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

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On Sep 2018

Prof. Somashekhar Nimbalkar

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

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Muzaffarnagar Medical College,
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,
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
(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)
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 : November | Volume : 16 | Issue : 11 | Page : UC11 - UC15 Full Version

Incidence of Intraoperative Hypotension and Bradycardia in Spinal Anaesthesia with 0.5% Bupivacaine alone and 0.5% Bupivacaine with Fentanyl for Abdominal Hysterectomy: A Cross-sectional Study

Published: November 1, 2022 | DOI:
Swathy Sudan, Remani Kelan Kamalakshy, Sunil Raveendran, Ranju Sebastian

1. Senior Resident, Department of Anaesthesiology, Government Medical College, Thrissur, Kerala, India. 2. Assistant Professor, Department of Anaesthesiology, Government Medical College, Thrissur, Kerala, India. 3. Associate Professor, Department of Anaesthesiology, Government Medical College, Thrissur, Kerala, India. 4. Assistant Professor, Department of Anaesthesiology, Government Medical College, Thrissur, Kerala, India.

Correspondence Address :
Dr. Remani Kelan Kamalakshy,
Assistant Professor, Department of Anaesthesiology, Government Medical College, Thrissur-680596, Kerala, India.


Introduction: Bupivacaine hydrochloride, when used for spinal anaesthesia, is associated with varying degree of hypotension and bradycardia. Intrathecal opioids provides haemodynamic stability and improves quality of perioperative analgesia.

Aim: To compare the incidence of intraoperative hypotension, bradycardia and its side-effects when using 0.5% hyperbaric bupivacaine alone and with 25 μg fentanyl added to it for subarachnoid block for abdominal hysterectomy.

Materials and Methods: This cross-sectional study was conducted at Government Medical College, Thrissur, Kerala, India from June 2019 to May 2020 on 96 American Society of Anaesthesiologists Physical Status (ASA-PS) I and II patients posted for total abdominal hysterectomy under lumbar subarachnoid block. They were divided into Group A and B, carrying 48 patients in each group. Group A received 3.3 mL of 0.5% hyperbaric bupivacaine alone. Group B received 3.3 mL of 0.5% hyperbaric bupivacaine and 25 μg fentanyl. Haemodynamic characteristics, analgesic properties and side-effects were compared between Group A and Group B. Data were entered in Microsoft Excel Software, and analysed using Statistical Package for the Social Sciences (SPSS) software version 16.0 and p-value <0.05 was considered as statistically significant.

Results: The incidence of hypotension in group A was 41.7% and in group B was 39.6%. Incidence of analgesia was significantly higher in group B (group A- 181.2±4.9, group B- 220.9±13.9). In group A, no one had nausea and vomiting. In group B, 8.3% experienced nausea and vomiting and none in both groups experienced pruritus.

Conclusion: There was no difference in the development of hypotension and bradycardia when fentanyl was added to bupivacaine for spinal anaesthesia and had the advantage of increased duration of postoperative analgesia.


Haemodynamic stability, Intrathecal opioids, Postoperative analgesia, Rescue analgesia

Spinal anaesthesia produces intense motor, sensory and sympathetic block. Excellent anaesthesia and analgesia produced by motor and sensory block makes spinal anaesthesia the choice of anaesthesia for surgeries below the level of umbilicus. Level of spinal blockade depends on the dose, concentration, volume and baricity of local anaesthetic administered (1),(2). Surgeries of obstetrics and gynaecology, pelvic, perineal, urological and lower limb surgeries are usually done under spinal anaesthesia. Spinal anaesthesia is simple to perform, economical and produces complete muscle relaxation and has the advantage of avoiding unnecessary airway interventions as in general anaesthesia. However, the adverse effect of spinal anaesthesia is the occurrence of hypotension and bradycardia.

Some degree of hypotension is always associated with spinal anaesthesia. Another disadvantage is that duration of anaesthesia and analgesia depends on the duration of action of local anaesthetic used (3). Spinal anaesthesia is preferred when the expected duration of surgery is 1-2 hours. Additives, like opioids can be used with local anaesthetics for subarachnoid block to prolong the duration of anaesthesia (4). Hypotension and bradycardia if not detected and treated promptly can lead to intraoperative cardiac arrest or even death (5).

Bupivacaine hydrochloride is the most common local anaesthetic used for subarachnoid block. It is a long acting amide group local anaesthetic and can be used for surgeries taking one to two hours duration. Onset of action and duration of action of local anaesthetics depend on the pKa (ionisation constant) and protein binding characteristics (6). Bupivacaine has a pKa of 8.16 and 96% protein bound makes its onset of action slower with a long duration of action (7).

Opioids are one of the major group of drugs used intrathecally and epidurally as additives along with local anaesthetics. Intrathecally administered opioids acts on the opioid receptors present in the spinal cord, brain, and activation of peripheral and central receptors after systemic absorption. Lipid solubility is the most important characteristic of opioids that determines the potency of a particular drug. Fentanyl is a highly lipid soluble opioid and has a rapid onset and short duration of action. A study by Ebrie AM et al., compared the effect of fentanyl added to low dose and conventional dose of bupivacaine and found that duration of analgesia was prolonged after adding fentanyl to bupivacaine and incidence of hypotension was less when low-dose bupivacaine is used (8).

The present study aimed to compare the incidence of hypotension, bradycardia, development of side-effects and duration of analgesia between two groups receiving bupivacaine alone and bupivacaine in combination with fentanyl.

Material and Methods

This cross-sectional study was conducted in Government Medical College, Thrissur, Kerala, India, from June 2019 to May 2020. The study was undertaken after obtaining approval from the Institutional Ethical Committee (IEC) [Order No: B6-8772/2016/MCTCR(10) dated 15/11/2018].

Inclusion criteria: Total 96 patients belonging to American Society of Anaesthesiologists Physical Status (ASA-PS) class I and II, aged between 40-60 years undergoing total abdominal hysterectomy under spinal anaesthesia were the study group.

Exclusion criteria: Patient refusal, patients on drugs like beta blockers, antiarrhythmic, antianginal, bleeding disorders or on anticoagulants, space occupying lesions of brain, spine deformity, stenotic valvular lesions were excluded from the study.

Sample size calculation: The sample size was calculated based on the study by Unal D et al., (9). α=0.05, β=0.1, σ1=13.1, μ1=95.5, μ2=87.5, σ2=10.1 ratio(r)=1, Sample size was calculated by using the equation, n=(Z1-α/2+Z1-β)2 (σ12 +σ22/r)/(μ12)2 and included 48 patients in each group.

Study Procedure

Informed written consent was taken from all patients after explaining the procedure. Preanaesthetic check-up was done. Routine investigations like complete haemogram, renal function tests, liver function tests, prothrombin time, international normalised ratio, Chest X-ray, Electrocardiography (ECG), were advised and verified. Preoperatively all selected patients were explained about the spinal anaesthesia. All patients were given T. alprazolam 0.5 mg, T. ranitidine 150 mg and T. metoclopramide 10 mg, on the previous night and in the morning of surgery.

On the day of surgery, patients were taken to the operation theatre and 18G intravenous cannula was secured and preloaded with ringer lactate solution 10 mL/kg body weight. ECG, Pulse Oxymeter and non invasive Blood Pressure (BP) cuff were attached and baseline Heart Rate (HR), Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Mean Arterial Pressure (MAP) were recorded. Patients were premedicated with Inj. Midazolam 0.02 mg/kg i.v. and Inj. Ondansetron 0.08 mg/kg IV. In the lateral decubitus position and under strict aseptic precautions local infiltration with 2 mL of 2% lignocaine was given and lumbar puncture was performed at L3-L4 interspace through a mid-line approach using a 23-gauge Quincke Babcock spinal needle. Group A patients received 3.3 mL of 0.5% hyperbaric bupivacaine and Group B received 3.3 mL of 0.5% hyperbaric bupivacaine with 25 μg fentanyl.

After intrathecal injection patients were made supine and Oxygen (4 L/min) administered via simple face mask. Vitals were monitored and recorded every three minutes for the first 15 minutes, then every five minutes till 30 minutes and then every 10 minutes till 60 minutes and 120 minutes and throughout the surgery period. Duration of effective analgesia was measured as the time from intrathecal drug administration to the time when patient demands for rescue analgesia postoperatively. Incidence of intraoperative hypotension and bradycardia were recorded in each group. Decrease in SBP >25% from baseline or a fall below 90 mmHg was considered as hypotension and treated with i.v. mephentermine 6 mg and i.v. fluids as required. HR <50 beats per minute was taken as bradycardia and planned to treat with i.v. atropine 0.6 mg if bradycardia occurs. Incidence of adverse effects, like nausea, vomiting, pruritus also was recorded.

Statistical Analysis

The data obtained from both the groups (A and B) were recorded and entered in Microsoft Excel Software, and analysed using SPSS software version 16.0 and p-value <0.05 was considered as statistically significant. In both groups, the continuous variables age, height, weight and duration of surgery were summarised as mean and standard deviation. Categorical independent variable ASA category was summarised as proportions between both groups. Duration of analgesia, haemodynamic parameters (SBP, DBP, MAP and HR) at different time points were summarised as mean±Standard deviation and compared between the groups using unpaired t-test. Incidence of hypotension, bradycardia, nausea, vomiting or pruritus were summarised as proportions and Chi-square test or Fisher’s exact test was done to find association with drugs given depending on the distribution.


Demographic characteristics like age, weight, height, duration of surgery and ASA physical status of both groups were comparable (Table/Fig 1).

The SBP, DBP, MAP and HR was comparable between the groups at baseline (Table/Fig 2).

Hypotension and heart rate reduction from baseline was 41.7% and 16.2% in group A (bupivacaine) and in group B (bupivacaine+fentanyl) 39.6% and 11.6%, respectively. There was no statistical significance between groups (Table/Fig 3).

The HR <50/minutes was considered as bradycardia. Both the groups showed a decreasing trend throughout the study period without statistically significant fall in heart rate (Table/Fig 4). Fall in SBP was similar in both groups group A (bupivacaine), group B (bupivacaine+fentanyl) (Table/Fig 5). Decrease in DBP was comparable between groups (Table/Fig 6).

Decrease in MAP was similar in both groups (Table/Fig 7). Incidence of hypotension was comparable in both groups at different time points of observation during the surgery. The incidence of hypotension was comparable between groups and it was not statistically significant. Hypotension is fall in SBP >25% from baseline. In present study maximum fall in SBP was at 12 minutes (Table/Fig 8)a,b. The duration of analgesia was significantly higher in group B (bupivacaine+fentanyl) (Table/Fig 9). Incidence of nausea and vomiting was similar with Fisher’s exact p-value 0.12. None in both groups experienced pruritus.


Bupivacaine hydrochloride is the most common local anaesthetic used for spinal anaesthesia. It is a long-acting amide local anaesthetic with high protein binding and high pKa. Onset of action of bupivacaine is slow compared to other local anaesthetics because of its high pKa. Duration of action is also longer as its protein binding is high. Spinal anaesthesia with bupivacaine can be given for surgeries taking 1-2 hours duration. Opioids when used with local anaesthetics express a synergistic action. Fentanyl is a lipophilic opioid with rapid onset of action. Addition of fentanyl to bupivacaine improves the quality of anaesthesia, provides haemodynamic stability and increases duration of postoperative analgesia. Reason for hypotension in spinal anaesthesia are blockade involving T1 to T4 sympathetic fibres, decreased adrenal medullary secretion causing reduction in catecholamine circulation and venous and arteriolar dilation leading to reduction in preload and after load. Bradycardia results from blockage of sympathetic fibres involving preganglionic cardiac accelerator fibres from T1 to T5. Another reason is activation of stretch receptors in the right atrium in response to decreased venous return. The present study aimed to compare the haemodynamic characters, postoperative analgesia and side-effects when fentanyl is given along with bupivacaine heavy for abdominal hysterectomy.

In the present study group A received 3.3 mL of 0.5% hyperbaric bupivacaine alone and group B received 3.3 mL of 0.5% hyperbaric bupivacaine with 25 μg fentanyl. There was a decrease in SBP, DBP, MAP, and HR in both the groups. But the fall in BP and HR were not statistically significant. Same dose of bupivacaine in both groups may be the reason for comparable haemodynamic characteristics.

The HR decreased from the baseline with onset of sympathetic blockade and it showed a decreasing trend throughout the procedure. The mean HR showed no significant decrease between the groups. In a study conducted by Bogra J et al., in parturients planned for caesarean section, bradycardia was found in 10-15% cases in each group and the overall incidence of bradycardia was 7% (10). In the present study no incidence of bradycardia occurred at any point of time, but a decrease in HR from the baseline was noted in both study groups during the period of blockade. Decrease in HR was 16.2% in group A (bupivacaine) and 11.66% in group B (bupivacaine+ fentanyl). Heart rate never went below the cut-off value of 50 in either group. In study by Bogra J et al., parturients posted for caesarean section and pregnancy induced physiological changes might be the reason for bradycardia.

The maximum fall in SBP was at 12 minutes from the onset of sympathetic blockade, which was different from the study conducted by Bogra J et al., in which maximum fall in SBP was noticed after 25 minutes in all groups. On comparing the haemodynamic stability of bupivacaine and bupivacaine+fentanyl, they found that the latter was more stable. They also found that the intraoperative hypotension increased with increasing doses of bupivacaine, however along with fentanyl it increased more. This was different from present study in which bupivacaine+fentanyl group showed more haemodynamic stability.

Incidence of hypotension was similar in both groups and the findings were comparable with the study by Fernandez-Galinski D et al., (11). They compared hyperbaric bupivacaine 12.5 mg with saline and the same dose of bupivacaine with 25 μg fentanyl for geriatric patients. The blood pressure response of both groups was similar. Duration of analgesia was significantly higher in group B (bupivacaine with fentanyl). This was in similarity with the study of Shim SM et al., in which duration of postoperative analgesia increased with addition of fentanyl to bupivacaine (12).

Study by Unal D et al., showed similar results when different doses of bupivacaine with 25 μg of fentanyl was used (9). They studied the quality of block, haemodynamic stability, quality of anaesthesia, perioperative complication, and hospital release criteria. Time of request for first analgesia postoperatively was longer in group in which fentanyl was added. Ben-David B et al., studied 50 patients undergoing ambulatory surgical arthroscopy with diluted small dose of bupivacaine alone and 10 μg fentanyl added to bupivacaine and found that adding fentanyl increases the duration of sensory block with less intense motor block and early recovery to micturition or street fitness (13).

Wong CA et al., conducted a trial to determine the optimal dose of intrathecal fentanyl with 2.5 mg bupivacaine. They added 0,5,10,15,20,25 μg with 2.5 mg bupivacaine for labour analgesia and found that duration of analgesia was more with higher dose of fentanyl. There was no difference in the incidence of nausea and vomiting or in foetal heart rate tracing changes between groups (14). Shende D et al., compared two groups of patients, 0.3 mL of 0.9% saline added to 2.5 mL of 0.5% bupivacaine in Group I, and 0.3 mL of fentanyl (15 μg) to 2.5 mL of 0.5% hyperbaric bupivacaine in group 2. They found that adding 15 μg fentanyl to hyperbaric bupivacaine markedly improved intraoperative anaesthesia for caesarean section (15).

Observations of the present study results were similar to those by Gauchan S et al., in which duration of sensory block was prolonged when fentanyl was added to intrathecal bupivacaine and duration of effective postoperative analgesia also prolonged in fentanyl group (16). Martyr JW et al., (17) and Singh H et al., (18) in their study observed similar results.

When comparing side-effects between groups, in group A (bupivacaine) none experienced nausea, vomiting, and pruritus. But in Group B (bupivacaine+fentanyl), 8.3% experienced nausea and vomiting but no one had pruritus but it was statistically not significant. Lipid soluble opioids in minimum dose may not stimulate pruritus (19). Nausea and vomiting in group B may be attributed to intrathecal fentanyl (20).


The volume in each group was different and height of the participants was not taken as criteria for comparison. These parameters can affect ascend of the drugs and haemodynamic characteristics.


There was no difference in the incidence of intraoperative hypotension or bradycardia between groups and there is an added advantage of increasing the duration of postoperative analgesia by adding fentanyl to bupivacaine. Combination of bupivacaine and fentanyl was found to be superior to bupivacaine alone group as the quality of anaesthesia was better


Miller R. Miller’s anaesthesia. 9th ed. Philadelphia: Elsevier; 2020. Spinal, Epidural and Caudal Anesthesia; p1414-1446.
Spinal anesthesia - NYSORA. Accessed date: Sep 2022.
Gupta R, Verma R, Bogra J, Kohli M, Raman R, Kushwaha JK. A comparative study of intrathecal dexmeditomidine and fentanyl as adjuvants to bupivacaine. J Anaesthesiol Clin Pharmacol. 2011;27(3):339-43. Doi: PMID: 21897504. [crossref] [PubMed]
Kyokong O, Charuluxananan S, Sriprajittichai P, Poomseetong T, Naksin P. The incidence and risk factors of hypotension and bradycardia associated with spinal anesthesia. J Med Assoc Thai. 2006;89(Suppl 3):S58-64.
Stoelting’s Handbook of Pharmacology and Physiology in Anesthetic Practice, third edition P (211-236).
Morgan & Mikhail’s Clinical Anesthesiology 5th edition p-278-82.
Cousins & Bridenbaugh’s Neural Blockade in clinical anesthesia and pain medicine fourth edition; p.70-118.
Ebrie AM, Woldenyohanis M, Abafita BJ, Ali SA, Zemedkun A, Yimer Y, et al. Hemodynamic and analgesic effect of intrathecal fentanyl with bupivacaine in patients undergoing elective caesarean section; A prospective cohort study. PLoS One. 2022;17(7):e0268318. Doi: 10.1371/journal.pone.0268318. PMID: 35797265; PMCID: PMC9262178. [crossref] [PubMed]
Unal D, Ozdogan L, Ornek HD, Sonmez HK, Ayderen T, Arslan M, et al. Selective spinal anaesthesia with low-dose bupivacaine and bupivacaine + fentanyl in ambulatory arthroscopic knee surgery. J Pak Med Assoc. 2012;62(4):313-18.
Bogra J, Arora N, Srivastava P. Synergistic effect of intrathecal fentanyl and bupivacaine in spinal anesthesia for caesarean section. BMC Anesthesiol. 2005;5(1):5. Doi: PMID: 15904498. [crossref] [PubMed]
Fernandez-Galinski D, Rue M, Moral V, Castells C, Puig MM. Spinal anesthesia with bupivacaine and fentanyl in geriatric patients. Anesth Analg. 1996;83(3):537-41. Doi: PMID: 8780277. [crossref] [PubMed]
Shim SM, Park JH, Hyun DM, Jeong EK, Kim SS, Lee HM. The effects of adjuvant intrathecal fentanyl on postoperative pain and rebound pain for anorectal surgery under saddle anesthesia. Korean J Anesthesiol. 2018;71(3):213-19. Doi: PMID: 29684993. [crossref] [PubMed]
Ben-David B, Solomon E, Levin H, Admoni H, Goldik Z. Intrathecal fentanyl with small-dose dilute bupivacaine: Better anesthesia without prolonging recovery. Anesth Analg. 1997;85(3):560-65. Doi: PMID: 9296409. [crossref] [PubMed]
Wong CA, Scavone BM, Slavenas JP, Vidovich MI, Peaceman AM, Ganchiff JN, et al. Efficacy and side-effect profile of varying doses of intrathecal fentanyl added to bupivacaine for labor analgesia. Int J Obstet Anesth. 2004;13(1):19-24. Doi: [crossref] [PubMed]
Shende D, Cooper GM, Bowden MI. The influence of intrathecal fentanyl on the characteristics of subarachnoid block for caesarean section. Anaesthesia. 1998;53(7):706-10. Doi: PMID: 9771182. [crossref] [PubMed]
Gauchan S, Thapa C, Prasai A, Pyakurel K, Joshi I, Tulachan J. Effects of intrathecal fentanyl as an adjunct to hyperbaric bupivacaine in spinal anesthesia for elective caesarean section. Nepal Med Coll J. 2014;16(1):05-08.
Martyr JW, Stannard KJ, Gillespie G. Spinal-induced hypotension in elderly patients with hip fracture. A comparison of glucose-free bupivacaine with glucose-free bupivacaine and fentanyl. Anaesth Intensive Care. 2005;33(1):64-68. Doi: PMID: 15957693. [crossref] [PubMed]
Singh H, Yang J, Thornton K, Giesecke AH. Intrathecal fentanyl prolongs sensory bupivacaine spinal block. Can J Anesth. 1995;42:987-91. Doi: PMID: 8590509. [crossref] [PubMed]
Kumar K, Singh SI. Neuraxial opioid-induced pruritus: An update. J Anaesthesiol Clin Pharmacol 2013;29(3):303-07. Doi: PMID: 24106351. [crossref] [PubMed]
Shin DW, Kim Y, Hong B, Yoon SH, Lim CS, Young S. Effect of fentanyl on nausea and vomiting in caesarean section under spinal anesthesia: A randomized controlled study. J Int Med Res. 2019;47(10):4798-07. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/59764.17009

Date of Submission: Aug 21, 2022
Date of Peer Review: Sep 17, 2022
Date of Acceptance: Oct 07, 2022
Date of Publishing: Nov 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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