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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
Postoperative Analgesia in Laparoscopic Cholecystectomy following Intraperitoneal Magnesium Sulphate: A Prospective Cohort Study
Correspondence Address :
Dr. Komu Fijul,
Assistant Professor, Department of Anaesthesia, Government Medical College,
Kozhikode-673008, Kerala, India.
E-mail: fij2007@gmail.com
Introdution: Postoperative pain and discomfort after laparoscopic cholecystectomy is partly because of distension, tearing, separation of parietal peritoneum and surgical manipulation. Intraperitoneal administration of Magnesium Sulphate (MgSO4) is thought to desensitise the after effects of pneumoperitoneum in addition to providing analgesia.
Aim: To analyse the effect of intraperitoneal magnesium sulphate on postoperative analgesia and occurrence of shoulder pain after laparoscopic cholecystectomy.
Materials and Methods: The present study was a prospective cohort study which was conducted at the Government Medical College, Kozhikode, Kerala, India, from February 2019 to December 2020, included 60 adult patients scheduled for elective laparoscopic cholecystectomy under general anaesthesia were selected and they were divided into two groups, group M and group N. Patients in group M received 30 mg/kg MgSO4 which was instilled into the gallbladder bed intraperitoneally by the surgeon after resection of gallbladder and patients who did not receive MgSO4 were included in group N. Postoperative pain was assessed using Visual Analog Scale (VAS) and VAS score> 3 was managed with Intravenous (IV) paracetamol 15 mg/kg. If pain was not relieved by this, IV tramadol 50 mg was supplemented. Time to first rescue analgesic, the total analgesic requirement and the incidence of shoulder pain in 24 hours were noted. Haemodynamics, recovery profile, incidence of Postoperative Nausea and Vomiting (PONV), any adverse events were also noted and analysed.
Results: Mean pain scores (VAS) were significantly lower in group M and time to first analgesic requirement was longer in group M (4.23±2.31 hours) compared with group N (1.07±0.67 hours), PONV was significantly higher in group N. Sedation scores were significantly high in group M and there were no significant differences in haemodynamic and recovery profile and incidence of shoulder pain in both the groups.
Conclusion: Intraperitoneal instillation of MgSO4 provides effective postoperative analgesia and reduces nausea and vomiting in patients undergoing laparoscopic cholecystectomy without any significant side-effects.
Gallbladder, Nausea and vomiting, Postoperative pain
Minimally invasive laparoscopic surgeries are now increasingly preferred over open procedures. Laparoscopic cholecystectomy has multiple advantages like less metabolic response to stress, maintenance of diaphragm and pulmonary function, less postoperative complications, lower incidence of postoperative ileus, early mobilisation, shorter hospital stay, reduced postoperative pain and better acceptance in terms of cosmetics. With these advantages, laparoscopic cholecystectomy is being increasingly done as day care procedure, despite effective postoperative analgesia remaining a major deterrent. Rosero EB and Joshi GP, in a large multicentric study on ambulatory laparoscopic cholecystectomy, found out that postoperative pain was one of the main diagnoses for readmission (1). Moreover, it has been hypothesised that persistent pain after laparoscopic cholecystectomy may predict development of chronic pain (eg.,: post cholecystectomy syndrome) (2).
The fact that acute pain after laparoscopic cholecystectomy is complex in nature and does not resemble pain after other laparoscopic procedures suggests that effective analgesic treatment should be multimodal (3). Various options like parenteral analgesics (opioid and non opioid), infiltration with Local Anaesthetics (LA), epidural and intrathecal opioids and LA, intercostal nerve blocks, subcostal and transverse abdominal plane block are employed.
Parenteral opioids are the main stay in postoperative pain management in laparoscopic cholecystectomy. Opioids, due to its inherent adverse effects like nausea, vomiting, ileus and respiratory depression can be undesirable and can cause morbidity, prolonged hospital stay and patient dissatisfaction. Newer modes of analgesia with different routes of administration and opioid avoidance can be a welcome change in laparoscopic cholecystectomy.
Magnesium is the fourth most common cation in the body and the second most abundant intracellular cation in the body after potassium. MgSO4 reduces postoperative pain by reduction of an influx of calcium into the cells and by antagonising N-methyl-D-Asparatate (NMDA) receptors, vital components for pain processing as well as neuronal signalling in the central nervous system. This receptor blockade decreases postoperative pain by virtue of blocking both visceral and somatic fibres. Pathways of visceral sensation are diffusely organised peripherally as well as centrally and NMDA receptors are involved in nociceptive visceral input processing (4). The mechanism of analgesia in intraperitoneal route may be by blocking multiple glutamate subtype of NMDA receptors expressed on peripheral nerve terminals present on the gallbladder resection bed and port site as these receptors contribute to peripheral nociceptive sensation (5),(6). Many studies have explored the feasibility of intraperitoneal administration of MgSO4 with LA and LA with opioids concluding that addition of LA with MgSO4 resulted in longer duration of analgesia and prolonged the time for rescue analgesics (7),(8).
However, there are less studies on MgSO4 alone instilled intraperitoneally and no consensus with regard to dose, timing and manner of administration. This study evaluated the analgesic effects of MgSO4 alone in laparoscopic cholecystectomy, a surgery with complex pain characteristics. Aim of this study was to analyse the effect of intraperitoneal MgSO4 on postoperative analgesia and occurrence of shoulder pain after laparoscopic cholecystectomy.
The present study was a prospective cohort study which was conducted at the Government Medical College, Kozhikode, Kerala, India, from February 2019 to December 2020. The approval from Institutional Research and Ethics Committee (IREC) (GMCKKD/RP 2019/IEC/82) was obtained on 21st January 2019.
Written informed consents were taken from all patients. Ninety patients who underwent laparoscopic cholecystectomy were assigned to two groups. Patients who received intraperitoneal instillation of 30 mg/Kg of MgSO4 were included in Group M and those who did not receive were included in Group N till the sample size of 30 was reached in each group.
Inclusion criteria: Patients who belonged to American Society of Anaesthesiologist Physical Status (ASA PS) I and II between the age of 20-60 years and of Body Mass Index (BMI) 18-30 kg/m2 were included in the study.
Exclusion criteria: Pregnant and lactating females, patients with history of autonomic dysfunction, renal or neurological disorders, patients with chronic pain on opioids and patients taking beta blockers were excluded from the study.
Sample size calculation: Sample size calculation was done using the formula n=(Zα+Zβ)2 × SD2 ×2/d2 where Zα=1.96, Zβ=0.84, SD=standard deviation, d=effect size (0.31) (9). Standard Deviation (SD) was 24.87 and sample size was calculated to be 30 (10).
All patients were assessed preoperatively by detailed history, physical examination and laboratory evaluation including baseline serum magnesium level. On the day before surgery, procedure was explained to each patient. All patients were kept nil per oral overnight and premedicated in the previous night with tablet alprazolam 0.25 mg and tablet ranitidine 150 mg and tablet metoclopramide 10 mg. They were advised fasting of eight hours for solids and two hours for clear liquids.
Standard anaesthetic technique was followed for all patients in both the groups. On arrival to the operation theatre, after application of preinduction monitors (ECG, pulse oximeter, non invasive blood pressure, ETCO2) an 18 G IV line was secured. After noting all baseline vital parameters, all patients were pre medicated with injection glycopyrrolate 0.004 mg/kg, injection midazolam 0.02mg /kg, and injection fentanyl 2 microgram/kg intravenously.
After preoxygenation general anaesthesia with injection propofol 2.5 mg/kg intravenous was given as inducing agent and injection succinylcholine 1.5 mg/kg intravenously as muscle relaxation for intubation. Patient was intubated with appropriate size cuffed endotracheal tube. Anaesthesia was maintained with oxygen in nitrous oxide and isoflurane mixture and muscle relaxation obtained with injection Atracurium. Ventilation was adjusted to maintain normocapnia (ETCO2 between 35-38).
A nasogastric tube was introduced and the laparoscopic procedure was carried out in a standard fashion. Intra-abdominal pressure was maintained around 12-14 mmHg. After the removal of gallbladder, in group M, 30 mg/kg of MgSO4 diluted to 30 mL with 0.9% normal saline was instilled intraperitoneally by surgeon through the port and the patient was kept at Trendelenburg position for 10 minutes. After skin closure local infiltration was given with 3 mL 0.25% bupivacaine at each port site. In group N also, where patients did not receive intraperitoneal MgSO4, port site infiltration was given using same drug and dose at the end of surgery.
Neuromuscular blockade was reversed with intravenous neostigmine 0.05 mg/kg with glycopyrrolate 0.01 mg/kg and patient was extubated, after ensuring complete reversal. The level of sedation was noted using Ramsay Sedation score and serum magnesium level was checked after 30 minutes of extubation (11). Vitals were monitored and kept stable throughout the procedure and the postoperative period. Patient was assessed postoperatively for incisional, visceral pain and shoulder pain at the 1st, 2nd, 3rd, 6th, 12th and 24th hour of postoperative period using Visual Analog Scale (VAS) score. It was assessed by noting the patient’s facial expression and over all reaction to the intensity of pain and assigning appropriate number ranging from 0-10; ‘0’means no pain to 10 means worst possible pain which was plotted on a horizontal straight line 10 cm length and asking the patient to mark his/her pain on that scale. Postoperative pain (VAS >3) was managed with Inj. paracetamol 15 mg/kg IV infusion, if pain not relieved or VAS>3 even after administration of paracetamol or if patient complained of pain (VAS>3) before six hours of paracetamol administration, injection tramadol 50 mg IV was given intravenously as second line rescue analgesic.
Time to request first analgesic, total analgesic requirement in the first 24 hours, the incidence and type of pain, especially shoulder pain at the end of 24 hours, recovery characteristics which included extubation time in minutes (from the end of anaesthesia to extubation), time of emergence (time to first response to a simple verbal command following discontinuation of isoflurane), time to achieve full Modified Aldrete Score which was considered fit for discharge from Post Anaesthesia Care Unit (PACU) were monitored (12). Haemodynamic parameters like Heart rate (HR), systolic, diastolic mean arterial pressures were noted up to 30 minutes after MgSO4 administration. PONV was evaluated using four-point nausea score (0-none, 1-mild, 2-moderate, 3-severe). Sedation was assessed with Ramsay Sedation Score. Complications such as cardiovascular, respiratory and neurological side-effects or allergic reactions if any were looked for in the intraoperative and postoperative period.
Statistical Analysis
Statistical analysis was done using IBM SPSS (Statistical Package for the Social Sciences) Statistics for Windows, Version 18.0. Armonk, NY: IBM Corp. Continuous variables such as age, weight, duration of surgery were represented as mean with standard deviation and association between these variables were analysed using Student’s t-test. The quantitative data was analysed using the unpaired student’s t-test for significance. The categorical variables such as sex, ASA PS were represented as numbers with percentages. Association between these variables was tested using Chi-square test. VAS scores were represented as mean with standard deviation and association between the two groups was tested by Mann-Whitney U test. The p-value <0.05 was considered as statistically significant.
A total of 60 patients, 30 in each group, were included in the study. Patients in both groups were comparable with respect to demographic parameters like age, sex, and weight. Duration of surgery and ASA physical status were also comparable (Table/Fig 1). Baseline serum magnesium concentrations were comparable in the two groups (p=0.83). Postoperative serum magnesium concentrations in group M were not significant as compared with group N and with baseline.
Time to first analgesic requirement was longer in group M than in group N and the difference was statistically significant with p-value of <0.001. Incidence of shoulder pain was found to be below 10% and statistically insignificant between the two groups (Table/Fig 2).
Mean pain scores were significantly lower in group M when compared with group N during the first six postoperative hours (Table/Fig 3).
Postoperative nausea was high in the group N than group M, especially during the 1st two hours of postoperative period. There was no incidence of vomiting in group M as compared with four patients in group N. This was statistically significant with a p-value of 0.008. Sedation scores were slightly high in the magnesium group M than group N which was statistically significant during the 2nd and 3rd hour of postoperative period. Recovery characteristics in terms of extubation time and emergence time were not significantly different. Also, there was no significant difference in time to reach the full Aldrete score. As regards haemodynamic parameters, baseline mean arterial pressure and heart rate in the two groups were comparable. There were no perioperative side effects in both the groups.
Magnesium sulphate, one of the major cations in the body, has been used through various routes as an adjuvant analgesic. Normal serum magnesium values range between 1.6-2.5 mg/dL. As MgSO4 has a half-life of 30 minutes, the serum magnesium level was determined 30 minutes after intraperitoneal instillation of the study solution, and the mean magnesium level reached up to 2.26±0.8 mg/dL in comparison to the preoperative baseline value of 1.86±0.17 in the current study.
The efficacy of intraperitoneal instillation of local anesthetics both alone and in combination with other drugs including MgSO4 has been demonstrated in numerous studies on laparoscopic cholecystectomy, but there is no consensus regarding the dose, concentration, site, and manner of administration (7),(8),(10),(13),(14). This study was devised to evaluate the analgesic and recovery characteristics of instilling MgSO4 alone intraperitoneally. Blood magnesium level and the sedation score in the PACU were also studied to conclude a safe and effective level of MgSO4 after peritoneal instillation.
Results of this study showed that MgSO4 improved the postoperative analgesic profile. There was significantly lower postoperative pain in group M compared with group N. Mean pain scores (VAS) were significantly lower in group M compared with group N during the first six postoperative hours. Time to first analgesic requirement was also significantly longer in this study.
Similar to the present study, the interventional study group of Ali RM et al., where they used 20 mL of 10% MgSO4 instilled intraperitoneally after the creation of pneumoperitoneum and before any dissection, showed the efficacy of instilling MgSO4 as evidenced by comparable VAS scores with the current study, especially during the first six hours of postoperative period (14). The time to first analgesic requirement was longer in group M (9.2±3 hours) than in control group C (2.4±1.3 hours) when compared with this study where only 4.23±2.31 hours of analgesia was observed in magnesium group M and 1.07±0.67 hours in group N. This difference may be due to drug administration early in the intraoperative period which might have resulted in prevention of central sensitisation before the surgical stimulus.
Lee DH et al., found that 80% of patients suffered from shoulder pain in the first 24 hours (15). Other reported incidences of shoulder pain vary between 25-60% in laparoscopy (16),(17). The incidence was less than 10% in this study. This could be due to careful emptying of pneumoperitoneum and saline irrigation and suctioning before MgSO4 instillation. Washing the diaphragmatic surface by a sizeable amount of saline dilutes carbonic acid, a strong diaphragmatic irritant formed by carbon dioxide in moist peritoneal surfaces and reduces the severity of diaphragmatic irritation.
Maharjan SK and Shrestha S, compared intraperitoneal instillation of bupivacaine, alone and in addition to MgSO4 in 60 patients posted for laparoscopic cholecystectomy (18). They concluded that combined instillation of intraperitoneal bupivacaine plus MgSO4 at the end of surgery rendered better analgesic control and less consumption of analgesics in first 24 hours in comparison to the sole bupivacaine group. Saadawy IM et al., in a double blinded study, reported that both IV lignocaine and MgSO4 50 mg/kg improved postoperative analgesia and postoperative opioid requirements in patients undergoing lap cholecystectomy (19). Abdel-Raouf M and Amer H, studied the postoperative analgesic effects of intraperitoneal NMDA receptor antagonists MgSO4 and ketamine delivered intraperitoneally in patients undergoing laparoscopic cholecystectomy. They concluded that intraperitoneal co-administration of either magnesium sulphate or ketamine with bupivacaine 0.25% at the end of surgery is effective in reducing postoperative shoulder pain and analgesic requirement following laparoscopic cholecystectomy (20).
The effect on nausea and vomiting after intraperitoneal MgSO4 administration in laparoscopic cholecystectomy as observed in the present study was similar to the findings in a study done by Ali RM et al., (14). In the current study there was significant reduction in nausea and vomiting in group M in comparison to group N. NMDA receptors are present in both emetic pathways and structures associated with final common pathway for vomiting. Magnesium, by virtue of being a NMDA blocker has the potential to become a broad-spectrum antiemetic (21). However, there is not much literature available on the direct effects of MgSO4 on nausea and vomiting currently.
Patient recovery characteristics and haemodynamic parameters like HR and mean arterial pressures in present study were comparable and no significant difference was noted between both groups. Even though sedation scores were significantly high in group M in the second and third postoperative hour, all the patients were easily arousable during this period. Also, none of the patients had a sedation score of more than 3.
Intraperitoneal instillation of MgSO4 appears to be a safe and valid technique which aids in reducing postoperative pain after laparoscopic cholecystectomy as evidenced from the findings of the current study and conclusions drawn from similar studies exploring the feasibility of intraperitoneal MgSO4. A dose of 30 mg/kg also appears to be sufficient in combating the common but troublesome problem of nausea and vomiting associated with laparoscopic surgeries.
Limitation(s)
This study included only ASA I and II patients. A study on patients with multiple co-morbidities would be able to shed more light on the effects of intraperitoneal instillation of MgSO4, especially the direct antiemetic action.
Intraperitoneal instillation of MgSO4 in laparoscopic cholecystectomy provides effective postoperative analgesia without any significant side-effects as evidenced by lower pain scores in the first 24 hours and reduced total analgesic consumption in a 24-hour period. It also reduces the incidence of nausea and vomiting significantly.
DOI: 10.7860/JCDR/2022/59201.16860
Date of Submission: Jul 24, 2022
Date of Peer Review: Aug 12, 2022
Date of Acceptance: Aug 19, 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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