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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
Original article / research
Full Version
Comparison between Plain Ropivacaine, Ropivacaine with Buprenorphine and Ropivacaine with Clonidine for Intrathecal use in Lower Limb Orthopaedic Surgeries: A Randomised Controlled Trial
Correspondence Address :
Dr. D Vasanth,
M2/136, 12th Cross Street, R.M.colony, Dindigul, Tamil Nadu, India.
E-mail: vasanth_1686@yahoo.com
Introduction: Ropivacaine is an amide local anaesthetic agent. The lower limb surgeries involves the great somatic pain. By using these adjuvants such as buprenorphine and clonidine with local anaesthetic agent to know the effective intraoperative and postoperative analgesia.
Aim: To compare the anaesthetic characteristics in terms of quality of blockade when intrathecal ropivacaine with buprenorphine and ropivacaine with clonidine as adjuvant.
Materials and Methods: The present study was a double-blinded randomised control trial in which a total of 75 subjects were divided into three groups, with 25 per group-group R (Inj. Ropivacaine 0.75%-3 mL with 0.2 mL sterile water), group RB (0.2 mL Buprenorphine with Inj. Ropivacaine 0.75% 3 mL), and group RC (0.2 mL Clonidine with Inj. Ropivacaine 0.75% 3 mL). Onset and duration of blocks were observed. Haemodynamic parameters, and pain score were monitored intraoperatively and postoperatively. Data was entered in MS excel sheet and analysed using Statistical Package for the Social Sciences (SPSS) software version 16.0. The p-value <0.05 were considered as statistically significant.
Results: The onset time of sensory and motor blockade for group RC was significantly more in comparison to R and RB groups (sensory block-5 minutes 50 seconds vs 3 minutes 39 seconds vs 3 minutes 50 seconds); and (motor block-6 minutes 52 seconds vs 4 minutes 39 seconds vs 4 minutes 74 seconds). Group RC had significantly longer duration of sensory block than R and RB groups (327 minutes 88 seconds vs 166 minutes 60 seconds (167 minutes) vs 222 minutes 44 seconds).
Conclusion: Ropivacaine with clonidine showed significantly more duration of sensory block, motor block and time for first rescue analgesia with haemodynamic stability than ropivacaine and ropivacaine with buprenorphine.
Adjuvants, Local anaesthetic, Opioids, Spinal anaesthesia
In recent years, with increase in number of lower limb orthopaedic surgeries. It has become crucial for practitioners in the field of anaesthesia to search for appropriate practices that reduce the complications caused by anaesthesia for patients with lower limb surgery (1). The term “neuraxial anaesthesia” implies the placement of local anaesthetic in or around the central nervous system. Spinal anaesthesia is a neuraxial anaesthesia procedure in which local anaesthetic is placed completely in the intrathecal space (subarachnoid space). Other neuraxial techniques comprise epidural and caudal anaesthesia (2),(3). The selection of local anaesthetic is based on the potency of the agent, onset and period of anaesthesia, and adverse reactions to the drug (4). Ropivacaine is a newer amide local anaesthetic that is being utilised more frequently in spinal anaesthesia. Ropivacaine has the tendency of reversible inhibition of sodium ion influx in nerve fibres. The drug is less lipophile, which make it less lethal to the cardiovascular and central nervous system. It has reduced motor blocking potency with a powerful analgesic effect, because it selectively prevents nerve fibres engaged in pain conduction (A-delta and C fibres) to a superior degree than those controlling motor purpose (A-beta fibres) (5),(6).
The addition of an adjuvant extends and reinforces the sensory blockade produced by local anaesthetics with reduction in dose of the latter, thus dipping the side-effects. Adjuvants are drugs that enhance the efficacy or potency of other drugs when given concurrently (7). Buprenorphine is a centrally acting lipid soluble analogue of alkaloid thebaine. It displays analgesic property both at spinal and supraspinal levels. It has constantly proven to lengthen the duration of anaesthesia. At higher doses, it triggers pruritus, drowsiness, nausea and vomiting (8),(9),(10),(11),(12). Clonidine is a partial alpha-2 adreno-receptor agonist and also centrally acting. Its analgesic impact is expected to be mediated by attaching post-synaptic α-2 receptors in the dorsal horn of the spinal cord, ensuing in lessened nociceptive transmission. It does not affect proprioception or create a motor blockade. When utilised as a neuraxial accessory for pain support after caesarean delivery, key abdominal and orthopaedic surgery, clonidine lengthens the period of analgesia and anaesthesia. Ropivacaine is less cardiotoxic than bupivacaine (13),(14),(15),(16). To compare the effects of ropivacaine, ropivacaine with buprenorphine and ropivacaine with clonidine for intrathecal use in lower limb orthopaedic surgeries. The primary outcomes were time taken for the onset and duration of sensory and motor blockade. The quality of analgesia, postoperative analgesic requirement, and the hemodynamic variables were the secondary outcomes.
This double-blinded randomised control trial was carried out at atertiary care hospital, Ammapettai, Tamil Nadu, India, from December 2019 to June 2021. The trial is registered under clinical trial registry of India with the registration number CTRI/2020/02/023197. Institutional Ethical Committee approval was obtained (IEC NO:2019/559). Informed written consent was obtained from each participant.
Inclusion criteria: American Society of Anaesthesiologists (ASA) physical status I and II, age between 18-60 years, both male and female gender, patient undergoing lower limb orthopaedic surgery.
Exclusion criteria: Patient refusal, allergic to opioids/local anaesthetics, Body Mass Index (BMI) >30 kg/m2, patient with recent history of cardiovascular accident, coagulation disorder, recent Cardio Vascular System (CVS) abnormalities, poorly controlled hypertension, poorly controlled diabetes mellitus, emergency orthopaedic surgery.
Sample size calculation: The sample size was calculated based on the study by Singh AP et al., (17). The sample size required for each group was 25. The total sample considering the mean and standard deviation of buprenorphine+ropivacaine time to reach Bromage 3 as 2.75±0.42, mean and standard deviation of fentanyl+ropivacaine time to reach Bromage 3 as 3.1±0.47, at 95% confidence interval with 80% power was:
N=(Z1-α/2+Z1-β)2 * 2*σ2/(μ1-μ2)2
where, Z1-α/2- two tailed probability for 95% confidence interval=1.96
Z1-β-two tailed probability for 80% power=0.84
μ1-mean of buprenorphine+ropivacaine time to reach Bromage 3=2.75
μ2-mean of fentanyl+ropivacaine time to reach Bromage 3=3.1
σ-average standard deviation of buprenorphine+ropivacaine time to reach Bromage 3 and fentanyl+ropivacaine time to reach Bromage 3=0.45
N=(1.96+0.84)2 *2* 0.4452/(2.75-3.1)2
N=25.38
However, the total number of patients recruited was 75. They were randomly divided into three groups of 25 each, by computer-generated list of random numbers. Group “R”-patients who received only local anaesthetic-Inj. Ropivacaine 0.75%-3 mL. Group “RB”-patients who received 0.2 mL (60 mcg) of preservative free Intrathecal Buprenorphine with local anaesthetic-Inj. Ropivacaine 0.75%-3 mL. Group “RC”-patients who received 0.2 mL (30 mcg) of preservative free Intrathecal Clonidine with local anaesthetic-Inj. Ropivacaine 0.75% 3 mL. The patient and performing anaesthetist were blinded to group allocation (Table/Fig 1).
Patients were explained the procedure of spinal anaesthesia after an IV access secured with 18 G or 20 G cannula. Baseline heart rate, blood pressure and oxygen saturation were recorded. Patients were explained about Visual Analogue Score (VAS) (18) and taught how to express the degree of pain on the scale. Under strict aseptic precautions through midline approach, intrathecal block was preformed between L2-L3 or L3-L4 intervertebral space using 23 or 25 G Quincke spinal needle in sitting position. After free flow of CSF, 3 mL of 0.75% ropivacaine with 0.2 mL of sterile water for group R patients and 3 mL of 0.75% ropivacaine with (0.2 mL) 60 mcg of buprenorphine for group RB patients were injected in to subarachnoid space. The dose of intrathecal buprenorphine was measured by using insulin syringe. 3 mL of 0.75% ropivacaine with (0.2 mL) 30 mcg of clonidine for group RC patients were injected in to subarachnoid space. The dose of intrathecal clonidine was measured by using insulin syringe. The time of intrathecal injection was noted.
The onset of analgesia was assessed as the time taken from the drug injected to the onset of sensory blockade (absence of pin prick sensation). The two-segment dermatomal regression of sensory block was recorded at various intervals. The duration of analgesia was assessed using VAS Zero to Ten score from no pain to worst painat 15,30,60 minutes and thereafter at 4-hour interval for 24-hour postoperative period. Patients above VAS score 3 received rescue analgesia in the form of Inj paracetamol 1g IV in the postoperative period. Time of first rescue analgesic required and VAS score at that time was noted. Quality of analgesia was assessed depending on number of doses of rescue analgesia given in 24 hours from the time of injection of drug in intrathecal space this was noted below and compared between the three groups.
During intraoperative and postoperative monitoring, Mean Arterial Pressure (MAP) >15% was taken as hypotension then treated Inj. ephedrine 6 mg IV with adequate fluid replacement and pulse rate <60/min taken as bradycardia then treated with Inj. atropine 0.6 mg IV.
Sensory blockade was tested by pin prick method and the time of onset was taken from time of injection of the drug into the subarachnoid space to loss of pin prick sensation. The time to achieve maximum sensory block was noted from time of injection of drug to loss of pin prick sensation at highest dermatomal level T6. Motor blockade was assessed using the Bromage Scale (19). Abdominal muscle relaxation was assessed by using the Rectus Abdominis Muscle (RAM) score useful in assessing the onset of maximum motor blockade. The time to achieve maximum motor blockade was noted from time of injection of the drug to maximum degree of motor block (Table/Fig 2) (20).
Statistical Analysis
Data was entered in MS excel sheet and analysed using SPSS software version 16.0. Analysis variance by One-way Anova test or Kruskal-Wallis test (variable is not normally distributed) across different times. Paired t-test was used to find the statistical difference. The p-values <0.05 were considered statistically significant.
The mean age among R group was higher than RB and RC group but the difference was not statistically significant (p-value=0.27). The mean BMI among R group was higher than RB and RC group but the difference was not statistically significant (p-value=0.40) (Table/Fig 3). The mean onset of sensory block in group R was significantly lower than groups RB and RC. The mean onset of motor block among R was also significantly lower than groups RB and RC (Table/Fig 4). The mean duration of sensory block and motor block in group RC was significantly longer (Table/Fig 5). The intra-op pulse rate and MAP were compared among the groups (Table/Fig 6), (Table/Fig 7). The VAS score in group RC was significantly lesser than groups RB and R, in the first 4 hours of postoperative period and for 0, 15 and 30 minutes VAS scores were 0 (Table/Fig 8). RC group had hypotension and bradycardia were present for a few patients.
The search for safer subarachnoid block with lesser dose local anaesthetic agent by adding adjuvant seems to be never ending. Ropivacaine is amide group of local anaesthesia with lesser cardiotoxic than bupivacaine. Buprenorphine is an opioid adjuvant which acts on μ and κ receptors. Clonidine is a partial agonist alpha 2 adrenoceptor which used as analgesic and is sedative. The impact of buprenorphine or clonidine when used as adjuvant with ropivacaine intrathecally were observed. Buprenorphine and clonidine subsequently increased the duration of both sensory and motor block. This reduced the conversion of subarachnoid block in to general anaesthesia due to faster level regression and better postoperative analgesia in lower limb orthopaedic surgeries. The onset and duration of sensory block for RC group was significantly more in comparison to R and RB group. According to this study RC group had longer duration of sensory block.
Chhabra AR et al., showed that in ropivacaine-clonidine group, there was significant extension of sensory block and motor block. Time to reach peak sensory level were statistically significantly more in ropivacaine clonidine group in comparison to ropivacaine fentanyl group (6.86±3.73 vs. 8.61±7.18). Time to reach peak motor level also was more in ropivacaine clonidine group in comparison to ropivacaine fentanyl group (6.02±2 vs.7.05±3.2). Hypotension and bradycardia was seen in 8.6% patients in ropivacaine-clonidine group, whereas pruritus was reported by 8.6% patients in ropivacaine fentanyl group (21). The study shows similar result as indicated in this present study in terms of onset of action.
Singh M et al., showed that period taken for beginning of the sensory and motor block was considerably shorter in ropivacaine with clonidine category in contrast with ropivacaine category. Mean value of extent of analgesia was suggestively elevated in subjects who got clonidine as an adjuvant which was contrast to the result obtained from this present study (22).
The RC group showed significantly more duration of sensory block motor block and time for first rescue analgesia. Also total number of doses of Inj. paracetamol 1g IV from time of injecting the spinal drug till 24 hours was significantly more group. The haemodynamic changes among the groups shows the RC showed significant bradycardia, increased systolic blood pressure and mean arterial pressure in comparison to R and RB group.
Studies have shown that clonidine addition have prolonged the duration of motor block in comparison to other adjuvants like Kumar N et al., showed that in ropivacaine clonidine group had extended duration of analgesia. The duration of motor block was significantly more in clonidine group in comparison to only ropivacaine group (281.25±25.58 min vs. 244.88±6.51 min) and the mean duration of sensory analgesia was (4vs.51.10±13.79 362.60±5.96 min). The incidence of bradycardia and hypotension was meaningfully more in ropivacaine clonidine category as compared to only ropivacaine group (23).
Verma O et al., showed buprenorphine and fentanyl with bupivacaine in spinal anaesthesia offered good quality intraoperative and postoperative analgesia. Bupivacaine with buprenorphine considerably extends sensory and motor block. Duration of analgesia and sedation were longer in buprenorphine group than fentanyl group (24). In this present study, sedation was not seen with RB group.
Shruthijayaram BA showed that duration of sensory and motor block was significantly extended with dexmedetomidine group in comparison with buprenorphine or saline. Dexmedetomidine delayed the time for first analgesic need postoperatively (25). The study results were similar as present study in terms of onset of action.
This study was also a quest for safer local anaesthetic agent along with an adjuvant for intrathecal use. The anaesthetic fraternity moving towards the opioid free analgesia to over come its adverse effects. No study previously compared the buprenorphine and clonidine intrathecally with ropivacaine. The results of this study, shows that clonidine is no longer a lesser adjuvant than buprenorphine and also had superior sensory and motor block. This encourages to use clonidine than buprenorphine for safer anaesthesia practice and lesser conversion of general anaesthesia because of block regression.
Limitation(s)
This was a single centre study. The duration of surgery and nature of procedure might have an influence in postoperative pain. By studying the outcome for single orthopaedic produce may give a better reliable postoperative pain score and its management.
Clonidine when used as an adjuvant, in addition to prolonging duration of sensory and motor block and also delays the time of requirement for first rescue analgesia thereby reduces the consumption of postoperative analgesia than the control and buprenorphine groups. The side-effects like hypotension and bradycardia were observed in clonidine group but was minimal. Hereby concluding that clonidine usage as adjuvant has significant advantage over using plain local anaesthetic drug or with buprenorpine intrathecally.
DOI: 10.7860/JCDR/2022/56753.16841
Date of Submission: Mar 30, 2022
Date of Peer Review: May 05, 2022
Date of Acceptance: Jun 13, 2022
Date of Publishing: Sep 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
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