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

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Dr Mohan Z Mani

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On Sep 2018




Prof. Somashekhar Nimbalkar

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Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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

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




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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
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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 : September | Volume : 16 | Issue : 9 | Page : UC44 - UC47 Full Version

Effect of Fentanyl and Dexmedetomidine as Additives to 0.5% Ropivacaine in Ultrasound Guided Supraclavicular Brachial Plexus Block for Elective Upper Limb Surgeries: A Randomised Clinical Trial


Published: September 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/58281.16929
M Umamaheshwar, KM Shwetha, Ramarao Bhogadi

1. Professor, Department of Anaesthesiology, Vydehi Institute of Medical Sciences, Bangalore, Karnataka, India. 2. Ex-Assistant Professor, Department of Anaesthesiology, Vydehi Institute of Medical Sciences, Bangalore, Karnataka, India. 3. Ex-Postgraduate Student, Department of Anaesthesiology, Vydehi Institute of Medical Sciences, Bangalore, Karnataka, India.

Correspondence Address :
KM Shwetha,
1131, Sobha Clovelly, Subramanya Pura Road, Gowdanapalya, Bangalore -560066, Bangalore, Karnataka, India.
E-mail: drshwethakm@gmail.com

Abstract

Introduction: Supraclavicular brachial plexus block is a superior alternative to general anaesthesia for upper limb surgeries, and use of ultrasound makes it safe and efficient in implementation. Ropivacaine, having significantly higher threshold for cardiotoxicity and neurotoxicity and more potent blocker of A and C fibres, renders good sensory blockade and lesser motor. Hence, to overcome this, additives are added.

Aim: To evaluate the block characteristics with addition of either fentanyl or dexmedetomidine to 0.5% ropivacaine for supraclavicular brachial block.

Materials and Methods: This randomised double-blinded clinical trial, was conducted on 50 patients posted for upper limb surgeries under supraclavicular brachial plexus block were randomly allocated to either receive 30 mL of 0.5% ropivacaine with 50 μg fentanyl (Group RF) or 30 mL of 0.5% ropivacaine with 50 μg dexmedetomidine (Group RD). The time for onset of sensory block and motor block were noted. Intraoperative hemodynamics were monitored in all the patients. Postoperatively Visual Analog Scale (VAS) scoring for pain, the time for rescue analgesia and the duration of sensory and motor blockade were noted.

Results: Both groups were comparable with respect to age, gender and American Society of Anaesthesiologists (ASA) grading. The onset of both sensory (p-value 0.008) and motor block (p-value 0.0005) was faster in Group RD compared to Group RF which was highly significant statistically. The duration of sensory (p-value 0.0005) and motor block (p-value 0.0005) was longer in Group RD compared to Group RF which was highly significant statistically. The requirement for rescue analgesia was lesser in Group RD since the mean VAS score was persistently low which was statistically significant (p-value <0.01) compared to Group RF.

Conclusion: The blockade improved better with addition of dexmedetomidine than fentanyl to 0.5% ropivacaine. There were no increased incidence for side effects.

Keywords

Haemodynamics, Motor block, Side effects

Brachial plexus block is achieved commonly via interscalene, supraclavicular, infraclavicular, or axillary approach. Out of which, supraclavicular block is considered as “spinal of the arm” as it can anaesthetize the entire arm just distal to the shoulder. The use of ultrasound for supraclavicular brachial plexus block has improved the success rate of the block, as it decreases the incidence of pneumothorax and local anaesthetic systemic toxicity (1). Regional anaesthesia has several advantages like excellent peri-operative analgesia, avoidance of airway instrumentation, avoidance of opioid-related side-effects, decreased recovery time and improved patient satisfaction (2). Regional anaesthesia techniques have been limited by three major factors like local anaesthetic agent’s slow onset time, short duration of action and limited duration of post-operative analgesia.

Short acting and long acting local anaesthetic have been combined together to have a shorter onset of action and longer duration of action. Also, several adjuvants have been used with local anaesthetics during blocks.Alpha-2 agonists like clonidine, dexmedetomidine, opioids like fentanyl, tramadol and steroids like dexamethasone have been used to prolong neural blockade (3). Various studies have concluded that the addition of perineural dexmedetomidine to local anaesthetics significantly shortened the onset of sensory and motor block, prolongs the duration of analgesia, and prolongs the time to first analgesic request with minimal side effects (4),(5),(6). Addition of fentanyl to local anaesthetics enhances postoperative analgesia, but the duration of this effect was very brief (7). The present study was conducted to compare the additives dexmedetomidine and fentanyl with ropivacaine in supraclavicular brachial plexus block. The block was performed under ultrasound guidance to achieve maximum success and better block characteristics.

The primary outcome measures were the onset and time to complete sensory and motor block and the total duration of post-operative analgesia. Secondary objectives were the haemodynamic changes following the block,sedation (Ramsay sedation score), and any side effects of drugs used or complications related to block between the two groups.

Material and Methods

This randomised double blinded study was conducted between January 2018 to June 2019 in the Department of Anaesthesiology, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, Karnataka, India. The Institutional Ethics Committee had provided the clearance (VIEC/2017/APP/114).

Sample size calculation: Based on the study by Cham S et al.,(4) the mean±SD of the onset of motor block of two groups was 3.06±0.25 and 3.26±0.45 minutes respectively, considering confidence Interval of 95% and power of 80% with anticipated mean difference of 0.2 and assumed standard deviation of 0.25, the sample size was estimated employing the below-mentioned formula

n = [2*{Z(1- α/2)+Z1-β}2*σ2]/d2

Zα/2=(α/2)th quantile of normal distribution
Zβ=(β) thquantile of normal distribution
D=difference in means
σ2 =population variance

And the calculated sample size of each group was 25 in each group,total 50.

Inclusion criteria: A total of 50 patients posted for upper limb surgeries under regional anaesthesia, belonging to American Society of Anaesthesiologists (ASA) grade I & II, aged between 18 and 60 years, weighing 50 to 70 kgs were included in the study.

Exclusion criteria: Patients with known allergy to the study drug, those uncooperative for the block or any psychiatric illness history were excluded from the study.

The patients satisfying the inclusion criteria were thoroughly evaluated, and written informed consent was obtained. Using the sealed envelope method, patients were randomly allocated into two groups (Table/Fig 1):

GROUP RF: 30 mL 0.5% ropivacaine + 50 μg fentanyl

Group RD: 30mL 0.5%ropivacaine + 50μg Dexmedetomidine.

Procedure

All patients were premedicated with Injection (Inj.) Ondansetron 4mg IV and Inj. midazolam 0.03 mg/kg IV & Inj. Glycopyrrolate 0.2 mg IV 30 mins before the procedure. Patients were shifted to the Operation Theatre (OT) on the day of surgery, all ASA Standard monitors attached, IV access secured and baseline vitals were noted. The block was performed at least 30 minutes before the start of surgery, under sterile aseptic precautions under guidance of Seimensacuson freestyle ultrasound L8-3 MHz Linear Transducer and 22 g stimuplex needle. After completion of the injections of local anaesthetic mixture, patients were evaluated at 5 min interval for 30 mins for developing the sensory and motor block. Completion of injection was considered as time 0. Plexus block was considered successful when all the three trunks (upper, middle and lower trunks) were effectively blocked for both sensory and motor components. Surgery was started after achievement of successful blockade. In case of inadequate blockade due to any reason, the case was converted to general anaesthesia at the end of 30 minutes and it was not considered in the study.

Sensory block was assessed by pin prick test using a 3- point scale graded as

• Score 0: sharp pain;
• Score 1: touch sensation only felt; (analgesia),
• Score 2: No sensation felt; (anaesthesia). Motor block was determined by thumb abduction (radial nerve), thumb adduction (ulnar nerve), thumb opposition (median nerve), and flexion of elbow (musculocutaneous nerve) according to the modified Bromage scale on a 3- point scale as,
• Score 1: Partial block,
• Score 2: Almost complete block.
• Score 3: Total block (4). Time of onset of sensory block, defined as the time from completion of injection to the time sensory block began to be detected in the distribution of any one of the major nerves. Time of onset of motor block, defined as the time between injection of local anaesthetic and inability to move the joints was noted. Time of complete sensory block was defined as pin prick score of 2 for all nerves. Time of complete motor block was defined as inability to move the joints or score 3. The onset and duration of sensory and motor block, time for complete sensory and motor block were noted.

Haemodynamic monitoring (heart rate, blood pressure) was noted for every 5 min till the end of the surgery. Degree of sedation was assessed at all intervals as that of vital parameter monitoring using the Ramsay Sedation Scale. Postoperatively, patients were monitored till the onset of pain and recorded as the time to first rescue analgesia. Pain was assessed by a standardised Visual Analogue Scale (VAS) every hour. The nursing staff was directed to administer first rescue analgesic Inj.Diclofenac sodium 75 mg IV when VAS ≥3 and second rescue analgesic Inj. Tramadol 50 mg IV if pain was not controlled with one analgesic drug. Any complication related to study drugs or the procedure like haematoma, pneumothorax, Horner’s syndrome, recurrent laryngeal nerve palsy, bradycardia, hypotension, pruritus were noted.

Statistical Analysis

The data was collected in Microsoft (MS) Excel and statistical analysis was done using International Business Management (IBM). Statistical Package for Social Sciences (SPSS) statistics software 23.0 version. The results were expressed in terms of percentages and proportions and expressed in the form of tables and graphs. To describe about the data, descriptive statistics frequency analysis, percentage analysis were used for categorical variables and the mean and Standard Deviation (SD) were used for continuous variables. To find the significant difference between the bivariate samples in independent groups the unpaired sample t-test and the Mann-Whitney U test was used. To find the significance in categorical data, Chi-Square test was used similarly if the expected cell frequency is less than 5 in 2×2 tables, then the Fisher's Exact test was used. In all the above statistical tools, the probability value /p-value <0.05 was considered as significant level.

Results

Total of 50 patients included in the study were analysed. There was no statistically significant difference (p-value >0.05) between the two groups with respect to age, gender and ASA grading (Table/Fig 2). From (Table/Fig 3), it is evident that the onset of both sensory and motor block was significantly faster in Group RD compared to Group RF. The time to complete sensory block and motor block was significantly lower in Group RD compared to Group RF. The duration of sensory and motor block was significantly longer in Group RD compared to Group RF. The trends in mean heart rate depict that they remained lower than mean baseline values in both the groups (Table/Fig 4). However, this difference in mean heart rates compared to respective preoperative mean baseline values was found to be statistically significant (p<0.01) in group RD, it was statistically significant from 25 mins interval onwards, however none of the patients had bradycardia neither in Group RD nor Group RF.

A mean MAP lower than mean baseline MAP was observed in Group RD, there was no statistically significant difference in MAP upto 60 minutes from the time of administration of block. However, the statistically significant (p-value <0.05) difference was seen from interval of 90 mins onwards (Table/Fig 5). Based on Ramsay sedation score, out of 25 patients in Group RD, a score of 3 was noted in 19 patients and 6 patients had a score of 2. In Group RF, all the 25 patients had a score of 1 (Table/Fig 6). There was high statistically significant difference (p-value <0.01) in terms of sedation among Group RF and GroupRD. The requirement for rescue analgesia was also lesser in Group RD since the mean VAS score was persistently low i.e. 0.2±0.58 at 10 hrs and 4.36 ± 0.76 at 12 hrs which was statistically significant (p-value <0.01) compared to Group RF where the mean VAS score was 4.08±1.12 at 10 hrs and 4.88±0.44 at 12 hrs (Table/Fig 7). A total of four patients in group RF requested for rescue analgesia at 6 hrs and their VAS score were high even after first rescue analgesia was given. No episode of respiratory distress or hypoxemia, Horner’s syndrome, nausea, vomiting, recurrent laryngeal nerve palsy was observed in any of the patients during the study, technical complication of supraclavicular brachial plexus block administration such as haematoma formation, pneumothorax was not noted in any of patients during the study.

Discussion

The present study was carried out to compare fentanyl and dexmedetomidine as adjuvant to ropivacaine in ultrasound guided supraclavicular brachial plexus block. Ultrasound guidance produces superior peripheral nerve block success rates (1).

Ropivacaine is a long-acting amide local anaesthetic agent, is less lipophilic than bupivacaine, and is leads to a reduced motor blockade due to lesser penetration into large myelinated motor fibres. It is also associated with decreased potential for central nervous system toxicity and cardiotoxicity (8). Increasing the concentration of ropivacaine from 0.5% to 0.75% fails to improve the onset or duration of the block, while using 0.25% ropivacaine for subclavian perivascular brachial plexus block requires frequent analgesia and supplementation (9). Adjuvants were added with ropivacaine to enhance its quality of anaesthesia in regional blocks (10). Dexmedetomidine is a more selective α-2 adrenergic agonist and has revolutionised the field of anesthesia (11). Considering all this, to achieve the most effective technique and drugs for upper limb surgeries, this study used ultrasound guidance for the block with 0.5% ropivacaine and additives of dexmedetomidine 50 μg and fentanyl 50 μg.

In the present study, none of the patients were excluded from the study because of block failure. There was 100% success rate because of the use of ultrasound for block. Kathuria S et al., (5) conducted a study where dexmedetomidine was used as adjuvant to ropivacaine in ultrasound guided supraclavicular block. They also achieved good quality of anaesthesia and none of thier patients required general anaesthesia.In a landmark guided supraclavicular block conducted by Sahi P et al., (12), 7 patients were excluded from the study as there was block failure and converted to general anaesthesia.

The onset of sensory and motor blockade was lesser in the group with dexmedetomidine as adjuvant compared to fentanyl group and the postoperative analgesia was longer in the dexmedetomidine group in the present study. Cham S et al., (4) conducted a study using Inj. Fentanyl 1μg/kg or Inj. Dexmedetomidine 1 μg/kg as adjuvant to 30 mL of 0.5% ropivacaine, and observed that the onset of sensory and motor block was faster in dexmedetomidine group and duration of sensory and motor block and duration of analgesia was prolonged in dexmedetomidine group which was similar to the present study. Mangal V et al., (13) observed that addition of Inj. dexmedetomidine 1 μg/kg to 20 mL of 0.75% ropivacaine significantly shortened the onset of sensory and motor block in landmark guided supraclavicular brachial plexus block. Sahi P et al., (12) conducted study on landmark-guided supraclavicular plexus block with 0.5% Ropivacaine and additives of either fentanyl 1μg/kg or dexmeditomedine 1 μg/kg. Dexmedetomidine produced a more prolonged duration of motor and sensory block and postoperative analgesia as compared to fentanyl, which was significant. The mechanism of the analgesic actions of α2 agonists is multifactorial.

A number of supraspinal and spinal sites modulate the transmission of nociceptive signals in the CNS. Peripheral α2 adrenoceptors may also mediate the antinociception (5). Kathuria S et al., compared the effect of perineural dexmedetomidine as additive to ropivacaine and intravenous dexmedetomidine. They hypothesized that it is mainly the direct peripheral action of dexmedetomidine on nerves in block, which is responsible for these improvements rather than due to central action of dexmedetomidine after absorption through block site into systemic circulation resulting in its systemic effects (5).

There were no significant haemodynamic changes in any of the study groups in the present study, however looking at the trends of heart rate in dexmedetomidine group it was noted that mean HR during the study remained lower than mean baseline HR, but none of the patients had bradycardia. Bradycardia was noticed in study patients given dexmedetomidine as adjuvant and was treated with Inj. atropine in various other studies (4),(5),(13). Hypotension, nausea and vomitting was noted in few studies (4),(13). This is because of the activation of post-synaptic α-2 receptors by dexmedetomidine which leads to sympatholysis and results in decrese in blood pressure and heart rate (11). In these studies, the dexmeditomedine dose used was either 1 μg/kg or 100 μg. Probably because the authors used a fixed lesser dose of 50μg in all patients, they didn’t find bradycardia or nausea, vomiting in any of their patients.

The patients in dexmedetomidine group, in the present study, were well sedated and did not require any supplemental sedation, whereas in fentanyl group none of the patients were sedated and were given some additional sedation. Similar to the present study, sedation was seen in majority of patients where dexmedetomidine was used as adjuvant in brachial plexus block compared to the control group (12),(13),(14). The sedative effects in dexmedetomidine group is because of systemic absorption of the drug and its action on locus ceruleus and is mediated by hyperpolarization of noradrenergic neurons thus inhibiting noradrenaline release and inhibiting activity in descending medullospinal noradrenergic pathways (11).

Thus, with the use of appropriate technique, appropriate concentration of local anaesthetic and the additives, there was a 100% success of block, good intraoperative and postoperative analgesia with no serious side effects. Dexmedetomidine 50 μg as additive was superior compared to fentanyl in all parameters compared in the present study.

Limitation(s)

The plasma level of the study drugs were not measured, and patients in the paediatric and geriatric age groups and patients with ASA III and above were not included in the study.

Conclusion

Dexmedetomidine and fentanyl when used as additives to ropivacaine for brachial plexus block enhance the readiness for the surgery. Considering faster onset of both sensory and motor blockade and prolonged duration of analgesia and good quality of anaesthesia for patients with no requirement of further sedation and lack of haemodynamic instability, 50 μg dexmedetomidine is an attractive choice for supraclavicular brachial plexus block as an additive. Hence 50 μg of dexmedetomidine can safely be used as adjuvant to 30 mL of 0.5% ropivacaine without any significant side effects.

References

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DOI and Others

DOI: 10.7860/JCDR/2022/58281.16929

Date of Submission: Jun 09, 2022
Date of Peer Review: Jul 23, 2022
Date of Acceptance: Aug 17, 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. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jun 15, 2022
• Manual Googling: Aug 16, 2022
• iThenticate Software: Aug 30, 2022 (25%)

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