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

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On Sep 2018

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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.
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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.
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Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

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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)
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.
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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.
On April 2011

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
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : January | Volume : 17 | Issue : 1 | Page : UC01 - UC04 Full Version

Low Dose Bupivacaine (0.25%) with Fentanyl vs Ropivacaine (0.25%) with Fentanyl for Caudal Analgesia in Paediatric Patients: A Randomised Clinical Study

Published: January 1, 2023 | DOI:
Balwinder Kaur Rekhi, Parmod Kumar, Kanica Mishra, Manjeet Singh, Gurjit Singh Gandhi

1. Professor, Department of Anaesthesia, Government Medical College, Patiala, Punjab, India. 2. Professor and Head, Department of Anaesthesia, Government Medical College, Patiala, Punjab, India. 3. Junior Resident, Department of Anaesthesia, Government Medical College, Patiala, Punjab, India. 4. Senior Resident, Department of Anaesthesia, Government Medical College, Patiala, Punjab, India. 5. Assistant Professor, Department of Anaesthesia, Government Medical College, Patiala, Punjab, India.

Correspondence Address :
Dr. Gurjit Singh Gandhi,
House No. 617, Near Jain Temple, Modern Valley, Fatehgarh Sahib-140406, Patiala, Punjab, India.


Introduction: Caudal epidural block is one of the most common regional techniques in paediatric anaesthesia for infraumbilical surgeries. Though bupivacaine is widely used because of its long duration, ropivacaine is a newly emerging drug having differential neuraxial blockade with less motor block and reduced cardiovascular and Central Nervous System (CNS) toxicity. To further increase the duration and quality various adjuvants have been added.

Aim: To compare low dose bupivacaine-fentanyl with ropivacaine-fentanyl in terms of hemodynamic stability, duration of analgesia, postoperative pain, level of sedation, and side-effects profile among patients undergoing infraumbilical surgery.

Materials and Methods: A double-blind, randomised study was conducted on 60 children undergoing elective infraumbilical surgery. Patients were randomly divided into two groups of 30 each into Bupivacaine-Fentanyl (BF) group and Ropivacaine-Fentanyl (RF) group, using a simple envelope method. After securing airway, caudal block was given. Group BF received 0.25% bupivacaine 0.5 mL/kg with fentanyl 0.5 mcg/kg and Group RF received 0.25% ropivacaine 0.5 mL/kg with fentanyl 0.5 mcg/kg. Postoperative pain was assessed using the Face, Legs, Activity, Cry, Consolability (FLACC) pain assessment scale, for 12 hours. The hemodynamics, duration of analgesia, rescue analgesia requirement and side effects (bradycardia, hypotension, respiratory depression, retching, urinary retention, vomiting) were noted and analysed statistically.

Results: The mean duration of analgesia in the BF group was 270±46.60 minutes and in the RF group was 430±68.83 minutes (p-value <0.001). Patients requiring rescue analgesia were 12 in Group BF and 5 in Group RF. Mean FLACC reached ≥4 at 4.5 hours in group BF and at 7 hours in group RF. There was no significant difference in hemodynamics and side-effects profile (bradycardia, hypotension, respiratory depression, retching, urinary retention, vomiting) between the two groups.

Conclusion: Low dose caudal ropivacaine-fentanyl combination is superior to that of caudal bupivacaine-fentanyl with respect to duration and intensity of intraoperative and postoperative analgesia.


Adjuvants, Haemodynamic stability, Infraumbilical surgeries, Postoperative analgesia, Sedation score

Postoperative pain is an annoying subjective sensation for both children and their parents and relief from postoperative pain is challenging in children (1). Caudal epidural, the most commonly used regional analgesia technique, is virtually free of measurable hemodynamic effects, thus adding a new dimension to the evolving necessity of paediatric postoperative pain management, but with the disadvantage of short duration of action after single injection (2),(3).

Prolongation of caudal analgesia using a single-shot technique has been achieved by the addition of various adjuvants such as opioids, ketamine, clonidine and dexmedetomidine (3). Bupivacaine was a popular drug in regional anaesthesia for years until toxic reactions were reported. Ropivacaine, the S-enantiomer of the amide local anesthetic, produces differential neural blockade, with less motor blockade, cardiovascular and neurological toxicity, making it suitable for day-care surgery in children (4). Fentanyl, a lipophilic opioid, acts on substansia gelatinosa on the dorsal horn of spinal cord by blocking fibres carrying nociceptive impulses both pre and postsynaptically. It comprises of certain undesirable side effects like nausea, vomiting or respiratory depression (5),(6).

The present study was conducted using low dosage of drugs to avoid any unwanted motor weakness, urinary retention and respiratory depression and, hence, to allow early ambulation and less hospital stay. Similar studies have encountered unnecessary motor blockade which might be because of usage of higher drug dosage (2),(4).

Previous studies that used low dose drugs found remarkable analgesia intraopertively and postoperatively with minimal side effects.

A study compared low dose ropivacaine 0.2% (0.5 mL/kg) alone (Group R) and in combination with fentanyl (0.5 mcg/kg) (Group RF) for caudal anaesthesia in paediatric patients found superior duration of analgesia in Group RF (14.86 hours) with no case of motor blockade, urinary retention and respiratory depression after the surgery (7) . Another study reported that caudally administered 0.5 mL/kg bupivacaine 0.25% plus ketamine 0.5 mg/kg or bupivacaine 0.25% plus tramadol 1 mg/kg provided significantly longer duration of analgesia in children undergoing inguinal hernia surgery (8).
Yet another study was conducted to compare the analgesic effect of clonidine 2 mcg/ kg as an adjunct (administered i.v. or caudal) with bupivacaine 0.25%, 0.5 mL/kg for caudal block in hypospadias repair which revealed no difference in analgesic effect between the two groups and also an absence of motor blockade (9).

The aim of the present clinical trial was to compare the efficacy of low dose bupivacaine-fentanyl and low dose ropivacaine-fentanyl combinations in children aged 1-8 years undergoing infraumblical surgeries. The primary outcome measures were intensity of intraoperative and postoperative analgesia, duration of analgesia, and need for rescue analgesic. The secondary outcome measures were hemodynamic changes, level of sedation and side-effects.

Material and Methods

The present double-blind, randomised study was conducted in 60 paediatric patients undergoing infraumbilical surgeries at Department of Anaesthesia, Rajindra Hospital, Government Medical College, Patiala, from April 2021 to January 2022. Ethical clearance was obtained from Institutional Ethics Committee (IEC No.BFUHS/2K21p-TH/5411).

Inclusion criteria: Paediatric patients of either gender aged between 1-8 years {American Society of Anaesthesiologists (ASA) classification grade ASA I and ASA II}.

Exclusion criteria: Children whose parents refused to participate in the study, patients with history of developmental delay or delayed milestones, mental retardation, child with suspected coagulopathy or bleeding diathesis, hypersensitivity to local anaesthesia, sacral bone abnormality, spina bifida and local sepsis at puncture site.

During enrollment 60 children of either sex were assessed for eligibility. They were randomised into two groups (30 children in each) using sealed envelopes.

- Group BF: received 0.25% bupivacaine 0.5 mL/kg with fentanyl 0.5 mcg/kg diluted in normal saline.

- Group RF: received 0.25% ropivacaine 0.5 mL/kg with fentanyl 0.5 mcg/kg diluted in normal saline.

Sample size calculation: Sample size was calculated with PS Power and Sample size Calculations Version 2.1.30 (William Dupont and Walton D Plummer). The sample size required was calculated considering an alpha error of 0.05, power 0.90 or 90%, assumed difference in dose of total amount of rescue analgesic as 5 with standard deviation of 5.5, which resulted in a predicted sample size of 28.6 (2). Rounding up, 60 patients were included in the present study.

Volume of drug was kept constant in all groups to avoid bias. The investigator, who did not participate in care of the patients, prepared all the study medications according to group assignment. Another investigator, who was blinded to group assignments, performed caudal blocks in all patients. Follow-up and analysis were done.


Fasting protocol was followed and premedication with intranasal midazolam 0.2 mg/kg was given to each child 30 minutes prior to surgery (10). Multi parameter monitoring was done for Electrocardiograph (ECG), Partial pressure of Oxygen (SpO2), Blood Pressure (BP), Heart Rate (HR), End-Tidal Carbon Dioxide (EtCO2). Caudal block was given. Surgery was allowed to proceed after 15 minutes of caudal block. The caudal block was considered failure, if increase in heart rate or mean arterial pressure was more than 20% of baseline. In case of failure, patient was excluded from study.

The hemodynamic parameters SpO2, HR, Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP) and Mean Arterial Pressure (MAP) were monitored continuously during preoperative and intraoperative period and documented intraoperatively for every five minutes up to 30 minutes and then every 10 minutes up to completion of surgery.

Face, Legs, Activity, Cry, Consolability (FLACC) scale: (Table/Fig 1) for pain assessment was measured at 30 minutes, 1 hour, 2 hours, 3 hours, 6 hours and 12 hours after surgery was used (11). The duration of analgesia was defined as the time from caudal placement of drug to the first recording of FLACC scale ≥4. Rescue analgesia had been provided with syrup paracetamol 10 mg/kg whenever the pain score was ≥4.

Sedation score: (Table/Fig 2) was assessed when the patient was shifted to recovery room up to 12 hours (12).

Statistical Analysis

Data was analysed using IBMM Statistical Package for the Social Science (SPSS) software version 22.0. Numerical data was expressed as mean and standard deviation and statistical analysis was done using the Analysis of Variance (ANOVA) test to compare both the groups. For skewed data/scores Kruskal Wallis H-test was used. Distribution of gender was compared using Chi-square test. The p-value of <0.05 was considered statistically significant.


A total of 60 paediatric patients of age group 1-8 years were enrolled in the study. Caudal block was successful in all the patients.The demographic data of the two groups did not differ (Table/Fig 3). There was no significant difference in the preoperative haemodynamic parameters between the two groups (Table/Fig 4),(Table/Fig 5).

Mean duration of analgesia was significantly earlier (4.5 hrs) in Group BF than in Group RF (7 hours) (Table/Fig 6). Patients requiring rescue analgesia were significantly more in Group BF (n=12) than in Group RF (n=5) (Table/Fig 6). Mean FLACC reached ≥4 earlier in group BF (4.5 hours) as compared to group RF (7 hours) (Table/Fig 7).

Vomiting was noticed in five patients in Group BF and in three patients in group RF. No other side effects (bradycardia, hypotension, respiratory depression, retching, urinary retention) were noticed in either group (Table/Fig 8).


In recent years paediatric regional anaesthesia has gone through significant development with advances in safety, pharmacology and block techniques (2). Among various techniques of regional analgesia caudal epidural analgesia in combination with general anaesthesia or alone provides safe, reliable and efficient analgesia for both high-risk and general paediatric surgical patients undergoing various sub umbilical surgeries (4). This long acting regional technique provides good postoperative analgesia and smooth recovery period facilitating early discharge (2).

In this study 0.5 mL/kg (low dose) of 0.25% ropivacaine or 0.25% bupivacaine was used for caudal analgesia to avoid motor blockade in postoperative period which could be explained by drug concentration being insufficient in blocking large motor fibres (13).

Duration of analgesia and postoperative pain: In the present study, ropivacaine-fentanyl group had prolonged duration of analgesia. The mean FLACC reached ≥4 earlier in group BF as compared to group RF, which is similar to other studies.

Doctor TP et al., compared ropivacaine (0.2 or 0.25%) or bupivacaine (0.25%) with fentanyl for caudal block. They concluded that time for first rescue analgesic for group the former was superior than the later, and the requirement of inhalational agent intraoperatively was less in the ropivacaine-fentanyl group (4).

Sengupta S et al., (2015) compared bupivacaine 0.25% 0.7ml/kg with fentanyl 1 mcg/kg and ropivacaine 0.25% 0.7 mL/kg with fentanyl 1mcg/kg for infraumbilical surgeries and found that the duration of analgesia was longer in the ropivacaine group (2). Kumar M et al., found a higher postoperative pain score in Group B {Bupivacaine 0.2% (1 mL/kg)} as compared to Group A {Ropivacaine 0.2% (1mL/kg)}, with group A having good analgesia clinically (13).

Rescue analgesia requirement: In the present study, more number of patients in group BF required rescue analgesia as compared to group RF signaling superiority of ropivacaine fentanyl group. Ahmad S et al., in a study found that the rescue analgesia requirement was significantly lower in group B {Ropivacaine 0.2% (1 mL/kg)} as compared to group A {Bupivacaine 0.25% (1 mL/kg)} (14). Sengupta S et al., concluded that intensity of postoperative analgesia produced by ropivacaine was better than bupivacaine (2).

Sedation score: In the present study, the mean sedation score (SS) during postoperative period was comparable at all intervals in both groups (12). A study conducted by Kumar M et al., revealed no statistical difference in sedation score between two groups {0.2% ropivacaine (1 mL/kg) or 0.2% bupivacaine (1 mL/kg)} which is in agreement with present study (13).

Side-effects: In the present study, some of the patients had episodes of vomiting which was similar in both the groups. None of the patients in both groups developed bradycardia, hypotension, respiratory depression, pruritis, fever and urinary retention.

Acharya R et al., (2013) compared caudal bupivacaine (0.25%, 2mg/kg) alone and with two different doses of fentanyl (0.5mcg/kg and 1 mcg/kg) and also reported that the incidence of vomiting was similar in both the groups. No patient suffered from respiratory depression, urinary retention and pruritus similar to the present findings (15). Chipde SS et al., also found no adverse effects such as nausea, vomiting, pruritus during a comparative study between bupivacaine (0.25%, 1 mL/kg) and ropivacaine (0.25%, 1 mL/kg) for caudal block (16). Sengupta S et al., while comparing ropivacaine-fentanyl and bupivacaine-fentanyl for caudal analgesia also found no significant adverse effects between the two groups (2).

In contrast to forementioned studies, there are two studies where authors observed urinary retention in patients. Metzelder ML et al., in a retrospective study compared the incidence of impaired postoperative micturition between penile block anaesthesia and caudal anaesthesia and found that the rate of impaired postoperative micturition was significantly higher in children undergoing caudal anaesthesia. The use of high volume (0.2%, 1 mL/kg) ropivacaine as compared to low dose, as used in the present study, could be the probable explanation (17).

Kumar M et al., in a study found that more number of patients had urinary retention in group B 0.2% bupivacaine (1mL/kg )} than group A {0.2% ropivacaine (1 mL/kg)} (13). The probable reason could be the higher dose of bupivacaine and ropivacaine used as compared to the present study. None of the children in both groups were found to have respiratory difficulty and pruritis (13).


Since it is a landmark-based study (blind procedure) and due to non availability of ultrasound machine, the spread of local anaesthetic solution could not be visualised in the epidural space.


Low dose and low concentration of drugs have an equipotent analgesic efficacy with lesser side-effects including motor block. Ropivacaine-fentanyl combination has a better intraoperative and postoperative analgesic property in comparison to bupivacainefentanyl combination. However, a similar hemodynamic and sideeffect profile exist for the two. Hence, low dose ropivacaine-fentanyl combination can be used as an alternative to bupivacaine-fentanyl combination for paediatric postoperative pain care through the caudal route as a safe and effective agent.


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Choudhuri AH, Dharmani P, Kumarl N, Prakash A. Comparison of caudal epidural bupivacaine with bupivacaine plus tramadol and bupivacaine plus ketamine for postoperative analgesia in children. Anaesth Intensive Care. 2008;36(2):174-79. [crossref] [PubMed]
Hansen TG, Henneberg SW, Walther-Larsen S, Lund J, Hansen M. Caudal bupivacaine supplemented with caudal or intravenous clonidine in children undergoing hypospadias repair: A double-blind study. Br J Anaesth. 2004;92(2):223-27. [crossref] [PubMed]
Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology. 2017;126:376-93. [crossref] [PubMed]
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Ali G, Kala N, Rather MA, Taj A, Maqbool S, Bhat KA. Comparative evaluation of caudal Ropivacaine and Ropivacaine with Clonidine for postoperative analgesia in children. J Evol Med Dent Sci. 2015;14:50-4.
Kumar M, Gupta KK, Kataria AP. Comparison of caudal ropivacaine 0.2% with bupivacaine 0.2% in Paediatricc patients–a randomised controlled trial. Anesth Essays Res. 2019:141-46.
Ahmad S, Mohammad K, Ahmad M, Nazir I, Ommid M, Nabi V, et al. Caudal analgesia in Paediatricc patients: Comparison between bupivacaine and ropivacaine. Internet J Anesthesiol. 2012;30:3. [crossref]
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DOI and Others

DOI: 10.7860/JCDR/2023/56902.17189

Date of Submission: Apr 17, 2022
Date of Peer Review: May 21, 2022
Date of Acceptance: Sep 08, 2022
Date of Publishing: Jan 01, 2023

Author declaration:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

• Plagiarism X-checker: Apr 21, 2022
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