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

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Dr Mohan Z Mani

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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."



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




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
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It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



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




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : December | Volume : 16 | Issue : 12 | Page : UC10 - UC14 Full Version

Low Interscalene Brachial Plexus Block with Dexmedetomidine and Clonidine as Adjuvants to Local Anaesthetic Mixture: A Double-blind Randomised Clinical Study


Published: December 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/57123.17249
Balwinder Kaur Rekhi, Tripat Kaur Bindra, Lovepreet Kaur, Priyanka Mehta, Simrit Kaur

1. Professor, Department of Anaesthesiology and Intensive Care, Government Medical College, Patiala, Punjab, India. 2. Professor, Department of Anaesthesiology and Intensive Care, Government Medical College, Patiala, Punjab, India. 3. Junior Resident, Department of Anaesthesiology and Intensive Care, Government Medical College, Patiala, Punjab, India. 4. Senior Resident, Department of Anaesthesiology and Intensive Care, Government Medical College, Patiala, Punjab, India. 5. Associate Professor, Department of Anaesthesiology and Intensive Care, Government Medical College, Patiala, Punjab, India.

Correspondence Address :
Simrit Kaur,
6, Malwa Enclave, Dera Baba Jassa Singh Road, Patiala, Punjab, India.
E-mail: drsimrit29@gmail.com

Abstract

Introduction: For routine and emergency upper limb surgeries, brachial plexus block is better alternative to general anaesthesia. As compared to classic Interscalene brachial plexus Block (ISB), Low Interscalene Block (LISB) deposit Local Anaesthetic (LA) more caudad causing sensory-motor blockade of upper limb. It acts as bridge between supraclavicular and classic ISB. Local anaesthetic mixture are used to shorten the onset of sensory-motor blockade. Alongside, various adjuvants are mixed with LA to further improve quality of block.

Aim: To compare the efficacy of dexmedetomidine and clonidine as adjuvants to LA mixture in LISB for upper limb surgeries to assess onset and duration of sensory-motor block and to observe any complication associated with block.

Materials and Methods: This double-blind, randomised prospective clinical study was conducted on 90 patients, aged 18-60 years, posted for upper limb surgeries with American Society of Anaesthesiologists (ASA) grade I, II at a tertiary care centre of Government Medical College, Patiala, Punjab, India from February 2021 to November 2021. The patients were randomly divided into three groups. Group I: levo-bupivacaine 0.5% (20 mL)+lignocaine 2% (10 mL)+Normal Saline (NS) (1 mL), group II: levo-bupivacaine 0.5% (20 mL)+lignocaine 2% (10 mL)+dexmedetomidine 50 mcg (1 mL), group III: levo-bupivacaine 0.5% (20 mL)+lignocaine 2% (10 mL)+clonidine 50 mcg (1 mL). The parameters observed were: onset and duration of sensory and motor block, any intraoperative complication. Data was compiled with the help of MS-Excel and analysis done with IBM Statistical Package for Social Sciences (SPSS) version 22.0.

Results: The mean onset time of sensory and motor block was faster in group II (4.20±0.62, 5.25±0.89 min) as compared to group III (5.24±0.99, 6.23±0.96 min) and group I (6.48±0.87, 7.03±1.02 min). The mean duration of sensory and motor block was prolonged in group II (743.38±12.55, 673.21±22.29 min) as compared to group III (480.65±14.72, 433.03±7.28 min) and group I (311.28±5.75, 272.03±6.09 min). No adverse effect was observed during this study.

Conclusion: Dexmedetomidine was more effective than clonidine as an adjuvant to LA mixture (0.5% levobupivaciane+2% lignocaine) in low interscalene brachial plexus block and no episode of pneumothorax and phrenic nerve palsy was seen.

Keywords

Motor block, Pneumothorax, Sensory block

The brachial plexus regional anaesthesia facilitates surgery on ambulatory and conscious patients, providing perfect intraoperative anaesthesia, analgesia and muscle relaxation with fewer adverse effects, decreased requirement of postoperative opioids, shorter hospital stay, unlike general anaesthesia (1),(2),(3). Brachial plexus can be blocked through several approaches classified as: classic interscalene block, low interscalene, supraclavicular block, infraclavicular and axillary block (4).

Low interscalene approach has conquered the drawbacks of the classical interscalene approach. In the low approach on interscalene groove, the site selected for blockade of brachial plexus is two-third of the distance caudally from the C6 vertebral level. It is known to involve a short effect distance from the C5 nerve root to the C8 nerve root and to diffuse local anaesthetics via the deep cervical fascia and reported to achieve appropriate sensory-motor block required for upper limb surgeries (5). According to the latest anatomic study, the phrenic nerve separates inferomedially from brachial plexus 3 mm for each centimetre the nerve courses caudally, (6) thus moving caudal from the C6 level, phrenic nerve shifts away. Hence phrenic nerve blockade is avoided by LISB (7).

Various types of LA and their combinations are being used so as to reduce the dose and to have a synergistic action for achieving block (8). Combining two amide LA agents like (bupivacaine and lignocaine) offers the clinician and patient the best effects of both drugs, the fast onset of lignocaine and prolonged duration of bupivacaine (9).

Nowadays, levobupivacaine (S(-)-enantiomer of bupivacaine having a similar pharmacological profile, with lesser cardiotoxicity and having a wider safety margin when compared to racemic bupivacaine and therefore is being favoured LA for regional block (10),(11).

As adjuvants alpha-2 adrenergic receptor agonists, clonidine and dexmedetomidine have been used frequently, because of their sedative, perioperative sympatholytic, analgesic and cardiovascular stabilising effects (4). For many years clonidine has been used as an adjunct to local anaesthetic agents in various regional techniques (12). It is a selective α-2 adrenergic agonist with some α-1 agonist properties (13). Clonidine improves sensory and motor blockade of neuraxial and peripheral nerves after injection of local anaesthetic solution without affecting the onset (12). Dexmedetomidine new alpha-2 adrenergic receptor agonist, which is characterised by being eight times more selective towards α2 adrenoreceptors as compared to clonidine (13). Its α2:α1 binding selectivity ratio is 1620:1 compared to 220:1 for clonidine, and thus alongside enhancing sensory and motor blockade, it also reduces the unwanted haemodynamic side-effects of α1 receptors (14),(15).

Keeping in mind the combination of LA mixture (0.5% levobupivacaine having longer duration of action plus 2% lignocaine having rapid onset of action) and adjuvants, the present study was designed to compare the effects of dexmedetomidine and clonidine as adjuvants to LA mixture in upper limb surgeries using LISB approach. The primary objectives were sensory-motor blockade. The secondary objectives were intraoperative monitoring of Blood Pressure (BP), Respiratory Rate (RR), Heart Rate (HR) ans SpO2 and intraoperative complications.

Material and Methods

The double-blind, randomised prospective clinical study was conducted at tertiary care centre, from February 2021 to November 2021. The Ethics Committee Approval (No BFUHS/2K21p-TH/5412 dated 22/01/2021) and written informed consent from patients were obtained.

Inclusion criteria: This study included 90 patients, aged 18-60 years of either gender, posted for upper limb surgeries with ASA grade I, II.

Exclusion criteria: Patients who refused, had known allergy to medications used in this study, infection at the site injection or had coagulopathy were excluded from the study.

Ninety patients were randomly divided into three groups of 30 each using computer generated randomisation (Table/Fig 1).

Sample size calculation: The three independent groups to be compared were of equal size n, and were drawn from the population. Sample size was calculated by using the formula:

n=(r+1)/r SD2 (Zβ-Zα)2/(d)2

n=Sample size, α=0.05, β=0.001 and 1-β is power of study=95%

Minimum required n=25.088=25, but a sample size of 30 for each group was considered.

Group I: Levo-bupivacaine 0.5% (20 mL)+Lignocaine 2% (10 mL)+NS (1 mL)
Group II : Levo-bupivacaine 0.5% (20 mL)+Lignocaine 2% (10 mL)+Dexmedetomidine 50 mcg (1 mL)
Group III : Levo-bupivacaine 0.5% (20 mL)+Lignocaine 2% (10 mL)+Clonidine 50 mcg (1 mL)

One ampule of clonidine containing 150 mcg/1 mL diluted with NS to get 50 mcg/mL of clonidine)

Depending upon the group allotted, the syringe labelled with the patient’s name containing the respective drug solution was handed to the investigator, performing the block, by an assistant who did not participate in the study. An independent observer not included in the study then observed the parameters. Blinding was opened at the end of the study.

Preanaesthetic checkup including detailed clinical history, airway examination and thorough systemic examination was done on every patient. Fasting protocol was followed. Premedication with alprazolam 0.25 mg and omeprazole 20 mg orally given the night before elective surgery.

Anaesthesia Technique

On the day of surgery, after shifting the patient to the operating room, all standard monitors were connected, which included Non Invasive Blood Pressure (NIBP), five lead Electrocardiograph (ECG), pulse oximeter for monitoring vitals. Intravenous line was secured for intravenous fluid.

The patient was made to lie in the supine position with the arm by the side of the trunk and the head slightly turned away from the side to be blocked. The following landmarks for block were marked: The clavicle, posterior border of clavicular head of sternocleidomastoid muscle, external jugular vein (usually crosses the interscalene groove at the level of trunks).

Identification of interscalene groove was made easier by asking the patient to raise head off the table to accentuate the sternocleidomastoid muscle. While palpating the interscalene groove, patient was asked to sniff forcefully to make the muscles tense.

Under aseptic preparation of the area, skin wheal was raised with 1-2 mL of LA at the determined needle insertion site.The fingers were pressed between the anterior and middle scalene muscles to shorten the skin brachial plexus distance. The stimulating needle connected with the peripheral nerve stimulator was inserted 3-4 cm (approximately two finger breadths) above the clavicle and advanced at an angle almost perpendicular to the skin plane.The nerve stimulator was initially set to deliver 0.8-1.0 mA (2 Hz, 0.1 ms). The needle was advanced slowly until appropriate twitches of muscles of the brachial plexus were elicited. This typically occurred at 1-2 cm depth in most patients. Once appropriate muscles twitches were elicited, LA solution was injected slowly in increments of 5 mL with intermittent aspiration to rule out the intravascular injection.

Following parameters were observed after injecting anaesthetic solution:

Primary Outcomes

Onset of sensory blockade: After injecting drug, the time to achieve grade 3 Hollmen scale was considered as onset of sensory blockade.

Hollmen scale 3 (16)

1=normal sensation of pinprick
2=pinprick felt as sharp-pointed but weaker compared with the same area in other limb
3=pinprick recognised as touch with a blunt object
4=no perception of pinprick

Onset of motor blockade: Time to achieve grade 3 of Hollmen scale was considered as onset of motor blockade.

Hollmen scale 3

1=normal muscle function
2=slight weakness in function
3=very weak muscular action
4=complete loss of muscle action

Duration of sensory block: From the time of administration of drug till regression of block to grade 2 using Hollmen scale.

Duration of motor block: From the time of administration of drug till recovery of grade 2 of Hollmen scale i.e. slight weakness in muscle function.

Secondary Outcomes

Monitoring of the patients for BP, SpO2, RR, HR was done continuously and recorded throughout the surgery and observed for any intraoperative complication (bradycardia, hypotension, hypoxaemia or any signs of horner’s syndrome, hoarseness of voice, breathing difficulties or use of accessory muscles of respiration or drop in saturation below 90% suggestive of diaphragmatic palsy or pneumothorax).

In case of pain, supplementary analgesia was given with intravenous 50 μg of fentanyl. Block was considered inadequate when sensory anaesthesia was not achieved within 30 min. General anaesthesia was given subsequently to these patients, who were then excluded from the analysis.

Statistical Analysis

Data was compiled with the help of MS-Excel and analysis done with IBM SPSS version 22.0. Results were reported in terms of Mean, Standard Deviation (SD) (min-max) and percentage. Analysis of Variance (ANOVA), Tukey post hoc test, Kruskal Wallis H test were applied to find the significance of study parameters on a continuous scale among three groups (intergroup analysis) on metric parameters and Pearson Chi-square test on a categorical scale between the groups, respectively. Statistical significance was taken as p-value <0.05, and p-value <0.001 was taken as statistically highly significant. The p-value >0.05 was taken as statistically non significant.

Results

As shown in (Table/Fig 2) all three groups were comparable in the terms of mean age, gender, weight and ASA grade (p-value was >0.05).

As shown in (Table/Fig 3), onset of sensory blockade and motor blockade were faster in group II as compared to group III and group I. These differences were statistically significant. The mean duration of sensory and motor blockade was maximum in group II as compared to group III and I. These differences were statistically significant.

As shown in (Table/Fig 4), the mean heart rate was comparable in all the three groups at all time intervals. There was no statistically significant difference in the mean HR as the p-value at all times was >0.05.

As shown in (Table/Fig 5), the mean arterial blood pressure was comparable in all three groups. There was no statistically significant difference in the mean as p-value at all times is >0.05. At 10 min, a fall in diastolic blood pressure from baseline was observed in all the patients, but the difference was statistically and clinically insignificant in all three groups.

As shown in (Table/Fig 6), Respiratory rate was comparable in all three groups. There was no statistically significant difference in the mean as p-value at all times was >0.05 in all three groups.

No episode of bradycardia, hypotension or phrenic nerve palsy was observed.

Discussion

In the present study, low interscalene brachial plexus block was used to deposit LA more caudad on brachial plexus in contrast to classic interscalene brachial plexus block, For greater spread to the lower trunk involving the ulnar nerve. Therefore it resulted in appropriate sensory-motor block required for upper limb surgeries. Moreover, this approach avoids phrenic nerve injury.

A LA mixture containing a LA having rapid onset can hasten the onset time for sensory and motor blockade. In the present study, 2% lignocaine along with 0.5% levobupivacaine was used to accelerate the onset of the block. Further, adding adjuvants to the LA mixture helped improve the quality and duration of the block. In this study, α2 agonist- Clonidine or Dexmedetomidine as an adjuvant has been used.

Onset of the sensory and motor blockade was fastest in group II as compared to group III and the group I individually.

The results was consistent with those of Kaur H et al., (17), Sreeja R et al., (18), Krishan G et al., (19) and Tripathi A et al., (20) These studies also concluded that the onset of sensory-motor blockade was significantly earlier and the duration of blockade was prolonged in dexmedetomidine group as compared to the group with clonidine and group with LA alone.

Kaur H et al., (17) concluded that addition of 1 μ/kg dexmedetomidine to 0.25% levobupivacaine for supraclaviclar plexus block shortens sensory, motor block onset time and extends sensory-motor block durations. In this study, the drugs studied were 40 mL of solution containing 30 mL 0.5% levobupivacaine and 10 mL 1% lignocaine, and 40 mL of solution containing 30 mL 0.25% levobupivacaine and 10 mL 1% lignocaine with dexmedetomidine 1 μ/kg for supraclavicular brachial plexus block.

Sreeja R et al., (18) reported that the duration of analgesia was significantly higher in Group B {bupivacaine 0.5% (20 mL)+ dexmedetomidine 1 μg.kg-1} as compared to Group A {bupivacaine 0.5% (20 mL)+clonidine 1 μg.kg-1}. The mean time for onset of a sensory block as well as motor block was significantly less in Group B.The study by Krishan G et al., (19) found that both clonidine and dexmedetomidine, when used as an adjuvant to 0.5% levobupivacaine, decreased the onset of sensory and motor blockade and prolonged the duration of sensory and motor blockade but dexmedetomidine was a better alternative to clonidine as an adjuvant to local anaesthetic agent.

Tripathi A et al., (20) concluded that addition of dexmedetomidine prolongs the durations of sensory and motor block and duration of analgesia and improves the quality of anaesthesia as compared with clonidine when injected with bupivacaine in supraclavicular brachial plexus block.

All the three groups in this study were comparable in terms of heart rate, mean arterial blood pressure, respiratory rate. There was no clinical or statistically significant difference amongst any of the groups as the p-value obtained was >0.05. During the present study, no episode of bradycardia, hypotension, hypoxemia was observed in either of the group. This might be because of the use of low doses of dexmedetomidine and clonidine, at which only early onset and prolonged duration of the block were seen without any haemodynamic side-effects. Similar to the present study, when lower dose of dexmedetomidine was used by Swami SS et al., (21), the incidence of bradycardia and hypotension was not significant. In the present study, a 50 μg dose of dexmedetomidine was present in group II. Bernard JM and Macarie P (22) conducted a study evaluating the effects of adding 30-300 μg clonidine to lignocaine for axillary brachial plexus anesthesia. The study concluded that the addition of a small dose of clonidine hastened the onset of the block and improved the efficacy of surgical anaesthesia alongside limiting alpha two agonist side-effects to the sedation only. According to this study, the best dose to use clinically is between 30 μg and 90 μ μg. In the present study, a 50 μg dose of clonidine was used in group III.

In the present study, there was no episode of diaphragmatic palsy, pneumothorax, Horner syndrome or hoarseness of voice. This was probably because a low interscalene block was used in which the block was performed below the level of the C6 vertebra. At this level phrenic nerve divides 3 mm per cm as it descends caudally from the brachial plexus, thereby reducing the incidence of hemidiaphragmatic palsy and other respiratory complications. Park SK et al., (5) also used a low approach interscalene brachial plexus block on patients undergoing surgery of upper extremities. None of the patients in their study experienced complications. There were no signs of dyspnea or hemidiaphragmatic paralysis.

Limitation(s)

The block was not ultrasound-guided which would have helped use less volume and dosage of the local anaesthetic mixture for achieving an adequate block.

Conclusion

The results of the present study concludes that LISB provides adequate sensory and motor block for upper limb surgeries without significant adverse effects. Using LA mixture (lignocaine+ levopuvacaine) provides rapid onset of block due to lignocaine. The addition of dexmedetomidine produces significantly faster onset of sensory-motor blockade with prolonged duration followed by clonidine and LA mixture, respectively. Using LISB approach there is less chance of phrenic nerve blockade and less incidence of ulnar sparing. Therefore, LISB should be preferred for upper limb surgeries with LA mixture.

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DOI and Others

DOI: 10.7860/JCDR/2022/57123.17249

Date of Submission: May 03, 2022
Date of Peer Review: May 31, 2022
Date of Acceptance: Aug 26, 2022
Date of Publishing: Dec 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: May 04, 2022
• Manual Googling: Aug 18, 2022
• iThenticate Software: Aug 23, 2022 (23%)

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