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

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On Sep 2018




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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 Academy of Higher Education and Research , Kolar, Karnataka
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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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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 : August | Volume : 16 | Issue : 8 | Page : UC18 - UC22 Full Version

Efficacy of Intranasal Dexmedetomidine with Lidocaine versus Intranasal Lidocaine alone in Awake Fiberoptic Nasotracheal Intubation- A Randomised Clinical Study


Published: August 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/55878.16756
Mandeep Kaur, Parmod Kumar, Balwinder Kaur Rekhi, K Priyaa Cathrine

1. Assistant Professor, Department of Anaesthesia and Intensive Care, Government Medical College and Rajindra Hospital, Patiala, Punjab, India. 2. Professor and Head, Department of Anaesthesia and Intensive Care, Government Medical College and Rajindra Hospital, Patiala, Punjab, India. 3. Professor, Department of Anaesthesia and Intensive Care, Government Medical College and Rajindra Hospital, Patiala, Punjab, India. 4. Junior Resident, Department of Anaesthesia and Intensive Care, Government Medical College and Rajindra Hospital, Patiala, Punjab, India.

Correspondence Address :
Balwinder Kaur Rekhi,
House No. 4, Street No. 2, Teg Colony, Patiala-147001, Punjab, India.
E-mail: balwinder.rekhi@yahoo.com

Abstract

Introduction: Awake Fiberoptic Intubation (AFOI) is considered as the gold standard technique in patients with predicted and unpredicted difficult airway. It is best performed with the patient awake to maintain spontaneous ventilation. Dexmedetomidine has been successful in several clinical settings including AFOI due to its diverse actions like sedation, analgesia, anxiolysis, cardiovascular stabilising effect and preservation of respiratory function.

Aim: To assess the efficacy of using dexmedetomidine intranasally with lidocaine in AFOI in comparison to using lidocaine alone in terms of haemodynamic stability, sedation, ease of intubation, patient’s satisfaction with the procedure and reduction in intraoperative propofol requirement.

Materials and Methods: This randomised clinical study was conducted on 100 patients of either gender aged between 18 to 60 years with American Society of Anesthesiologists (ASA) physical status I or II scheduled for elective surgeries under general anaesthesia at Government Medical College and Rajindra Hospital, Patiala, India from February 2021 to November 2021. The patients were randomly divided into two groups of 50 each namely group D (intranasal dexmedetomidine 2 mcg/kg+lidocaine 10%) and group L (intranasal lidocaine 10% alone). Maximum dose of 10% lidocaine was <5 mg/kg body weight in both groups.The various parameters were recorded in both the groups during AFOI and the data was analysed using Statistical Package for Social Sciences (SPSS) software version 22.0 and Microsoft excel. Descriptive statistics was done for all data and were reported in terms of mean, standard deviation and percentages.

Results: Among 100 patients, group D and group L comprises of 50 each. The mean heart rate during AFOI was 70.16±8.02 in group D, and 95.62±11.04 in group L. The Mean Arterial Pressure (MAP) during AFOI was 81.42±5.55 in group D and 101.78±6.22 in group L. There was statistically highly significant (p-value <0.001) decrease in mean heart rate and MAP (within normal clinical range) in group D as compared to group L. The mean Ramsay Sedation Scale (RSS) in group D was 3.66±0.48 and in group L was 2.32±0.55 (p-value <0.001). There was a significant difference (p-value <0.001) in patient tolerance, time to intubation, propofol requirement, patient satisfaction and anaesthesiologist satisfaction between the two groups. There was no significant decrease in Saturation of Peripheral Oxygen (SpO2) or respiratory depression in both groups (p-value=0.221).

Conclusion: Intranasal dexmedetomidine with lidocaine provides better haemodynamic stability and improves the quality of intubation, reduces propofol requirement, provides good patient and anaesthesiologist satisfaction and maintains oxygen saturation during AFOI.

Keywords

Haemodynamic stability, Propofol requirement, Sedation

Awake Fiberoptic Intubation (AFOI) is an effective technique for establishing airway access in patients having both anticipated and unanticipated difficult airway with respect to compromised airway, inadequate mouth opening as in temporomandibular joint disease, mandibular-maxillary fixation, severe facial trauma and burns, oropharyngeal mass, limited surgical field, when neck extension is to be avoided, vertebral artery insufficiency etc (1). During awake intubation, laryngospasm and coughing in response to intubation can increase the failure rate and the number of attempts of intubation. Both optimal intubating conditions and patient comfort are necessary while preparing the patient for fiberoptic intubation (2). Effective topical airway anaesthesia using drugs like lidocaine is essential in AFOI (1). Conscious sedation causes a minimally depressed level of consciousness that retains the patient’s ability to independently and continuously maintain an airway and respond appropriately to physical stimulation and verbal command. It makes the procedure more tolerable for patients and helps to ensure optimal intubating conditions (3).

Dexmedetomidine is another arrow in the anaesthesiologist’s quiver. It is a highly selective alpha-2 (α2) adrenergic receptor (α2-AR) agonist with sedative, analgesic properties, has anaesthetic sparing effect, sympatholytic property and also has cardiovascular stabilising property. It reduces delirium, preserves respiratory function and is useful in blunting haemodynamic responses in perioperative period (4). It has been suggested that a smaller dose or routes other than rapid intravenous delivery may help to minimise the haemodynamic risk of dexmedetomidine (5). Intranasal dexmedetomidine has shown to have a high rate of patient acceptance (6). Studies showed that sedative onset time of intranasal dexmedetomidine is 45-60 min with a peak effect at 90-105 min, the absolute bioavailability is 65% (35-93%) and the pharmacological effects are similar to that of intravenous route (7),(8). Dexmedetomidine has shown better endoscopy scores, lower recall of intubation, greater patient satisfaction, provides surface analgesia, has decongestant, antisialagogue, antishivering and antiemetic effects (9),(10). Apart from these, studies also show that dexmedetomidine prolongs the duration of both sensory and motor blockade induced by local anaesthetics irrespective of the route of administration. Dexmedetomidine enhances peripheral neural blockade due to its binding to (α2-AR) (11).

A study by Mirkheshti A et al., (2017) showed decrease in sudden changes in haemodynamic values and improved patient tolerance and intubation scores on use of intranasal Dexmedetomidine during fiberoptic bronchoscopy (12). Niyogi S et al., (2017) showed that intranasal dexmedetomidine was effective as intravenous dexmedetomidine in attenuating the haemodynamic stress response of laryngoscopy and endotracheal intubation (13). However, after extensive review of literature, author could find very limited number of studies on use of dexmedetomidine by intranasal route in AFOI, thus an endeavour has been made to further enhance our knowledge regarding the same.

The present study was conducted to compare the efficacy of using dexmedetomidine 2 mcg/kg intranasally with lidocaine 10% in comparison to intranasal lidocaine 10% alone during AFOI in terms of haemodynamic stability and degree of sedation as primary outcome variables. Patient’s tolerance, time to intubation, patient and anaesthesiologist satisfaction with the procedure and reduction in intraoperative propofol requirement were the secondary outcome variables.

Material and Methods

This randomised clinical study was conducted on 100 patients at Government Medical College and Rajindra Hospital, Patiala, Punjab, India from February 2021 to November 2021. Institutional Ethics Committee approval (No.BFUHS/2K21p-TH/54B dated 22/1/2021) was taken prior to starting the study. Written informed consent was also obtained from all the patients in their own vernacular language.

Inclusion criteria: Patients of either gender, aged between 18 to 60 years, belonging to ASA physical status I or II, and scheduled for various elective general surgeries (which included laparoscopic and open cholecystectomy, laparotomy, hemithyroidectomy etc.,) under general anaesthesia were included in the study.

Exclusion criteria: Patients with ASA physical status more than II, non fasting patient, thrombocytopenia or coagulopathy, nasal polyps, history of previous nasal surgery/nasal trauma, mentally ill patients, pregnant females, allergic to the drugs involved in the study were excluded from the study.

A Consolidated Standards for the Reporting of Trials (CONSORT) flowchart flow chart for this randomised clinical study is presented in (Table/Fig 1).

Sample size calculation: It was estimated based on pilot study, where mean difference in Ramsay Sedation Scale (14) in two groups was 1.34 with standard deviation (SD) of 0.07. The sample size was calculated with 95% confidence interval, 80% power and alpha level of 0.05, using the formula:

n=2σ2(Z1-α/2+Z1-β)22

Where n was calculated to be 46, sample size was taken as 50 for each group to increase the power of the study. The patients were randomly divided using sealed envelope method, into two groups of 50 each - group D and group L.

Procedure

Preanaesthetic check-up and routine investigations were done. Intravenous (i.v.) line was secured with 18 gauge i.v. cannula in the preoperative room. Patient’s baseline vitals i.e., Heart Rate, Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), MAP, SpO2 were documented and nasal patency was assessed before administration of drug in both the groups. Intranasal drug administration was performed 45 to 60 minutes prior to shifting patient to operation theatre.

Group D: Patients here received dexmedetomidine 2 mcg/kg (diluted with Normal Saline (NS) to make a total volume of 2 mL) intranasally as drops using a syringe without needle +10% lidocaine spray was administered 30 minutes later (each depression of release button delivered 0.1 mL=10 mg).

Group L: Patients here received 2 mL saline intranasally as drops using a syringe without needle+10% lidocaine spray was administered 30 minutes later.

In both groups 10% lidocaine was sprayed two times each into the more patent nostril, tonsillar pillars, posterior part of tongue and posterior pharyngeal wall. In this study high dose of dexmedetomidine (2 mcg/kg) was used in order to provide better sedation and improve the quality of intubation. Once patient was shifted to operation theatre, further preparation of airway was accomplished with local anaesthetic. All patients received inj. glycopyrrolate 0.2 mg intravenously to reduce secretions and inj. nalbuphine 0.2 mg/kg intravenously for analgesia, sedation and anxiolysis before AFOI. When sufficient level of sedation (Ramsay Sedation Scale of 4) was achieved, nasotracheal fiberoptic intubation was done. Once tracheal intubation was completed and the tube was secured, General Anaesthesia (GA) was induced using inj. propofol in titrated doses (with dose requirement monitoring) and anaesthesia was maintained. If RSS <3 or if the patient tolerance score during any part of AFOI procedure was ≥4 or if the anaesthesiologist was uncomfortable, rescue inj. propofol was given intravenously in incremental doses and the dose requirement was recorded. Occurrence of bradycardia during any part of the study was managed using inj. atropine 0.6 mg intravenously.

Parameters measured: HR, SBP, DBP, MAP, SpO2 were monitored as follows- at baseline, then after every 15 minutes interval on administration of intranasal drug. During AFOI procedure, vitals were taken every minute for first 5 minutes followed by every 5 minutes after AFOI for first 20 minutes. Sedation, patient tolerance, patient satisfaction and anaesthesiologist satisfaction score were measured as mentioned in (Table/Fig 2). Time to intubation and perioperative propofol requirement was also monitored.

Statistical Analysis

The data was analysed using Statistical Package for Social Sciences software (SPSS) version 22.0 and Microsoft excel. Descriptive statistics was done for all data and were reported in terms of mean, standard deviation and percentages. Appropriate statistical tests of comparison were applied. Categorical variables like age, gender were analysed with the help of Chi-square test and type of surgery with Fisher’s exact test. Continuous variables like HR, MAP, SpO2, patient tolerance score, patient and anaesthesiologist satisfaction score were analysed with Student’s t-test and Mann Whitney U test, where applicable. The p-value of <0.05 was taken as statistically significant and <0.001 was taken as highly significant.

Results

Demographic parameters: The distribution of patients according to age, gender and weight was similar in both groups. Both the groups were comparable and statistically non significant (p-value >0.05) (Table/Fig 3).

Haemodynamic parameters: The baseline HR, MAP and SpO2 were comparable and statistically non significant in both the groups (p-value >0.05) (Table/Fig 4).

Comparison of mean HR showed highly significant (p-value <0.001) decrease in heart rate (within normal clinical range) after administration of intranasal drug, during and after AFOI in group D as compared to group L (Table/Fig 5). Four patients experienced bradycardia (HR 50-59 bpm). Comparison of mean MAP showed statistically highly significant (p-value <0.001) decrease in MAP (within normal clinical range) after administration of intranasal drug, during and after AFOI in group D as compared to group L The mean heart rate during AFOI was 70.16±8.02 in group D, and 95.62±11.04, in group L. The Mean Arterial Pressure (MAP) during AFOI was 81.42±5.55 in group D and 101.78±6.22, in group L (Table/Fig 6).

There was no respiratory depression in both groups. Both groups maintained SpO2 above 93% throughout the study.

Sedation: Mean Ramsay Sedation Scale in group D was 3.66±0.48 and in group L was 2.32±0.55. There was statistically highly significant difference between the two groups (p<0.001). Group D patients experienced better sedation.

Patient tolerance and time to intubation: The mean patient tolerance score during and after AFOI showed statistically highly significant difference between the two groups (p-value <0.001). Group D patients showed higher tolerance compared to group L (Table/Fig 7). The mean time to intubation was 3.18±0.48 minutes in group D and 3.56±0.70 minutes in group L (p-value <0.001).

Propofol dose reduction: The number of patients who required rescue propofol were 45 (90%) in group D and 50 (100%) in group L respectively (p<0.05).The mean rescue propofol dose required in group D was 21.30±8.19 mg and in group L was 39.40±5.12 mg. The mean propofol required for induction of General Anaesthesia (GA).

Patient and anaesthesiologist satisfaction: The patient satisfaction 24 hours postoperatively and anaesthesiologist satisfaction was better in group D compared to group L (p-value <0.001) (Table/Fig 7).

Discussion

Dexmedetomidine is found to be useful to overcome the major challenges associated with AFOI in providing adequate sedation without respiratory depression and has cardiovascular stabilising properties. Intranasal dexmedetomidine being colourless, odourless, painless and tasteless is more acceptable to the patient than intravenous route (15). Moreover, it is well-known fact that dexmedetomidine enhances the peripheral neural blockade due to its binding to (α2-AR), thereby producing surface analgesia (10),(11). Above all dexmedetomidine given through intranasal route results in minimal haemodynamic perturbations.

The present study showed that intranasal dexmedetomidine 2 mcg/kg with 10% lidocaine was effective in attenuating haemodynamic response to AFOI. There was statistically significant decrease in mean heart rate (within the normal clinical range) after administration of intranasal drug, during and after AFOI in group D as compared to group L. A randomised controlled study by Wang SS et al., (2014) showed results similar to the current study, where the HR and MAP measured after administering intranasal drug, before laryngoscopy and after intubation was significantly lower in intranasal dexmedetomidine 2 mcg/kg group (16). Similarly findings were reported by Jambure NP et al., (2021), reported intranasal dexmedetomidine 2 mcg/kg caused statistically significant decrease in HR and MAP, after premedication and 15 min after intubation heart rate and MAP returned back to the baseline values, thus it reduced the haemodynamic stress response to tracheal intubation (17). The study by Jayaraman L et al., (2013) reported contrary findings, where there was no statistically significant attenuation of pressor response to tracheal intubation and there was no statistical difference in MAP by intranasal dexmedetomidine (18). The reason for not achieving obtunded pressor response could be due to a lower dose of intranasal dexmedetomidine (1 mcg/kg).

In the current study, four patients experienced bradycardia (HR 50-59 bpm) after administration of dexmedetomidine and were easily managed with inj. atropine. There was no significant decrease in SpO2 or respiratory depression in both groups (p-value=0.221).

In the present study, patients belonging to group D experienced good sedation compared to group L. The findings are similar to the study by Kumari P et al., (2021) who observed that the mean Ramsay Sedation Score was higher in dexmedetomidine + lidocaine group when compared to the other two groups (Fentanyl+Lidocaine and Saline+ Lidocaine) (14).

Dexmedetomidine binds to (α2-AR) of locus ceruleus and spinal cord which causes sedation and analgesia respectively (14). Thus in the present study, patients of group D showed better tolerance and overall patient satisfaction compared to group L. Similar findings were reported by Mirkheshti A et al., (2017), where local dexmedetomidine group showed better patient tolerance compared to local lidocaine alone (control) group (12). Similar to the present study, Kumari P et al., (2021) also reported that patients in dexmedetomidine group was more satisfied and comfortable with better cough scores during awake flexible fiberoptic broncoscopy procedure when compared to fentanyl or lidocaine alone (14).

In the present study, time to intubation was significantly less in group D compared to group L. In another study, the time taken to intubate the trachea was less in case of dexmedetomidine as compared to that of propofol. It was found that dexmedetomidine facilitated better vocal cord opening in 71% patients as compared to 58% patients in propofol group which could have contributed to the ease of intubation and lesser time to intubation in dexmedetomidine group (19).

The present study showed decrease in perioperative propofol requirement in intranasal dexmedetomidine with lidocaine group (Table/Fig 8). The induction dose of propofol required for GA in the present study was reduced by 33% in group D. The findings of the present study were similar to the study conducted by Bi Y et al., (2019) where it was observed that premedication with intranasal dexmedetomidine reduced the number of patients in need of rescue propofol and dose of rescue propofol required during the flexible fiberoptic broncoscopy (20). The findings of the current study also coincide with few other studies (21),(22),(23). A study conducted by Sen S et al., (2013) showed that dexmedetomidine reduced the mean requirement of propofol for induction and maintenance of anaesthesia by 48.08% and 61.87% respectively (21). LeGuen M et al., (2014) conducted a placebo controlled trial in which dexmedetomidine reduced the propofol requirement for induction and maintenance of anaesthesia by 23% and 29% respectively (22). Dutta A et al., (2019) concluded that dexmedetomidine causes a 15% reduction in propofol induction dose and 29% reduction in propofol maintenance dose while providing a consistent depth of anaesthesia state (23).

In this study, the anaesthesiologist satisfaction was significantly better in group D than group L. This could be because of the antisialagogue property of dexmedetomidine which causes decrease in secretions and hence provided a better field of vision during AFOI (11). Moreover, patients of group D experienced good sedation and were more co-operative which added to the comfort of the anaesthesiologist. This finding coincides with study by Candiotti KA et al., (2010) showed that anaesthesiologist satisfaction and comfort was better with dexmedetomidine. Anaesthesiologist indicated that the ease of achieving and maintaining target sedation level was significantly better with dexmedetomidine (24).

Limitation(s)

To achieve desired results intranasal dexmedetomidine needs to be administered 45 to 60 minutes prior to starting the procedure. This longer time to onset of action can sometimes be undesirable when there is long list of surgeries or when procedure needs to be started earlier.

Conclusion

Intranasal dexmedetomidine 2 mcg/kg with 10% lidocaine provides better haemodynamic stability and improves the quality of intubation during AFOI by decreasing time to intubation and improving patient tolerance. It also reduces propofol requirement, provides good patient satisfaction, anaesthesiologist satisfaction and maintains oxygen saturation during AFOI.

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DOI and Others

DOI: 10.7860/JCDR/2022/55878.16756

Date of Submission: Mar 06, 2022
Date of Peer Review: Apr 05, 2022
Date of Acceptance: May 12, 2022
Date of Publishing: Aug 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: Mar 12, 2022
• Manual Googling: Apr 22, 2022
• iThenticate Software: Jul 04, 2022 (17%)

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