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

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Dr Mohan Z Mani

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Dr Mohan Z Mani,
Professor & Head,
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Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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I wish JCDR a great success and I hope that journal will soar higher with the passing time."

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

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
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 : October | Volume : 16 | Issue : 10 | Page : UC35 - UC39 Full Version

Comparative Efficacy of Addition of Fentanyl and Neostigmine to Isobaric 0.75% Ropivacaine in Elderly Patients undergoing Transurethral Resection of Prostate under Spinal Anaesthesia: A Double-blinded Randomised Clinical Study

Published: October 1, 2022 | DOI:
Pragya Shukla, Sandeep Loha, Ravi Kumar Verma

1. Senior Resident, Department of Anaesthesiology, Institute of Medical Sciences - Banaras Hindu University, Varanasi, Uttar Pradesh, India. 2. Associate Professor, Department of Anaesthesiology, Institute of Medical Sciences - Banaras Hindu University, Varanasi, Uttar Pradesh, India. 3. Professor, Department of Anaesthesiology, Institute of Medical Sciences - Banaras Hindu University, Varanasi, Uttar Pradesh, India.

Correspondence Address :
Dr. Pragya Shukla,
C/o Dr. O.P. Mishra-154, Janki Nagar Bazardeeha, Varanasi, Uttar Pradesh, India.


Introduction: Ropivacaine is a well-accepted local anaesthetic drug used in spinal and peripheral nerve blocks. It provides a better Central Nervous System (CNS) and cardiovascular stability in comparison to bupivacaine. Adjuvants are also added with these drugs as they provide haemodynamic stability, increase efficacy, and decrease the dose requirement of the local anaesthetic drugs.

Aim: To determine the efficacy of isobaric 0.75% ropivacaine in combination with normal saline, fentanyl, and neostigmine in Elderly Patients Undergoing Transurethral Resection of Prostate Under Spinal Anaesthesia.

Materials and Methods: This double-blinded randomised clinical study was conducted in the Department of Anaesthesiology and Critical Care, Institute of Medical Sciences- Banaras Hindu University, Varanasi, Uttar Pradesh, India, from July 2018 to June 2019. The study included 90 patients who were divided into three groups of 30 subjects each. Ropivacaine combined with normal saline in group RNS, ropivacaine combined with fentanyl in group RFE and ropivacaine combined with neostigmine in group RNE, was administered intrathecally. Heart rate, respiratory rate, blood pressure, onset and duration of sensory and motor block, along with the duration of analgesia, were recorded at different time points. The Analysis of Variance (ANOVA) was used to compare the variables among the three study groups, and Student-Newman-Keuls post hoc test was used to compare the data between the groups.

Results: Patients in group RNE showed a significant fall in heart rate in comparison to groups RNS and RFE at all the time points. Respiratory rate followed a similar pattern in group RNE (p<0.001), except at 5 min and 90 min. Mean systolic blood pressure showed a significant rise in group RNE compared to the other two groups, while diastolic blood pressure followed a similar trend at 10, 20, 30, and 60 min. The SpO2 (%) was comparable among groups. The onset of sensory loss was significantly earlier in group RNE (239.6±28.8 sec) than in groups RNS (298.1±27.8 sec), and RFE (261.9±32.2 sec). The duration of the sensory block was significantly longer in group RFE (227.8±30.5 min). The mean time to the onset of motor block (480.7±30.2 sec) and analgesia (582.33±30.2 min) was longer in group RNE than in other groups.

Conclusion: The addition of neostigmine to ropivacaine intrathecally is a reliable method to prolong spinal anaesthesia but close monitoring of vitals is desirable.


Analgesia, Intrathecal, Motor, Sensory

Spinal anaesthesia is the most convenient anaesthetic technique used in surgery below the umbilicus. Its advantages over General Anaesthesia (GA) are reduced stress response, rapidity in onset, postoperative pain relief, shorter hospital stay, and cost-effectiveness. It is generally performed by using local anaesthetic drugs at different doses and baricity with or without the addition of an adjuvant. These adjuvants provide haemodynamic stability and decrease the dose requirement of the local anaesthetic drugs.The most commonly used local anaesthetic drug is bupivacaine. However, ropivacaine is also well accepted currently in spinal and peripheral nerve blocks, providing better Central Nervous System (CNS) and cardiovascular stability in comparison to bupivacaine (1),(2). As ropivacaine is approximately 40% less powerful than bupivacaine, it can be utilised for brief length surgeries (3).

Isobaric ropivacaine provides a similar sensory but shorter duration of the motor block with better haemodynamic stability compared to bupivacaine, and it is a desirable feature for early ambulation, voiding, and physiotherapy (4). Luck JF et al., compared the same doses of hyperbaric ropivacaine, bupivacaine, and levobupivacaine intrathecally and concluded that ropivacaine may be useful when prompt mobilisation is required (5).

Intrathecal opioids as an adjuvant act synergistically with local anaesthetic drugs to intensify sensory block while achieving a satisfactory quality of spinal anaesthesia at a much lower dose of local anaesthetic drugs (6),(7). Fentanyl is a commonly used centrally acting opioid that is usually combined with the local anaesthetic agent for perioperative anaesthesia and analgesia (6). Neostigmine is an adjuvant that causes analgesia by muscarinic receptor-mediated mechanisms. Neostigmine given intrathecally alone produces analgesia in humans at doses greater than 100 mcg (8),(9),(10). Dose of 25 mcg would be unlikely to cause side-effects and has produced evidence of analgesia in clinical trials (8),(9).

This study was conducted to observe the comparative efficacy of intrathecal administration of isobaric 0.75% ropivacaine in combination with normal saline as control, with fentanyl, and with neostigmine as adjuvants in relation to their effects on the duration of analgesia as a primary outcome. Vital parameters, onset, and duration of sensory and motor blockade were also recorded as a secondary outcome in patients with benign prostatic hypertrophy undergoing Transurethral Resection of the Prostate (TURP).

Material and Methods

Department of Anaesthesiology and Critical Care, Institute of Medical Sciences-Banaras Hindu University, Varanasi, Uttar Pradesh, India, from July 2018 to June 2019. The study protocol was approved by Institutional Ethical Committee (Dean/2018/EC/460) and written informed consent was obtained from all patients. The study was conducted in 90 adult patients, scheduled for TURP under spinal anaesthesia.

Inclusion criteria: Patients of age group 45-65 years, grades I and II prostratomegaly (11), American Society of Anaesthesiologists (ASA) grade I and II scheduled for elective TURP were included in the study.

Exclusion criteria: Patients, with CNS infections, progressive neurodegenerative disorders, severe cardiopulmonary disease, blood volume deficits, bleeding diathesis and coagulopathy, local infection and spine deformities, allergy to local anaesthetics and opioids and those who did not give consent were excluded from the study.

Sample size calculation: With α=5% (level of significance of two-tailed test), β=0.1 (90% is the power of the study with one-to-one ratio), δ=8.5 (mean difference) and σ=10 minutes (standard deviation), the sample size was calculated using the formula (12):

2N= 4(Za+Ab)2σ22

The final sample size for each group was found to be 30. Patients were randomly allocated through a computer-generated random table number to the following groups (Table/Fig 1).

Group RNS: Received 18.75 mg (2.5 mL) of ropivacaine 0.75% with (0.5 mL) normal saline intrathecally.
Group RFE: Received 18.75 mg (2.5 mL) ropivacaine 0.75% with 25 μg (0.5 mL) fentanyl intrathecally.
Group RNE: Received 18.75 mg (2.5 mL) ropivacaine 0.75% with 25 μg (0.5 mL) neostigmine intrathecally.

Study Procedure

All patients received tab. alprazolam 0.25 mg, tab. ranitidine 150 mg and tab. metoclopramide 10 mg on the night before surgery and 2 hrs before surgery as preanaesthetic medication. Before arriving in the Operation Theatre (OT), 5 mL/kg of 0.9% normal saline was given intravenously to all patients. The monitors were attached to the patients to record baseline vitals, i.e., heart rate, respiratory rate, non invasive blood pressure, and oxygen saturation (SpO2) before initiation of spinal anaesthesia.

In all groups, spinal anaesthesia was induced in the lateral decubitus position either at L2-3 or L3-4 interspace using 25 gauge Quincke’s type of spinal needle and the study medication was administered within 30 seconds into the subarachnoid space with aseptic precautions. The patients were then positioned in a supine position without head elevation. The T10 dermatome levels were targeted for the spinal block. All patients were given supplemental oxygen via a venti-mask at a rate of 5L/min throughout the operation.

Sensory block: Loss of sensation to pinprick bilaterally was determined with a blunt 27-gauge needle by a blind observer. Time to achieve the T10 dermatome level was noted.

Motor block: The level of motor blockade was assessed by the Bromage scale:

0- no motor block
1- not able to raise extended legs
2- not able to flex knees but able to move feet
3- not able to flex ankle joints

The patients were asked to move the extended legs, and when they were not able to lift them, the time was recorded, and also the resolution times of sensory and motor blockade were recorded.

Heart rate, respiratory rate, blood pressure, and SpO2 (%) were recorded at 1, 5, 10, 20, 30, 60, 90, and 120 min. Hypotension was defined as a decrease of more than 20% from the baseline systolic blood pressure and was treated with an intravenous (IV) bolus of 5 mg ephedrine, repeated every 3 min. Bradycardia was defined as the heart rate <40 beats per min and was treated with 0.5-1 mg of IV injection of atropin. The duration of analgesia was recorded by asking the patient about the onset of pain and for postoperative pain relief, a 75 mg Intramuscular (IM) injection of diclofenac sodium was given when required (first analgesic requirement). The study ended at the 24th hr after all data had been recorded.

Statistical Analysis

Data were analysed using the Statistical Package for the Social Sciences (SPSS) version 20.0 software version. The mean and standard deviation were calculated for different parameters. The Analysis of Variance (ANOVA) was used to compare the variables among the three study groups, and Student-Newman-Keuls post hoc test was used to compare the data between the groups. A p-value <0.001 was considered to be highly statistically significant and p<0.05 was significant.


The patients in all three groups were comparable for demographic data in terms of age, weight, height, and ASA grading (Table/Fig 2). Comparison of the the mean heart rates and respiratory rates at different time points are presented in (Table/Fig 3) and (Table/Fig 4), respectively. The patients of group RNE showed a significant fall in heart rate in comparison to groups RNS and RFE, at all time points (Table/Fig 3). The respiratory rate also followed a similar pattern to heart rate in group RNE, at different time points (p<0.001), except at 5 min and 90 min (Table/Fig 4).

Comparisons of mean systolic and diastolic blood pressure among the three groups are presented in (Table/Fig 5),(Table/Fig 6), respectively. Mean systolic blood pressure showed a significant rise at all time points in group RNE when compared with group RNS and group RFE.

Mean diastolic blood pressure was significantly higher in group RNE compared to group RNS and group RFE at 10, 20, 30, and 60 min of the observation period. However, it showed recovery and became comparable to that of group RNS and group RFE at 90 and 120 min. Moreover, the mean oxygen saturation percentage was almost similar in all three groups.

Mean onset of sensory loss (onset time of T10 level sensorial blockade) was significantly earlier in group RNE (239.6±28.8 sec) when compared to group RNS (298.1±27.8 sec) and group RFE (261.9±32.2 sec) (p<0.001). Whereas, the mean duration of sensory loss (at T10 level) was significantly prolonged in group RFE (227.8±30.5 min) when compared to group RNS (207.8±28.8 min, p<0.05), but comparable to group RNE (219.1±29.5 min). Mean time to onset of motor (Bromage score to become 3) was significantly earlier in group RNE (480.7±30.2 sec) when compared with group RNS (623.1±40.9 sec) and group RFE (597.9±32.1 sec) (p<0.001). The duration of motor blockade (Bromage score to become 0) was significantly prolonged in group RFE (244.7±28.3 min) and RNE (237.9±31.1 min), when compared with group RNS (202.3±30.7 min) (p<0.001) (Table/Fig 7).

Duration of analgesia was significantly prolonged in group RNE (582.33±30.2 min) than group RNS (211.96±26.7 min) and group RFE (291.50±30.3 min). Furthermore, group RFE also had a significantly longer duration of analgesia than group RNS (p<0.001) (Table/Fig 7). Various side-effects of drugs were noted during the observation period but were found to be non significant among the groups and are depicted in (Table/Fig 8).


The results of this study revealed that the mean duration of analgesia (first analgesia requirement time after the study drugs were given intrathecally) showed that it was significantly prolonged in group RNE than groups RNS and RFE (p<0.001). This is in accordance with the findings of Lauretti G et al., (13), Garg A et al., (14) and Shakya ML et al., (15), who also reported that the intrathecal neostigmine led to a prolonged duration of analgesia up to 12 hrs rather than intrathecal fentanyl. Pan PM and Mok MS, reported decreased requirement for other analgesics and provided longer postoperative analgesia with neostigmine compared to intrathecal fentanyl (16).

Furthermore, group RNS had a shorter duration of analgesia than group RFE. Chung CJ et al., showed that the addition of 10 μg fentanyl increases the duration of analgesia by approximately 40 min as compared to ropivacaine alone (17). Sanli S et al., showed that addition of 10 μg fentanyl to 15 mg hyperbaric ropivacaine prolonged the duration of analgesia by approximately 24 min and the time to the rescue analgesic dose administration by approximately 52 min (18).

The mean time of onset of sensory loss in group RNE was significantly earlier when compared with groups RNS and RFE. Furthermore, in group RFE the onset of sensory loss was earlier when compared with group RNS. Shakya ML et al., reported that the mean onset of sensory loss with bupivacaine and neostigmine was earlier than bupivacaine with fentanyl (15). McNamee DA et al., observed that onset, intensity, level, and duration had no significant differences in ropivacaine alone and in combination with fentanyl (19). Whereas, a study conducted by Chaudhary A et al., which compared ropivacaine alone or in combination with fentanyl 10 μg, it was observed that there was no significant difference between the groups for the onset of sensory block at level T10 (20). Luck JF et al., reported comparative analysis of bupivacaine, levobupivacaine, and ropivacaine and found no significant differences between the groups with regard to mean time to onset of sensory block at T10, extent of spread and mean time to maximum spread (5).

In the present study, the mean duration of sensory blockade was significantly longer in group RFE when compared with group RNS (p<0.05) which is similar to the study conducted by Gunaydin B and Tan ED, where they compared ropivacaine (15 mg) alone or in combination with fentanyl (20 μg) for the elective Caesarean section (21).

The mean time to onset of motor blockade (Bromage score to become 3) was significantly earlier in group RNE when compared with groups RNS and RFE. Whereas, duration of motor blockade (Bromage score to become 0) was significantly longer in groups RFE and RNE when compared with group RNS (p<0.001). Shakya ML et al., demonstrated that the mean onset of motor blockade was shorter in intrathecal neostigmine group than the fentanyl group (15). Faiz SH et al., showed that the addition of neostigmine to bupivacaine significantly decreased the recovery time when compared with control group (125±27.4 vs 138.33±30.27 min) (12). Thus, the combination of ropivacaine and neostigmine appears to be better in terms of onset and duration of motor blockade in patients with spinal anaesthesia for early ambulation surgeries.

On comparison of variations in mean heart rate at different time points, it was observed that group RNE showed a significant fall in heart rate in comparison to group RNS and RFE at all time points, whereas Shakya ML et al., found bradycardia in 0.03% of the patients on intrathecal administration of bupivacaine with neostigmine versus 0.13% in the bupivacaine with fentanyl group (15). Pan PM and Mok MS (16) and Carp H et al., (22) reported a lesser incidence of bradycardia with intrathecal neostigmine than fentanyl, suggesting the more haemodynamic stable effect of neostigmine. In the present study, the respiratory rate also followed a similar pattern like heart rate for group RNE at different time points (p<0.001), except at 5 min and 90 min. Thus, one should have a close observation of the heart rate and respiratory rate of patients receiving neostigmine with naesthetic medication during spinal anaesthesia.

The mean systolic BP was significantly lower in group RFE than groups RNS and RNE. It was further observed that in group RFE patients, systolic BP slightly increased after drug administration between 5 to 20 min, but settled to baseline at the end of 120 min. Furthermore, group RFE patients maintained their systolic BP, whereas, group RNS had a slight fall in their systolic BP after the drug was given intrathecally and was lower than the baseline throughout the procedure. Whereas, Shakya ML et al., found hypotension in 0.06% of cases receiving neostigmine and in 0.23% cases receiving fentanyl, and concluded that neostigmine maintains BP better in comparison to fentanyl (15). Akhtar N et al., compared ropivacaine with the combination of ropivacaine with fentanyl and observed that mean heart rate and arterial pressure decreased significantly from their baseline values in both the groups (23).

When the groups were compared for variation in mean diastolic BP, it was again found significantly different in group RNE at 10, 20, 30, and 60 min from groups RNS and RFE. There was a rise in diastolic BP at the above time points, but later it returned back to baseline. Incidence of hypotension was lesser with neostigmine than fentanyl, suggesting a more haemodynamic stable property of neostigmine as reported by other authors (16),(22). Again, one should be careful about BP changes while using neostigmine as it increases the incidence of hypotension that can be managed with routine clinical measures. Moreover, the mean oxygen saturation percentage was almost similar in all three groups.

Side-effects like nausea, vomiting, bradycardia, hypertension, and shivering were observed. Nausea was the most common side effect in all three groups, especially in the neostigmine group. Shakya ML et al., reported that the incidence of nausea and vomiting was higher in the case of intrathecal neostigmine (15). The rostral spread of neostigmine to the brainstem has contributed to the severity of these side-effects. Nausea as a common side effect of neostigmine limits its use, but with premedication like antiemetics, it can be easily controlled. Lauretti G et al., showed a dose-independent reduction of postoperative analgesia requirements, but a dose-dependent increase in the incidence of postoperative nausea and vomiting following the addition of various doses of intrathecally administered neostigmine (ranging from 25 to 100 μg) to 15 mg of hyperbaric bupivacaine 0.5% (13).

Thus, the findings of the present study demonstrated that haemodynamic instability can occur in combination of ropivacaine with neostigmine in comparison to ropivacaine with fentanyl or with normal saline. However, the major advantage of ropivacaine with neostigmine is that there is an early loss of sensory and motor components with prolonged duration of sensory and motor loss along with the prolonged period of analgesia which provides better comfort to patients undergoing spinal anaesthesia.


Extreme caution is required while preparing the drug to prevent contamination. Also, in the present study, all patients were either ASA physical status I or II. Results cannot be generalised to ASA physical status III and IV patients.


Although neostigmine had higher incidence of side-effects, especially nausea and bradycardia, most of the patients tolerated well. Therefore, it can be a good alternative as an adjuvant to ropivacaine in spinal anaesthesia in patients with benign prostate hypertrophy undergoing elective TURP under careful haemodynamic monitoring.


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DOI and Others

DOI: 10.7860/JCDR/2022/57705.17078

Date of Submission: May 12, 2022
Date of Peer Review: Jun 07, 2022
Date of Acceptance: Aug 10, 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

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