gan TJ et al., concluded that titrating propofol with BIS monitoring during balanced anaesthesia reduced propofol use significantly and improved recovery compared to the standard practice group (116 mcg/kg/hr vs 134 mcg/kg/hr respectively, p<0.001) (22). However, a study by Arya S et al., showed that use of BIS was associated with insignificant reduction of propofol dosage (p>0.05) (23). Another study by Struys MM et al., found similar induction doses of propofol when compared between closed-loop controlled administration of propofol using BIS and standard practice controlled administration with BIS (24). A significant decrease in propofol dosage was observed in males guided by BIS compared to those guided by sleep dose (1.66±0.33 vs 2.05±0.09 respectively, p=0.0001). This dose reduction of propofol was consistent with the findings of several studies (14),(25).

Alertness and Sedation: On arrival to the PACU, group A had more co-operative, oriented patients compared to group B. Similarly, Krupali et al., found that the BIS monitored group receiving propofol IV had less sedation compared to midazolam group post-operatively upto 45 minutes (26).


The study was conducted in elective patients adequately optimised for surgery among younger age group (18-60 years). A wider range of age would have given the idea of variations in haemodynamic parameters with propofol induction. The use of BIS over the routinely practiced sleep guided dose of propofol in terms of haemodynamics needs further trials with inclusion of geriatric age group, more study sample size and those subjects with existing co-morbidities. The dose reduction of propofol with comparatively better extubation score and lower sedation level as measured by Ramsay Sedation Scale helps in fast-tracking (although this could not be demonstrated in detail in present study).


BIS monitoring significantly reduces the consumption of propofol for induction of anaesthesia. Incidence of hypotension was similar in both the BIS guided group as well as sleep guided, non-BIS group. Patients with BIS monitoring were more cooperative and oriented on arrival to PACU than those without BIS monitoring.


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DOI and Others

DOI: 10.7860/JCDR/2022/55756.16330

Date of Submission: Feb 22, 2022
Date of Peer Review: Mar 12, 2022
Date of Acceptance: Mar 31, 2022
Date of Publishing: May 01, 2022

• 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

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