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

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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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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.
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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 : October | Volume : 16 | Issue : 10 | Page : UC01 - UC04 Full Version

Analgesic Effect of Intrathecal Nalbuphine in Comparison with Fentanyl as an Adjuvant with Hyperbaric Bupivacaine (0.5%) during Spinal Anaesthesia in Lower Abdominal Surgery: A Double-blinded Randomised Clinical Study

Published: October 1, 2022 | DOI:
Amlan Nath, Parvin Banu, Debangshu Bhanja Choudhury, Arunava Biswas, Syed Mohammed Naser

1. Postgraduate Student, Department of Anaesthesiology, Calcutta National Medical College and Hospital, Kolkata, West Bengal, India. 2. Associate Professor, Department of Anaesthesiology, Calcutta National Medical College and Hospital, Kolkata, West Bengal, India. 3. Assistant Professor, Department of Surgery, Calcutta National Medical College and Hospital, Kolkata, West Bengal, India. 4. Associate Professor, Department of Pharmacology, Maharaja Jitendra Narayan Medical College and Hospital, Coochbehar, West Bengal, India. 5. Professor, Department of Pharmacology, Calcutta National Medical College and Hospital, Kolkata, West Bengal, India.

Correspondence Address :
Dr. Arunava Biswas,
Maharaja Jitendra Narayan Medical College and Hospital, Coochbehar, Coochbehar, West Bengal-736101, India.


Introduction: Local anaesthetics are sometimes added with intrathecal adjuvants. Nalbuphine is a synthetic agonistantagonist of opioid μ receptor. Fentanyl is a highly potent lipophilic synthetic opioid with rapid onset of action and it acts like morphine. It can be used during spinal anaesthesia for the purpose of decreasing the postoperative pain.

Aim: To compare the safety and efficacy of preservative free intrathecal nalbuphine and fentanyl as additives to intrathecal hyperbaric bupivacaine (0.5%) for spinal anaesthesia.

Materials and Methods: A randomised double-blinded clinical study was undertaken at Calcutta National Medical College and Hospital, Kolkata, West Bengal, India during March 2020 to August 2021 in which a total of 100 patients, belonging to American Society of Anaesthesiology (ASA) physical status I and II and undergoing elective lower abdominal surgery, were randomised into two equal group of 50 each. Group N received intrathecally 0.5 mg of nalbuphine with 3 mL (15 mg) of 0.5% hyperbaric bupivacaine, and group F received 25 μg of Fentanyl with 3 mL (15 mg) of 0.5% hyperbaric. Visual Analogue Scale (VAS) score, Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Mean Arterial Pressure (MAP) and Heart Rate (HR) were recorded at varied intervals during intraoperative and postoperative period.

Results: Significantly lower (p-value <0.001) mean VAS scores was observed beyond six hour of postoperative period in the group F. No significant changes (p-value >0.05) in SBP, DBP, MAP and HR were there between the groups. Few adverse effects like (hypotension, nausea, vomiting) were observed more in the fentanyl group which was statistically insignificant (p-value >0.05).

Conclusion: Intrathecal fentanyl as compared to nalbuphine produces a significant postoperative analgesia when administered as an adjuvant with hyperbaric bupivacaine in cases of lower abdominal surgery.


Intrathecal route, Laparotomy, Supplement

Subarachnoid technique of anaesthetic blockade is regularly practiced for lower abdominal and lower limb surgeries. It is simple to carry out by injecting an anaesthetic drug into the subarachnoid space and with fast initiation of anaesthesia, which provides analgesia both intraoperatively and postoperatively. Spinal anaesthesia with lignocaine was highly popular earlier for short surgical procedures as it had a predictable onset and provided dense sensory and motor blockade of moderate duration (1). Unfortunately, issue of neurotoxicity had cast doubts on the intrathecal use of lignocaine. The phenomenon of “transient neurological symptoms” may be associated with all local anaesthetics; but it is 7-9 times more common with lignocaine than with bupivacaine (2). In view of debate and uncertainty surrounding the use of spinal lignocaine, in recent time hyperbaric bupivacaine (0.5%) has put back lignocaine as the gold standard drug for the safe conduct of spinal anaesthesia (3). Although sensory and motor blockade of bupivacaine is satisfactory and its duration of action is longer than that of lignocaine but its slower onset of action sometimes makes it less popular.

Opioid added to local anaesthetic for spinal anaesthesia was first introduced into clinical practice in 1979 with intrathecal morphine as the forerunner. In order to improve the intraoperative and postoperative analgesia, opioids along with local anaesthetics are administered together (4). Fentanyl, a synthetic opioid, has fast onset of action following intrathecal administration due to its high lipid soluble nature. It does not tend to migrate to the fourth ventricle in sufficient concentration to cause delayed respiratory depression when administered intrathecally (2). Its side-effects are much less as compared to morphine. It has become very popular additive to hyperbaric bupivacaine in recent times although, side-effects like pruritus, nausea and vomiting and unexpectedly possible occurance of serotonin syndrome related to intrathecal fentanyl has been reported. Intrathecal fentanyl shows a dose dependant duration of its effect (5).

Nalbuphine, an agonist-antagonist opioid, bind to μ receptors, where they produce limited responses (partial agonists) or no effect (competitive antagonists). In addition, nalbuphine often exert partial agonist actions at other receptors, including kappa and delta receptors (2). It was synthesised to produce analgesia without any unwanted μ agonist side-effects like respiratory depression, undesirable sedation, nausea, vomiting and urinary retention. There are relatively limited published data on the comparison between the effects of addition of nalbuphine and fentanyl as an adjuvant to bupivacaine in spinal block during lower abdominal surgery (6),(7),(8),(9).

Hence, the present study was undertaken with the aim to compare the safety and efficacy of preservative free intrathecal nalbuphine and fentanyl as add-on to intrathecal hyperbaric bupivacaine for spinal anaesthesia. The primary objective was to compare the efficacy of preservative free intrathecal nalbuphine and fentanyl as an additive to intrathecal hyperbaric bupivacaine for spinal anaesthesia. The secondary objective was to observe and compare haemodynamic change, and any adverse effect like hypotension, bradycardia, nausea, vomiting in both the groups.

Material and Methods

A randomised double-blinded study was undertaken at Calcutta National Medical College and Hospital, Kolkata, West Bengal (a tertiary care facility) in eastern India between March 2020 to August 2021. Institutional Ethics Committee (IEC) approval (RKC/459 Dated 17.01.2020) was obtained for initiating the study on patients of either sex undergoing elective lower abdominal surgery under spinal anaesthesia.

Inclusion criteria: Patients aged between 18 to 60 years, willing to give written consent for participation, belonging to ASA physical status I and ll were included.

Exclusion criteria: Patients with any contraindication to central neuraxial block, and with known hypersensitivity to any of the study drugs were excluded.

Sample size calculation: The required sample size after calculation turned upto n=41 in each study group which was converted to a round figure of n=50 each, thus recruiting a total on n=100. Sample size was calculated based on formula taking differences in mean and considering alpha and beta errors. Taking Z value of α error (Zα) as 1.96, Z value of β error (Zβ) as 1.28, success rate (p) as 90% (From pilot study conducted at this institution by this researcher) and difference between mean (d) 18 (10). During the screening a preanaesthetic evaluation of patients were done a day prior to the surgery and if found eligible for the study, counselling for the spinal anaesthesia procedure was done and informed consent was obtained from the patients. The patients were selected randomly with the help of online random numbers generator.


On arrival to the operating theatre, the identification of patient was done and consent was checked. Then multichannel monitors were attached and baseline parameters were noted. Electrocardiogram (ECG), SpO2 and Non Invasive Blood Pressure (NIBP) was monitored before, during and after the surgery. Then intravenous (i.v.) cannulation was done with 18G i.v. cannula and ringer lactate solution was infused at 15 mL/kg as preloading over 30 minutes and then was continued at maintenance rate. The subarachnoid block was performed with the study drugs with the patient in standard sitting position with a 25G Quincke needle at L3-L4 intervertebral space using midline approach maintaining strict aseptic condition.

Patients of group F received 25 μg of fentanyl with 3 mL (15 mg) of 0.5% hyperbaric bupivacaine, and group N patients were administered 0.5 mg of nalbuphine with 3 mL (15 mg) of 0.5% hyperbaric bupivacaine, diluted upto 4 mL in both the group. All drugs were taken accurately using a 10 mL syringe. The study drug was prepared by an individual who was not involved in the study (Table/Fig 1).

During operation, all patients received supplemental oxygen with nasal prongs using a flow rate 2 L/min. SBP, DBP, MAP and HR were recorded at the interval of 0, 2, 4, 6, 8, 10, 20, 30, 40, 50, 60 and 90 minutes.

Parameters assessed

Onset of sensory block: The sensory nerve block was assessed bilaterally by using loss of pin prick sensation technique with a 25G hypodermic needle in the mid clavicular line. The time to onset of the sensory block upto T8 dermatome was noted. Taking into consideration the time of spinal injection as zero, all other durations were calculated accordingly. Patients were observed for intraoperative complications like hypotension, bradycardia, nausea vomiting. Hypotension was defined as >20% fall in baseline MAP or a MAP <65 mmHg. lt was treated by fluid bolus for 5 minutes followed by i.v. inj. mephentermine of 3 mg if needed. Bradycardia was defined as heart rate <50 per minute and was treated with inj. atropine 0.6 mg intravenously. A data collection chart was used to record all physiological variables and drugs used during this research activity. During the course of the study, patients who suffered from any surgical complications like severe bleeding or needed reexploration or needed to be converted into general anaesthesia, such patients were excluded from the study.

In the postoperative period, patients were observed in recovery room for haemodynamic stability and any side-effects or need for additional medications were recorded. Patients were later moved to the ward after normalisation of vital parameters. In the recovery room and in the ward the haemodynamic parameters like MAP, HR starting immediately after operation then till 90 minutes were recorded.

Duration of sensory block: Sensory level of the block was assessed by loss of pin prick sensation using a blunt 25G hypodermic needle along the mid clavicular line bilaterally. The duration of sensory blockade was taken as time from the spinal injection to time of regression to T12 dermatome.

Assessment of analgesia pain was assessed by VAS (where 0 was considered no pain, and 10 as excruciating pain). Rescue analgesia in the form of intramuscular inj. diclofenac 75 mg was given if pain score was more than 4 or on patient's demand which was repeated if needed.

No analgesic was given in the immediate postoperative period until the patient requested for analgesia and time for first analgesia was recorded. Duration of postoperative analgesia was defined as the time between spinal injection and rescue analgesic.

Statistical Analysis

The categorical variables were indicated as the number and percentage of patients and they were compared across the groups using Pearson’s Chi-square test for Independence of Attributes/Fisher’s-exact test as seemed appropriate. The continuous variables were shown as mean, median and Standard Deviation and compared over the groups using unpaired t-test. The statistical software Statistical Package for the Social Sciences (SPSS) version 20.0 has been used for the entire analysis of this study. An alpha level of 5% was regarded as significant.


A total of 100 patients were recruited, divided into two equal groups, and administered the two study drugs. The demographic profile like age, gender, and baseline parameters were comparable between two groups as depicted in (Table/Fig 2).

There was a statistically significant change noted in the VAS among the study participants when compared between the groups. Fetanyl appeared to have a better pain control over nalbuphine beyond six hours in the postoperative period till 24 hours of assessment of pain sensation (Table/Fig 3). The mean time for rescue analgesia was significantly longer in the fentanyl group as compared to the nalbuphine group (p-value <0.0001).

The changes in SBP at different time intervals is depicted in (Table/Fig 4) which was found to be statistically insignificant (p>0.05) when compared among the two study groups. The changes in DBP as shown in (Table/Fig 5) was also found to be statistically insignificant (p>0.05) among the two group at different time intervals. When the MAP was assessed among both the study groups it was also found to be insignificant (p>0.05) across all the time intervals (Table/Fig 6). An insignificant change (p>0.05) in HR was found while comparing it between the two study groups during assessment at prefixed time intervals (Table/Fig 7).

The episodes of hypotension occurred in 14 (28%) in the fentanyl group and 10 (20%) in the nalbuphine group and nausea /vomiting occurred in 4 (8%) in the fentanyl group as compared to 1(2%) in the other group which was statistically insignificant (p>0.05).


In the current study, a comparison between a μ agonist- fentanyl with an opioid agonist-antagonist-nalbuphine on postoperative analgesia when used intrathecally with 0.5% hyperbaric bupivacaine were carried out. Wilson J suggested the intrathecal dose of fentanyl as 5-25 mcg as local anesthetic adjuvant (11). Palmar CM employed fentanyl as a sole agent for labour analgesia and showed that duration of analgesia did not increase by increasing its dose beyond 25 μg (12). Thus, intrathecal fentanyl at 25 μg dose was chosen for this study.

In the present study, the mean duration of analgesia of fentanyl group was significantly higher than nalbuphine group as indirectly reflected by observing the low VAS score at different time interval (Table/Fig 3). In contrast, according to Culebras X, postoperative analgesia following nalbuphine 0.5 mg as an intrathecal adjuvant lasted longer than 0.2 mg or 0.16 mg of the drug (13). This was also supported by Borah TJ (14), and Mukherjee A (15). This may have been caused by employment of different doses of adjuvants, local anaesthetics and also probably different postures of the patient. According to Palmar CM, the duration of analgesia of intrathecal fentanyl could not be increased above a dose of 25 μg (12). On the other hand Culebras X (13), Borah TJ (14), and Mukherjee A (15) stated that the duration of analgesia of intrathecal nalbuphine as adjuvant could be increased by increasing the dose. The significantly longer duration of analgesia was obtained with fentanyl group in this study, over nalbuphine group; which was supported by Prabhakaraiah UN et al., who reported a longer duration of analgesia with fentanyl group (16). This could be due to a difference in the type of study subjects selected for the conduct of those individual studies. With such findings the VAS score found in the fentanyl group was very significantly low beyond six hours postoperative period as compared to nalbuphine group (p-value <0.001) in the current study.

There was no significant change in onset of sensory block, regression of sensory block to T12 dermatome, MAP and mean HR from baseline values within either group of the present study. The finding was similar to those by Gupta K, who did not find any change in mean HR and SBP between fentanyl 25 μg and nalbuphine even with a very large dose of 2 mg (17). Adverse effects in between the study groups did not show any significant difference at any point during the study, which was same as in the study by Prabhakaraiah UN et al., (16).


The present study was conducted on patients of ASA grade I and II category. Including ASA III or ASA IV could have given different results. Moreover, patients with BMI>35kg/m2 were not included in this study where drug dose requirement could have been more which might have shown different results. Finally, onset of sensory block may be affected by many other factors like position of the patient which was not taken into account in the present study.


Considering more prolonged duration of analgesia, intrathecal fentanyl in postoperative period was found to be significantly better than nalbuphine when used as an adjuvant therapy with 0.5% hyperbaric bupivacaine in elective lower abdominal surgeries with insignificant adverse effects like hypotension, nausea and vomiting.


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DOI and Others

DOI: 10.7860/JCDR/2022/58698.16961

Date of Submission: Jun 26, 2022
Date of Peer Review: Jul 27, 2022
Date of Acceptance: Sep 12, 2022
Date of Publishing: Oct 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

• Plagiarism X-checker: Jun 27, 2022
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