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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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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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 : UC32 - UC36 Full Version

Comparison between Dexmedetomidine, Ketamine and Tramadol for Prevention of Perioperative Shivering under Spinal Anaesthesia: A Randomised Clinical Trial


Published: December 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/59358.17368
Tanwin Khan, Monu Yadav, Singam Geetha, R Gopinath, Padmaja Durga, Hima Chowdary

1. Senior Resident, Department of Anaesthesia and Critical Care, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India. 2. Additional Professor, Department of Anaesthesia and Critical Care, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India. 3. Associate Professor, Department of Anaesthesia and Critical Care, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India. 4. Professor, Department of Anaesthesia and Critical Care, ESI Hospital, Hyderabad, Telangana, India. 5. Professor, Department of Anaesthesia and Critical Care, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India. 6. Junior Resident, Department of Anaesthesia and Critical Care, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India.

Correspondence Address :
Dr. Singam Geetha,
Associate Professor, Department of Anaesthesia, Nizams Institute of Medical Sciences, Panjagutta, Hyderabad, Telangana, India.
E-mail: singamgeetha11@gmail.com

Abstract

Introduction: Perioperative shivering after spinal anaesthesia is a common complication. Ketamine and tramadol are routinely used to prevent perioperative spinal shivering. Ketamine has the side-effect of delirium while tramadol causes nausea and vomiting. Dexmedetomidine an alpha2 agonist is superior to tramadol and ketamine in view of better central vasoconstrictor tone regulation and less sympathetic activity.

Aim: To compare the efficacy, effect on haemodynamics, and any adverse effects of tramadol, ketamine and dexmedetomidine when used prophylactically to prevent perioperative shivering after spinal anaesthesia.

Materials and Methods: This, randomised, clinical study recruited adult patients aged 18-65 years, of American Society of Anaesthesiologists (ASA) I and II, of both genders undergoing surgery under spinal anaesthesia between February 2018 and August 2018. A total of 120 patients were assigned to four groups: T, D, K, and N, to receive Tramadol 0.5 mg/kg or Dexmedetomidine 0.5 μg/kg or Ketamine 0.25 mg/kg or normal saline 5 mL, respectively. Each study drug was diluted to 5 mL using normal saline and administered as a slow intravenous (i.v.) bolus injection five minutes before spinal anaesthesia. Patients received subarachnoid block in L3-4 or L4-5 space in sitting position with 0.5% hyperbaric bupivacaine 15 mg. Patients were monitored for shivering, (using a four-point scale), level of consciousness, heart rate, SpO2, respiratory rate, non invasive blood pressure, nausea and vomiting, at intervals of every five minutes for the first 30 minutes and every 15 minutes for the remaining observation period.

Results: Dexmedetomidine (n=0) offered lower incidence of shivering prevention after spinal anaesthesia than ketamine (n=2, 6.6%), tramadol (n=10,33%) and normal saline groups (n=11, 36.6%). Dexmedetomidine also provided the advantages of maintaining haemodynamics, respiratory rate, and consciousness, similar to ketamine or tramadol (p-value >0.05).

Conclusion: Dexmedetomidine is superior to ketamine and tramadol for the prevention of shivering after spinal anaesthesia.

Keywords

Alpha2 agonist, Hypothermia, Postoperative N-methyl-d-aspartate receptor antagonist

Shivering, a common postspinal anaesthesia occurrence, is defined as an involuntary, repetitive activity of skeletal muscles. The incidence of perioperative shivering is relatively high, approximately 40-70% after neuraxial anaesthesia (1),(2). It increases oxygen consumption and carbon dioxide production, induces lactic acidosis and causes patient dissatisfaction and discomfort (3). Shivering may also increase intraocular and intracranial pressure, increase wound pain, delay wound healing, and delay discharge from postanaesthetic care (4). It also has the disadvantage of interfering with the monitoring of blood pressure, electrocardiogram and oxygen saturation. When the preoptic region of the hypothalamus is cooled shivering is elicited as a physiological response to raise metabolic heat production through muscle contraction (5). The aetiology of intra/postoperative shivering is multifactorial and includes temperature loss, increased sympathetic tone, pain, and systemic release of pyrogens.

Spinal anaesthesia reduces the tonic vasoconstriction leading to impairment of thermoregulatory system and decrease in shivering threshold. Spinal anaesthesia with sensory loss extending upto T6 level may cause sympathetic paralysis resulting in extensive vasodilatation. Shivering can be controlled by non pharmacological and pharmacological methods. Non pharmacological means include covering the skin (e.g., surgical drapes, blankets or plastic bags) and forced-air warming using Baer-Hugger, i.v. fluid and blood warmers should be used to minimise the incidence of shivering while administering the i.v. fluids, blood and blood products during the operation. The irrigating solutions should be used after warming them closer to human body temperature for irrigating the wound during surgery. Also, heat loss and thus shivering can be minimised by using warm, humidified oxygen via nasal prongs throughout the surgery. As several neurotransmitter pathways of opioids, alpha2 adrenergic, serotonergic and anticholinergic receptors are involved, various pharmacologic agents have been used for prophylaxis and treatment of postspinal shivering like opioids like fentanyl, Tramadol (6),(7),(8), meperidine (6) anticholinergic: physostigmine, N-methyl-d-aspartate (NMDA) receptor antagonist ketamine (5) and α2 agonists clonidine (7) and Dexmedetomidine (8),(9),(10),(11).

Tramadol is a favoured and commonly used drug for postspinal anaesthesia shivering. It inhibits serotonin and noradrenaline uptake in the spinal cord and stimulates the secretion of hydroxyl-tryptamine, thus modulating the human temperature regulation centre. Ketamine, another agent, has gained popularity during the last decade. It is a competitive NMDA receptor antagonist that acts in thermoregulation by inhibiting norepinephrine uptake into postganglionic sympathetic nerve endings (12). Dexmedetomidine, a recent drug used for sedation decreases the shivering threshold by reducing the vasoconstriction (13). Dexmedetomidine has lower incidence of nausea and vomiting, than tramadol and also provides better sedation than ketamine (13). As perioperative shivering can be very harmful to the patients, the focus should be on prevention rather than treatment. Various studies have been conducted on tramadol and ketamine. But only a few trials are available on recent drug dexmedetomidine comparing with either tramadol or ketamine. Dexmedetomidine controls shivering better with lesser nausea than tramadol (14). Dexmedetomidine offers lower shivering with higher sedation than ketamine (15). As dexmedtomidine offers the dual advantage of lower incidence of nausea than tramadol and more sedation than ketamine, a trial necessiating the head-to-head comparison of dexmedetomidine with both these drugs is essential.

Hence, this clinical study was planned to compare the efficacy, effect on haemodynamics, and any adverse effects of tramadol, ketamine, and dexmedetomidine when used prophylactically to prevent perioperative shivering after spinal anaesthesia. The primary objective was the efficacy in reducing shivering. The secondary objectives were impact on the haemodynamics, level of sedation, and adverse effects.

Material and Methods

A randomised, clinical study was conducted between February 2018 and August 2018 in Nizams Institute of Medical Sciences, Hyderabad, Telangana, India. The study was started following approval of the Institutional Ethics Committee (IEC) (number: EC/NIEC/NIMS/2046/2017). Registration was obtained with the clinical trial registry of India (http://ctri. nic.in/Clinical trials), CTRI/2020/12/029892.

Inclusion criteria: A total of 120 adults between 18-65 years, ASA I and II, of both sexes undergoing lower limb or lower abdominal surgeries under spinal anaesthesia who gave informed consent were included in the study.

Exclusion criteria: Patient refusal, ASA III and IV, drug allergy, compromised cardiorespiratory functions, renal or hepatic disease, thyroid, and psychiatric disorders, severe diabetes or autonomic neuropathies, known history of substance or alcohol abuse, pregnant patients, obese (body mass index >30 kg/m2), contradictions to spinal anaesthesia, patients having Visual Analogue Scale (VAS) >6 intraoperatively were offered general anaesthesia and were excluded from the study.

Sample size calculation: The sample size was estimated based on a pilot study. At 80% of the statistical test with five patients in each group, using the formula:

Sample size n= 2(Zα+Z1-β)2×σ2/ (m1-m2)2

The mean±SD of incidence of shivering for the first sample were 70.1±2.3. And that for the second sample were 68±2.1. Hence minimum number of samples required in each group was 21. However, considering attrition 30 members in each group were considered.

Study Procedure

Subjects were divided into four groups of 30 each (Table/Fig 1), using simple randomisation, according to the computer-generated table of random numbers-group T-IV tramadol 0.5 mg/kg, Group D-IV dexmedetomidine 0.5 μg/kg, group K-IV ketamine 0.25 mg/kg and group N-normal saline was given. All patients received a standardised anaesthetic protocol after a detailed preanaesthetic examination. This included overnight fasting and premedication with Tab Alprazolam 0.25 mg and Tab Ranitidine 150 mg on the night before surgery. On arrival at the operation theatre, intravenous access with an 18G i.v. cannula was secured. In this study, all Operation Theatres (OTs) were maintained at an ambient temperature of 22°-25°C, and all fluids and drugs were kept at room temperature during the surgery. Preloading was done with Ringer’s Lactate solution at room temperature at 10 mL/kg rate before giving spinal anaesthesia. In the operating room, standard monitoring was done for level of consciousness, electrocardiogram, SpO2, respiratory rate, non invasive blood pressure:(systole and diastole), shivering, nausea and vomiting at intervals of every 5 minutes for the first 30 minutes and every 15 minutes for the rest of the observation period. A standard blanket was used to cover the patients, chest and upper limbs. One of the three study drugs alone with normal saline was given as a slow i.v. bolus injection five minutes prior to spinal anaesthesia. The drugs were diluted to a volume of 5 mL in a 5 mL syringe. Under sterile aseptic conditions, a subarachnoid block was performed using a 25G cutting, quincke spinal needle in L3-L4 or L4-L5 space in sitting position. About 15 mg of 0.5% hyperbaric bupivacaine was administered at a rate of 0.2 mL/sec in the subarachnoid space (after clear aspiration of CSF). Pinprick method at the midaxillary line was used to assess the level of spinal block. The patients were prepared for surgery as the block level of T10 was achieved.

All patients were observed for shivering and graded with a four-point scale (16): 0-No shivering, 1-piloerection or peripheral vasoconstriction but no visible shivering, 2-muscular activity in only one muscle group, 3-muscular activity in more than one muscle group, 4-whole body shivering. The level of sedation was assessed by a four-point ordinal scale (17): 0-Awake and alert, 1-drowsy and responsive to verbal stimuli, 2-drowsy and responsive to physical stimuli, 3-unarousable. Perioperative nausea and vomiting were assessed using the four-point ordinal scale: 0-no nausea/vomiting, 1-nausea, 2-retching, 3 -vomiting (17). Heart rate, SpO2, respiratory rate, non invasive blood pressure, were recorded at intervals of every five minutes for the first 30 minutes and every 15 minutes for the remaining observation period.

Statistical Analysis

Statistical analysis was carried out using Statistical Package for the Social Sciences (SPSS) version 21.0. Continuous data were calculated with the Analysis of Variance (ANOVA) test and represented as mean±SD. Both categorical data and ordinal data were mentioned as frequency and percentages. Categorical data (shivering, sedation, nausea and vomiting) were calculated with the Chi-square test.

Results

A total of 120 patients who underwent surgery under spinal anaesthesia, were studied. The four groups were comparable in terms of demographic data as there were no significant differences in terms of age, weight, sex and ASA grade (Table/Fig 2). Dexmedetomidine had a statistically lower incidence of shivering than ketamine and tramadol (Table/Fig 3). The heart rates, on comparison within all the groups, were not found to be statistically significant (p-value >0.05) from the baseline values upto 90 minutes (Table/Fig 4).

The SBP on comparison within dexmedetomidine and tramadol groups were found to be statistically insignificant (p-value >0.05) upto 90 minutes from the baseline values, but it was significantly more in the ketamine group at 30 minutes (Table/Fig 5). The DBP on comparison among all groups showed a similar variation (p-value >0.05) from the baseline values upto 90 minutes (Table/Fig 6).

The respiratory rate on comparison between the dexmedetomidine and tramadol groups was found to be similar (p-value >0.05) up to 90 mins, but respiratory rate was highest for ketamine from 15-75 min and the difference was significant (Table/Fig 7). Regarding SpO2, a similar variation was noted among all the four groups (p-value >0.05) upto 90 minutes (Table/Fig 8). The level of consciousness, nausea, and vomiting were similar among the four groups (p-value >0.05) upto 90 minutes (Table/Fig 9).

Discussion

Shivering is commonly experienced by the patients undergoing abdominal and lower limb surgeries under neuraxial blockade of spinal and epidural anaesthesia. The different pharmacological agents of opioids, ketamine, alpha 2 adrenergic agonists that are available are of limited use in view of side-effects. This randomised clinical trial was conducted to compare the efficacy in the prevention of shivering. Dexmedetomidine was found to be superior over tramadol and ketamine. The study by Bozgeyik S et al., on dexmedetomidine (0.5 μg/kg and Tramadol (2 mg/kg), concluded that both effectively prevent postspinal shivering, but dexmedetomidine had caused more sedation. Regarding shivering, results of the present study were comparable with dexmedetomidine being better than tramadol, but there was no incidence of sedation with dexmedetomidine (18).

Wang J et al., performed a meta-analysis of randomised controlled trials to compare dexmedetomidine with tramadol. They concluded that dexmedetomidine controls shivering better than tramadol, while also decreasing the incidences of recurrence (14). This was similar to the present study. Similarly, in the trial by Houssein M and Ibrahim I, dexmedetomidine group patients had reduced postspinal anaesthesia shivering but more profound sedation (grade 4) than ketamine (0.25 mg/kg) (15). Sahi S et al., conducted a trial between dexmedetomidine (1 μg/kg), clonidine (2 μg/kg), tramadol (1 mg/kg) along with normal saline. All three drugs prevented postspinal shivering, but tramadol had significantly less nausea and shivering (19). However, in the present study dexmedetomidine was more effective than tramadol in prevention of shivering. Hidayah MN et al., conducted a study between, ketamine (0.5 mg/kg), and tramadol (1 mg/kg) on postspinal anaesthesia shivering (20). The ketamine group had significant lower shivering (8%) than tramadol (16%) and control (24%) group, but significantly higher mean arterial blood pressure and heart rate at 5 and 15 minutes and behavioural changes and side-effects. Although in the present study, low doses of ketamine (0.25 mg/kg) and tramadol (0.5 mg/kg) were administered, the incidence of shivering was comparable with the observations of Hidayah MN et al., i.e. it was 6% in ketamine, 33% in tramadol, 33% in normal saline and 0% in dexmedetomidine. Patients had higher mean haemodynamic parameters in the ketamine group compared to other groups but without causing any side-effects.

Limitation(s)

As this study was conducted in a single centre this might not be applicable to the general population.

Conclusion

Present study concluded that dexmedetomidine is superior than ketamine and tramadol in the prevention of shivering after spinal anaesthesia (p=0.027). Dexmedetomidine also offers the advantage of maintaining in stable haemodynamics, respiratory rate and consciousness with low adverse effects of nausea and vomiting similar to other drugs.

References

1.
Esmat IM, Mohamed MM, Abdelaal WA, El-Hariri HM, Ashoor TM. Postspinal anaesthesia shivering in lower abdominal and lower limb surgeries: A randomized controlled comparison between paracetamol and dexamethasone. BMC Anaesthesiolgy. 2021;21(1):262. [crossref] [PubMed]
2.
Gupta P, Gupta M. Intrathecal tramadol for prevention of postanaesthesia shivering after subarachnoid block: A prospective randomized placebo-controlled comparison of two different doses (10 and 20 mg). Anaesthesia Essays and Researches. 2018;12 (2):495-500. [crossref] [PubMed]
3.
Ferede YA, Aytolign HA, Mersha AT. The magnitude and associated factors of intraoperative shivering after cesarean section delivery under spinal anaesthesia. A cross sectional study. Ann Med Sur. 2021;72:103022. [crossref] [PubMed]
4.
Lopez MB. Postanaesthetic shivering - from pathophysiology to prevention. Rom J Anaesth Intensive Care. 2018;25:73-81. [crossref]
5.
Lema GF, Gebremedhn EG, Gebregzi AH, Desta YT, Kassa AA. Efficacy of intravenous tramadol and low-dose ketamine in the prevention of post-spinal anaesthesia shivering following cesarean section: A double-blinded, randomized control trial. International Journal of Womens Health. 2017;9:681-88. [crossref] [PubMed]
6.
Tilahun A, Seifu A, Aregawi A, Abera B, Demsie DG. Effectiveness of meperidine versus tramadol on post spinal anaesthesia shivering in elective cesarean section: A prospective observational cohort study. Int J Sur. 2021;28:22-26. [crossref]
7.
Panneer M, Murugaiyan P, Rao S. A comparative study of intravenous dexmedetomidine and intravenous clonidine for postspinal shivering in patients undergoing lower limb orthopedic surgeries. Anaesthesia Essays and Res. 2017;11:151. [crossref] [PubMed]
8.
Botros JM, Mahmoud AMS, Ragab SG, Ahmed MAA, Roushdy HMS, Yassin HM, et al. Comparative study between dexmedetomidine and ondansteron for prevention of post spinal shivering. A randomized controlled trial. BMC Anesthesiology. 2018;18(1);179. [crossref] [PubMed]
9.
Nesioonpour S, Bayat S, Ghomeishi A, Behaeen K, Savaie M, Ahmadzadeh A, et al. Effect of intravenous dexmedetomidine on shivering in cesarean section under intrathecal anaesthesia: Randomized clinical trial. Anaesthesia Pain Medicine. 2022;12(3):e122735. [crossref]
10.
Lamontagne C, Lesage S, Villeneuve E, Lidzborski E, Derstenfeld A, Crochetière C, et al. Intravenous dexmedetomidine for the treatment of shivering during Cesarean delivery under neuraxial anaesthesia: A randomized-controlled trial. Canadian J Anaesth. 2019;66:762-71. [crossref] [PubMed]
11.
Sween LK, Xu S, Li C, O’Donoghue MA, Ciampa EJ, Kowalczyk JJ, et al. Low-dose intravenous dexmedetomidine reduces shivering following cesarean delivery: A randomized controlled trial. Int J Obstetric Anaesthesia. 2021;45:49-55. [crossref] [PubMed]
12.
Thangavelu R, George S, Kandasamy R. Prophylactic low dose ketamine infusion for prevention of shivering during spinal anaesthesia: A randomized double blind clinical trial. J Anaesthesiol Clinical Pharmacology. 2020;36:506-10. [crossref] [PubMed]
13.
Fern L, Misiran K. Comparison of dexmedetomidine, pethidine and tramadol in the treatment of post-neuraxial anaesthesia shivering. Southern African Journal of Anaesthesia and Analgesia. 2015;21:21-26. [crossref]
14.
Wang J, Wang Z, Liu J, Wang N. Intravenous dexmedetomidine versus tramadol for treatment of shivering after spinal anaesthesia: A meta-analysis of randomized controlled trials. BMC Anesthesiol. 2020;20(1);104. [crossref] [PubMed]
15.
Houssein M, Ibrahim I. Intravenous low-dose ketamine injection versus dexmedetomidine infusion for prevention of intraoperative shivering during spinal anaesthesia. Ain-Shams Journal of Anaesthesiology. 2016;9:524. [crossref]
16.
Wrench IJ, Singh P, Dennis AR, Mahajan RP, Crossley AWA. The minimum effective doses of pethidine and doxapram in the treatment of post-anaesthetic shivering. Anaesthesia. 1997:52(1):32-36. [crossref] [PubMed]
17.
Filos KS, Goudas LC, Patroni O, Polyzou V. Hemodynamic and analgesic profile after intrathecal clonidine in humans: A dose-response study. Anesthesiology. 1994;81:591-01. [crossref] [PubMed]
18.
Bozgeyik S, Mizrak A, Kiliç E, Yendi F, Ugur B. The effects of preemptive tramadol and dexmedetomidine on shivering during arthroscopy. Saudi J Anaesth. 2014;8:238-43. [crossref] [PubMed]
19.
Sahi S, Singh MR, Katyal S. Comparative efficacy of intravenous dexmedetomidine, clonidine, and tramadol in postanaesthesia shivering. Journal of Anaesthesiology and Clinical Pharmacology. 2016;32:240-44. [crossref] [PubMed]
20.
Hidayah MN, Liu CY, Joanna OSM. Ketamine and tramadol for the prevention of shivering during spinal anaesthesia. Clinica Terapeutica. 2014;165:193-98.

DOI and Others

DOI: 10.7860/JCDR/2022/59358.17368

Date of Submission: Aug 01, 2022
Date of Peer Review: Aug 31, 2022
Date of Acceptance: Oct 14, 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: Aug 08, 2022
• Manual Googling: Oct 07, 2022
• iThenticate Software: Oct 13, 2022 (21%)

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