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

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Dr Mohan Z Mani

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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."



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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
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.
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,
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 : March | Volume : 16 | Issue : 3 | Page : UC19 - UC23 Full Version

Efficacy of Magnesium Sulphate in Attenuation of Succinylcholine Induced Fasciculations- A Randomised Clinical Study


Published: March 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/53556.16160
S Bala Bhaskar, Y Vedashree, N Kiran Chand, D Srinivasalu

1. Professor, Department of Anaesthesiology, Vijayanagar Institute of Medical Sciences, Ballari, Karnataka, India. 2. Assistant Professor, Department of Anaesthesiology, Shridevi Institute of Medical Sciences and Research Hospital, Tumkur, Karnataka, India. 3. Associate Professor, Department of Anaesthesiology, Vijayanagar Institute of Medical Sciences, Ballari, Karnataka, India. 4. Professor, Department of Anaesthesiology, Vijayanagar Institute of Medical Sciences, Ballari, Karnataka, India.

Correspondence Address :
S Bala Bhaskar,
Professor, Department of Anaesthesiology, Vijayanagar Institute of Medical Sciences (VIMS), Ballari-583104, Karnataka, India.
E-mail: sbalabhaskar@gmail.com

Abstract

Introduction: Magnesium Sulphate (MgSO4) pre-administration is effective in reducing Succinylcholine (Sch) induced fasciculations due to its effect at presynaptic end plate. Magnesium competes with calcium at the presynaptic end plate of neuromuscular junction and inhibits the release of Acetylcholine (Ach) from the motor nerve terminal and to a lesser extent, decreases the sensitivity of the postjunctional membrane and reduces the excitability of the muscle fibre.

Aim: To evaluate three doses of MgSO4 in reducing the incidence and severity of fasciculations.

Materials and Methods: This prospective, randomised clinical trial was conducted at Vijayanagar Institute of Medical Sciences (VIMS), Ballari, India. Ninety consenting adult patients aged 20-50 years scheduled for elective surgeries with endotracheal intubation under general anaesthesia were randomly allocated into three groups- Group 1, Group 2 and Group 3, to receive Injection (Inj.) MgSO4 20 mg/kg, 30 mg/kg and 40 mg/kg, respectively, before induction. Induction with Inj. propofol (2 mg/kg) was followed by administration of Inj. Sch (1.5 mg/kg). The main outcome parameters were the incidence of fasciculations and grading of the severity. Haemodynamic responses from the basal levels and after intubation, and adverse effects to the study drugs were noted. Chi-square test was used to find the significance of study parameters on categorical scale among the groups. Probability values at <0.05 was considered as significant.

Results: The incidence of fasciculations was 90%, 53.4% and 43.4% in groups 1, 2 and 3, respectively. Greater number of patients had grade 3 fasciculations in group 1 (20%), compared to group 2 and group 3 (3.4% and nil), respectively. The fall in blood pressure after MgSO4 was comparable among the three groups. Systolic Blood Pressure (SBP) and Diastolic Blood Pressure (DBP) increased by 23.5% and 18.5%, 7.9% and 4.1% and 2.8% and 2.7% in groups 1, 2 and 3, respectively at one minute. The SBP and DBP at 3rd and 5th minute stayed at statistically significant greater levels in group 1 as compared to groups 2 and 3, but were similar in groups 2 and 3 overall. The Heart Rate (HR) changes followed similar trend in all 3 groups. Incidence of feeling of warmth was highest in group 3 as compared to other groups.

Conclusion: MgSO4 at 40 mg/kg can be the optimal dose to suppress Sch-induced fasciculations, with better attenuation of intubation associated haemodynamic changes.

Keywords

Anaesthesia, Blood pressure, Calcium, Heart rate, Intubation, Propofol

Despite more than seven decades of use, Succinylcholine (Sch) continues to be a popular agent because of excellent neuromuscular relaxation, it produces for endotracheal intubation (1). However, its use is associated with adverse effects and fasciculations are observed frequently, with an incidence of 95% (2). Fasciculations occur due to prejunctional depolarising action of Sch. The uncoordinated muscle contractions manifest because of repetitive firing of the motor nerve terminals and antidromic discharges (3).

Various pre-treatment modalities have been advocated to reduce the incidence and severity of these fasciculations including use of a self-taming dose of Sch, precurarising doses of Non Depolarising Neuromuscular Relaxants (NDMR), anaesthetic agents, lignocaine, MgSO4, opioids, pregabalin and gabapentin (2),(4),(5). Among these, only use of Non Depolarising Neuromuscular Blockers (NDMRs), lignocaine and MgSO4 have been associated with significant reductions in fasciculations (2). Magnesium competes with calcium at the presynaptic end plate of neuromuscular junction and inhibits the release of Acetylcholine (Ach) from the motor nerve terminal and to a lesser extent, decreases the sensitivity of the postjunctional membrane and reduces the excitability of the muscle fibre (6).

Previous studies attempting to study the effects of MgSO4 in reducing the incidence of fasciculations, included doses of 40 to 60 mg/kg. At 40 mg/kg doses, the reported reductions in incidence have been 50%, 65% and 92%, respectively (7),(8),(9). One study that used 60 mg/kg, showed only 35% reduction in incidence, probably attributable to faster rate of administration. The studies cited had drawbacks in terms of methodologies and confounders which could affect the outcomes- in terms of the induction agents, duration of administration of MgSO4, non assessment of preoperative Mg levels, and poor sample sizes. Hence, it was decided to assess effectiveness of smaller dose of 20 mg/kg and compare with 30 mg/kg and 40 mg/kg of MgSO4 in 3 groups in a better designed and implemented randomised trial.

The primary objective of the study was to assess the reduction in the incidence of Sch induced fasciculations. Secondary objectives included assessment of severity of the fasciculations, the attenuation of haemodynamic responses after intubation, the changes in the serum Magnesium (Mg) and Calcium (Ca) levels, Electrocardiogram (ECG) changes, urine output and respiratory rate.

Material and Methods

This randomised clinical trial was conducted from September 2017 to August 2018, at Vijayanagar Institute of Medical Sciences (VIMS), Ballari, India. The study was approved by Institutional Ethics Committee (No. VIMS/PG/IEC/17/2017-18/dt.8.6.17), and registered in the Clinical Trials Registry of India (CTRI Reg No: CTRI/ 2018/ 01/011484).

Inclusion criteria: After informed and written patient consent, 90 patients aged 20-50 years of either sex belonging to American Society of Anaesthesiologists (ASA) physical status grade I and II and modified Mallampati Airway (MMA) (Samsoon Young) class I and II, scheduled for elective surgeries under general anaesthesia participated in this trial.

Exclusion criteria: Patients with history of significant systemic disorders (cardiovascular, respiratory, central nervous system or renal system), pre-existing musculoskeletal disorders, hypo/hypermagnesemia with a diagnosed condition or with altered serum values, beta-adrenergic or calcium channel blocker usage and refusing for procedure were excluded from the study.

Sample size calculation: The incidence of fasciculations after administration of Sch was taken as 95%, based on a previously published meta-analysis of randomised controlled trials (2). A reduction in incidence of fasciculations by 30% (effect size) was assumed in group 1 as compared to this ‘control’ value. Previous studies showed an average reduction of 40% in fasciculations using MgSO4 at 40 mg/kg. Hence, a 30% reduction in this figure in group 2 (30 mg/kg) was assumed in the current study as effect size (7),(8). With 95% confidence interval, α error of 0.05 and power of 80%, sample size was calculated as 28 in each group. To account for possible dropouts during recruitment and study, 30 patients were included in each group.

The patients were randomly allocated to three groups of 30 each, based on computer generated random numbers (Table/Fig 1). The randomisation was implemented by allocation concealment using Sequentially Numbered Opaque Sealed Envelope (SNOSE) technique for the three groups. The envelop was opened in the morning of the surgery and the test drug administration and the monitoring was performed by different anaesthesiologists, with participant also blinded to allotment. Group 1 patients received Inj. MgSO4 20 mg/kg, Group 2 patients received Inj. MgSO4 30 mg/kg and Group 3 patients received Inj. MgSO4 40 mg/kg, intravenously over 10 minutes before induction.

Study Procedure

The primary outcome parameter (incidence of fasciculations) and secondary parameters (severity of fasciculations, attenuation of haemodynamic responses to intubation, serum Magnesium (Mg) and Calcium (Ca) levels, ECG changes, urine output and respiratory rate) were noted from the time of injection of test drugs till the surgery was completed. Patients were followed-up for 24 hour in the postoperative period.

Preoperative procedure: Thorough pre-anaesthetic evaluation was performed one day prior to the surgery. Preoperative investigations as per the surgical indication was obtained including resting ECG. The serum Mg and Ca levels were obtained in the evening prior to the day of surgery. The procedure of general anaesthesia and study was explained to the patients and written consent was obtained. The patients were advised overnight fasting and advised tablet alprazolam 0.5 mg and tablet ranitidine 150 mg on the night before surgery.

Intraoperative procedure: On shifting the patients to the operation theatre and after preinduction check of machine, monitoring for continuous ECG, heart rate, Non Invasive Blood Pressure (NIBP), and Pulse Oximetry (SpO2) was established and baseline values were noted. The study solution was prepared before anaesthesia procedure by a resident not involved in patient management or monitoring intra and postoperatively, as per group allocation, revealed by opening sealed envelope in the morning of surgery. The calculated dose was drawn from the 2 mL (50%) ampoules of Inj. MgSO4 and diluted to 20 mL with normal saline. This solution was administered over a period of 10 minutes via a syringe pump and patients were asked for their subjective feeling of warmth while receiving the drug or for any other complaints.

This was followed by administration of Inj. midazolam 30 μg/kg and Inj. fentanyl 2 μg/kg intravenously. Preoxygenation was performed with 8 lpm of oxygen flow rate using closed circuit followed by induction with Inj. propofol 2 mg/kg. After induction, a blood sample was drawn from the forearm from the opposite side of infusion of study drug for measuring serum magnesium and calcium levels, followed by administration of inj. succinylcholine 1.5 mg/kg. Patient was monitored for appearance of fasciculations and graded as Grade 0: no fasciculations, Grade 1: Fine fasciculations at eyes, neck, face or fingers without limb movement, Grade 2: Moderate fasciculations occurring at more than two sites or obvious limb movement and Grade 3: Severe sustained and widespread fasciculations (10).

Oral endotracheal intubation was performed after assessing complete muscular relaxation. If laryngoscopy time exceeded 30 seconds or multiple attempts were required for intubation, patients were excluded from the study. Heart Rate (HR), Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Mean Arterial Pressure (MAP), SpO2 and End Tidal Carbon Dioxide (EtCO2) readings were recorded at 1 minute, 3 minutes and 5 minutes after intubation and every 10 minutes thereafter till the end of surgery. Anaesthesia was maintained with oxygen, nitrous oxide (33:66) and isoflurane 1-2% and vecuronium. Intermittent positive pressure ventilation was balanced to maintain EtCO2 at 35-45 mmHg. The episodes of hypotension (MAP >20% of baseline) was managed with re-balance of anaesthesia and if necessary, treated with incremental doses of mephentermine 3 mg i.v. Bradycardia (HR <50 bpm and trend of further fall over one minute) was treated with incremental intravenous doses of 0.3 mg of atropine.

Postoperative procedure: At the end of surgery, neuromuscular blockade was reversed with Inj. neostigmine 0.05 mg/kg and Inj. glycopyrrolate 0.02 mg/kg and trachea extubated after adequate recovery of muscle power. Normal saline was maintained as the intravenous fluid from the beginning and only changed after sampling of blood was done for Mg and Ca. Incidence of bradycardia, arrhythmias, hypotension during intraoperative period was noted. During the postoperative period, patient HR, NIBP, SpO2, ECG, respiratory rate and urine output were monitored. Any other intraoperative and postoperative complications were noted.

Statistical Analysis

All data was entered in Microsoft Excel sheet; continuous variables as Mean±SD and categorical, as percentages. Data was cleaned before inferential statistical analyses and normal distribution of dependent variables was checked. Analysis of Variance (ANOVA) was used to find the significance of numeric study parameters among three groups of patients. Post-Hoc Tukey (two tailed, independent) was used to find the significance of study parameters on continuous scale between two groups (Inter group analysis). Chi-square/Fisher’s-exact test was used to find the significance of study parameters on categorical scale among three groups. The Statistical software Statistical Package for Social Sciences (SPSS) 20.0 and MedCalc 9.0.1 was used for the analysis of the data. Probability values at <0.05 were considered as significant for the various tests.

Results

Ninety patients were included, based on the selection criteria for the study. The patient characteristics including haemodynamic parameters were comparable among three groups (Table/Fig 2). The incidence of fasciculations was found to be 90%, 53.4% and 43.4% in groups 1, 2 and 3, respectively (Table/Fig 3). Group 1 patients had the most intense fasciculations. The severity of fasciculations was reduced in groups 2 and 3, with almost all of the group 3 patients having only grade 1 fasciculations (Table/Fig 3).

The relative falls in SBP and DBP after MgSO4 administration and immediately after induction were comparable among the three groups (Table/Fig 4). After one minute, there was increase by 23.5% and 18.5% in SBP and DBP, respectively in group 1 as compared to 7.9% and 4.1% in group 2 and 2.8% and 2.7% in group 3 (p=0.001 between group 1 and 2 and group 1 and 3). The increase in SBP in group 3 was statistically less as compared to group 2 (p=0.05). The observed increase in DBP did not differ significantly between groups 2 and 3. The SBP at 3rd and 5th minute stayed at statistically significant greater levels in group 1 as compared to groups 2 and 3. The SBP was maintained at a lower level in group 3 as compared to group 1 at 3rd and 5th minute (p=0.019 and 0.047, respectively). The DBP at 3rd and 5th minute stayed at statistically significant greater levels in group 1 as compared to groups 2 and 3 but there were no statistically significant differences between groups 2 and 3 during these times.

The baseline mean heart rate was comparable amongst the 3 groups as also after MgSO4 administration (Table/Fig 5). The mean heart rate was significantly high (16.7%) at 1 minute after intubation in group 1 as compared to groups 2 and 3 (6.8% and 3.7% from baseline, respectively). The heart rate remained at a higher level in group 1 as compared to groups 2 and 3 at 3rd and 5th minute also. Between group 2 and 3, the HR was better maintained in group 3 at 3rd minute (p=0.027) but at 5th minute, there were no significant differences.

Baseline serum Mg levels were comparable in the 3 groups. After administration of MgSO4, the increases were from 0.76±0.10 to 1.71±0.07 mmoL/l in group 1, from 0.77±0.08 to 2.41±0.06 mmoL/l in group 2 and from 0.76±0.08 to 2.82±0.10 mmoL/l in group 3 (Table/Fig 6). The serum Ca levels (preoperative and after MgSO4 administration) were 9.35±0.43 mg/dL and 9.5±0.47 mg/dL in group 1, 9.49±0.63 mg/dL and 9.5±0.49 mg/dL in group 2 and 9.69±0.49 mg/dL and 9.62±0.55 mg/dL in group 3 respectively. The p-value (2 tailed, ANOVA)- between groups: preoperative=0.11 and after MgSO4=0.68, and within groups: 0.48, 0.18 and 0.53 for groups 1, 2 and 3 respectively].

There were no significant ECG changes in any of the patients; the respiratory rate and the urinary outputs were within clinical ranges in the three groups. Feeling of warmth after MgSO4 administration was expressed by two patients, five patients and 10 patients in groups 1, 2 and 3 respectively. Two patients in group 3 complained of nausea which was not statistically significant.

Discussion

MgSO4 is among few drugs with proven benefit in reducing the incidence of fasciculations but the previous studies using different dosages of MgSO4 (40 mg/kg to 60 mg/kg) have shown inconsistent results and differing methodologies in terms of duration of administration and use of induction agents (7),(8),(9). The study compared three different doses (lower doses of 20 mg/kg and 30 along with the 40 mg/kg) of MgSO4 over 10 minutes before premedication and induction, along with assessment of serum Mg levels.

A dose of 20 mg/kg of MgSO4 was not at all beneficial, with fasciculations observed in 90% of patients, with 2/3rds of them being of moderate to severe grades. Doses of 30 mg/kg and 40 mg/kg reduced the incidence to nearly half. The dose of 40 mg/kg was most effective in reducing severity of fasciculations, with 92% having only mild grades, whereas at 30 mg/kg, only 60% had mild grades of fasciculations. The intubation responses were found to be best attenuated in groups 2 and 3 but not much in group 1. The serum Mg levels were found to reach therapeutic levels in groups 2 and 3 but not in group 1, after administration of MgSO4.

Mg attenuates Sch induced muscle fasciculations by decreasing the amount of Ach liberation and action and by depressing the excitability of the muscle fiber membrane (11) Magnesium, as compared to all other interventions to prevent fasciculations, is an endogenous electrolyte without the risks attributable to the sedatives, anaesthetic agents or relaxants when preadministered before Sch. The onset of action of MgSO4 (i.v.) is immediate and the duration lasts for about 30 minutes. Normal range of serum magnesium concentration is 0.7-1.1 mmoL/l (therapeutic: 2-4 mmoL/l) (6). The current study attempted to correlate the serum levels with the degree of fasciculations unlike other studies and observed that serum levels above 2.38±0.05 mmoL/l were associated with absent to mild grade fasciculations (Table/Fig 6).

Serum calcium levels were within normal ranges in all the groups, before and after administration of MgSO4. There were no intraoperative or postoperative effects attributable to Mg administration (hypotension, bradycardia, ECG changes, respiratory rate and urine output). It was observed that the patients receiving MgSO4 had a strange feeling of warmth, which may be explained by the peripheral dilation and pooling of blood in extremities. This feeling is dependent on the amount of MgSO4 administered in time unit and can be attenuated by injecting the drug over longer time period (12). Hence, in the present study MgSO4 was diluted to 20 mL with saline and administered over 10 minutes.

In a study on patients aged 18-60 years, using 2 mg/kg of Sch and MgSO4 at 40 mg/kg, the incidence of fasciculations was 50%, but half of them had moderate grades of fasciculations (8). In the present study, author uses similar doses, only mild grades of fasciculations were observed in 92% of cases. The routinely used doses of 1.5 mg/kg of Sch could be associated with greater incidence of fasciculations as compared to smaller or larger doses, but the relationship is variable with no strong and recent evidences being available (2),(13).

In a three group study comparing MgSO4 at 40 mg/kg with precurarising dose of vecuronium and saline, the incidence of fasciculations in Mg group was least at 65%, higher than that in the present study at same doses but nearly 77% of them had minimal grade (7). Tracheal intubation induced hemodynamic responses were attenuated significantly in Mg group.

One of the studies using higher dose of MgSO4 (60 mg/kg) after fentanyl-thiopentone induction was still associated with nearly 65% incidence of fasciculations. The study did not reveal fall of the BP from the baseline in the MgSO4 group, which is contradictory to the expectations at this dose. The short duration of administration of the drug (30 secs) may have contributed to this outcome (14). In a study of 50 patients administered MgSO4 at 40 mg/kg before fentanyl-propofol induction (followed by 2 mg/kg of Sch), as compared to the group not receiving MgSO4, there was a reduction in incidence of fasciculation to the extent of 92% in the MgSO4 group (9). The confounders in other studies include the type of induction agent used, inadequate or poorly defined sample sizes, the rate and duration of administration of MgSO4 before administration of Sch and correlation of serum levels of Mg with the grades of fasciculations. The onset of fasciculations was within 30-45 seconds after Sch administration in the present study. The duration of administration of MgSO4 in different studies was 10 seconds, 30 seconds, 60 seconds, 5 minutes and 10 minutes. Thus, the onset with adequate serum level of Mg may not have been reached to coincide with the onset of fasciculations with fast rates of administration (7),(8),(14),(15),(16). It was found that when administered in 20 mL volume over 10 minutes, the serum levels of Mg were achieved in the therapeutic range with 30 mg/kg and 40 mg/kg dosage of MgSO4 (but not 20 mg/kg).

Mg has been shown to inhibit catecholamine release during tracheal intubation, the decrease in blood pressure associated with peripheral vasodilatation. Studies purely targeting benefits of Mg towards attenuation of haemodynamic responses to intubation have suggested 30 mg/kg to be the optimum dose, with reduced risk of hypotension (12),(17). In the current study, decreases in SBP and DBP after induction were observed in groups 2 and 3, with the SBP fall being statistically significant in group 3 as compared to group 2. The SBP increased above basal levels at one minute after intubation in all the groups. The authors feel that this brief fall can be attenuated with judicious fluid loading before induction so that the maximum benefits related to attenuation of fasciculations can be better exploited at 40 mg/kg of MgSO4.

The amount of transmitter liberated at the nerve terminals varies directly with the logarithm of the Ca concentration, without affecting the sensitivity of the end-plate region to Ach. Thus, an excess of Ca could increase the amount of transmitter liberated and antagonise the effect of Mg on the motor nerve endings, the neuromuscular block being thereby relieved. So, the serum Ca levels were measured before and after administration of MgSO4, which did not change much within and between groups and hence, no inference could be drawn on potential role of Ca in interfering with the attenuating effect of Mg on the fasciculations (11),(18).

Limitation(s)

The presence and degree of fasciculations in the present study was graded with the widely used and valid scale (0 to 3 grades), but it carries risks of misinterpretation attributable to the observational skills of the recorder. Electromyography based maximum muscle action potential amplitude is a better means of quantifying the severity of visible muscle fasciculations, which was not utilised in the study.

Conclusion

Preadministration of intravenous MgSO4 in doses of 30 mg/kg and 40 mg/kg was effective in reducing the incidence of succinylcholine induced fasciculations by nearly 50% whereas, it was ineffective at 20 mg/kg. However, at 40 mg/kg, 90% of those affected had only mild grades. The dose of 40 mg/kg could also be better in attenuating the haemodynamic responses to laryngoscopy and intubation, without any other significant adverse effects. Therapeutic levels of serum Mg levels were achieved at 30 mg/kg and 40 mg/kg doses and not 20 mg/kg dose of MgSO4.

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DOI and Others

DOI: 10.7860/JCDR/2022/53556.16160

Date of Submission: Jan 01, 2022
Date of Peer Review: Jan 25, 2022
Date of Acceptance: Feb 24, 2022
Date of Publishing: Mar 01, 2022

AUTHOR DECLARATATION:
• 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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