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

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



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."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




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.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



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




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



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




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : January | Volume : 17 | Issue : 1 | Page : UC31 - UC35 Full Version

Comparative Study of Magnesium Sulphate versus Dexmedetomidine as an Adjuvant to Epidural Bupivacaine- A Randomised Controlled Trial


Published: January 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/60381.17401
PK Mohammed Shafi, Moona Abdul Kadiru, Neera Valsan, Biju Abraham, Ravi Kumar, Jijo Sebastian Aloysius

1. Assistant Professor, Department of Anesthesiology, MES Medical College, Malappuram, Kerala, India. 2. Associate Professor, Department of Anesthesiology, Malabar Medical College, Calicut, Kerala, India. 3. Assistant Professor, Department of Anesthesiology, Malabar Medical College, Calicut, Kerala, India. 4. Professor, Department of Anesthesiology, Government Medical College, Kannur, Kerala, India. 5. Professor, Department of Anesthesiology, Malabar Medical College, Calicut, Kerala, India. 6. Trust Registar Anesthetics, Department of Anesthesiology, Peterborough City Hospital NHS Foundation Trust, Peterborough, Cambridgeshire, India.

Correspondence Address :
Moona Abdul Kadiru,
Vishnumadom TD Nagar 33 Near Collectorate Kollam-691013, Kerala, India.
E-mail: moonakad@gmail.com

Abstract

Introduction: Neuraxial adjuvants are used to improve or extend analgesia. They have been utilised in several trials to prolong postoperative analgesia along with spinal anaesthesia, but as epidural anaesthesia is more haemodynamically stable, adding adjuvants to the above will have substantially less detrimental effects. Dexmedetomidine and magnesium sulphate may be used as adjuvants in neuraxial anaesthesia along with local anaesthetics.

Aim: To determine the impact of adding magnesium and dexmedetomidine in the lower limb and lower abdominal procedures as an adjuvant to epidural bupivacaine.

Materials and Methods: This randomised, single blinded study was conducted on 90 ASA (American Society of Anaesthesiologists) class I and II patients in the Department of Anesthesiology Government Medical college, Kannur, Kerela from September 2015 to September 2016. Following randomisation using the lottery approach, the patients were divided into groups M, D, and C, and given the appropriate drugs through the epidural route. Group D: Bupivacaine 0.5% 10 mL+Dexmedetomidine 0.5 mcg/kg (in 1 mL 0.9% saline); group C: Bupivacaine 0.5% 10 mL+Saline 0.9% (1 mL); group M: Bupivacaine 0.5% 10 mL+MgSO4 50 mg (in 1 mL 0.9% saline). Monitoring was done for the onset, duration, haemodynamic parameters, level of motor and sensory block attained and any adverse outcomes. Data were collected, and statistical analysis was done by Statistical Package for Social Science (SPSS) version 17.0 and Analysis of Variance (ANOVA) with repeated measurements and the contingency coefficient test were both used.

Results: Group D had greater postoperative analgesia (307.3±77.3 minutes), while the duration for the onset of sensory (13.1±1.3 minutes) and motor blockade was much shorter. Prolonged motor block and sedation, Ramsay sedation score>3 was observed in Group D.

Conclusion: The addition of dexmedetomidine to epidural bupivacaine may be beneficial in the context of the prolonged duration of motor and sensory blockade and arousable sedation.

Keywords

Central neuraxial block, N-methyl-D-aspartate receptor agonist, Postoperative pain local anaesthetic

Pain is an unpleasant sensation that originates from ongoing and impending tissue damage. Epidural placement is the safe, effective means of providing surgical anaesthesia and postoperative analgesia. No drug has yet been identified that specifically inhibits nociception without associated side effects.

Neuraxial adjuvants are used to improve or extend analgesia. These have been utilised to prolong postoperative analgesia along with spinal anaesthesia (1) but as epidural anaesthesia is more haemodynamically stable, adding adjuvants in the above will have a substantially less detrimental effect. Various drugs like dexmedetomidine, a selective alpha-2 adrenergic receptor agonist and magnesium sulphate may be used as an adjuvant in neuraxial anaesthesia along with local anaesthetics (1),(2),(3). Regional anaesthesia also brings along with it the benefits of postoperative analgesia which is the most demanded benefit by patients. It can reduce or avoid the hazards and discomfort of General Anaesthesia like sore throat, airway trauma and muscle pain. It also offers a number of advantages to outpatients undergoing surgery.

The most popular method for giving surgical patients anaesthesia as well as postoperative analgesia is epidural anaesthesia (4). The most desirable characteristics of modern surgery include early postoperative movement, rehabilitation, and minimum pain and discomfort (5),(6),(7). The gold standard medications include local anaesthetics like bupivacaine and lignocaine, either with or without adrenaline (7),(8). Traditional adjuvants include opioids like fentanyl, morphine, and buprenorphine; but they can have adverse effects including itching, urine retention, nausea, vomiting, and respiratory depression (9),(10),(11). Alpha-two agonists are one of many novel adjuvants to local anaesthetics that are currently being tested. These adjuvants have remarkable analgesic qualities and act by enhancement of the local anaesthetic, which is mediated by hyperpolarising nerve tissues by changing transmembrane potential and ion conductance at the locus coeruleus in the brainstem (12).

Another group of drug used as an adjuvant are magnesium sulphate. The analgesic effect of epidural magnesium sulphate (MgSO4) is because of its non competitive antagonism of N-methyl-D-aspartate (NMDA) receptor (13). Recent studies suggest the role of magnesium sulphate as an adjuvant to local anaesthetics in spinal anaesthesia (14).

Noxious stimulation leads to the release of glutamate and aspartate neurotransmitters, which bind to the NMDA receptor. Activation of these receptors leads to calcium entry into the cell and initiates a series of central sensitisation and long-term potentiation in the spinal cord, in the response of cells to prolonged stimuli. NMDA receptor signaling may be important in determining the duration of acute pain. Magnesium blocks calcium influx and non competitively antagonises NMDA receptor channels. Dexmedetomidine given epidural has more duration of sensory analgesia than magnesium sulphate in lower limb surgeries (15). Recent studies done on postoperative analgesia for Total Knee Replacement (TKR) (16) and thoracotomy (17) also has shown dexmedetomidine to be effective. They also mention that magnesium can be given as an alternative.

Hence, the current study was conducted with an aim to compare the efficacy of Dexmedetomidine and Magnesium sulphate as an adjuvant to epidural bupivacaine. The primary objective was to compare the onset, duration of sensory and motor block. Secondary objective was to compare the side effects including hypotension bradycardia, nausea, and vomiting sedation and shivering.

Material and Methods

This randomised single-blinded study was conducted in the Department of Anesthesiology, Government Medical College, Kannur, Kerala, India, from September 2015 to September 2016.The Institutional Ethical Committee (G1.274712/ACME/2015) was obtained.

Inclusion criteria: All adult 20-80 years, ASA I and II patients scheduled for lower limb and abdominal surgeries were included in the study.

Exclusion criteria: Patients with a history of adverse reactions to any study medications, history of analgesic use and chronic pain syndrome, patients with communication difficulties, age >80 years, infection at the injection site, mental disturbances, coagulopathy, cardiac complications were excluded.

Sample size calculation: The sample size was determined using data from the study by Shahi V et al., (15). The mean time to first epidural top up and difference in mean value of first epidural top up between group D and group M is (587.8±64.3 min) and (226.3±60.9 min) respectively. Therefore, with 80% power and a level of significance of 5%, 90 patients (30 in each group) were adequate to identify a difference of 25% across groups (Table/Fig 1).

Procedure

Soon after hospital admission, a full preoperative clinical assessment was performed. Complete blood count, random blood sugar, renal function test, serum electrolytes, screening tests, Electrocardiograms (ECG), and chest X-ray were done preoperatively. Following randomisation using the lottery approach, 90 patients who underwent lower limb and lower abdominal surgery were selected based on the criteria and randomly assigned to three groups- M, D and C, 30 patient each. They are as follows-

• Group C: Bupivacaine 0.5% 10 mL+Saline0.9%;
• Group M: Bupivacaine 0.5% 10 mL +MgSO4 50 mg (in 1 mL 0.9% saline); (1 mL).
• Group D: Bupivacaine 0.5% 10 mL+Dexmedetomidine 0.5 mcg/kg (in 1 mL 0.9% saline);

Following a thorough preanaesthesia evaluation and obtaining written consent, the patient was informed of the procedures and any potential complications. The night before surgery, all study participants received an injection of ranitidine 50 mg I.V. and a 0.5 mg alprazolam tablet as premedication. Before surgery, they were kept off solid food for atleast six hours and clear liquids for two hours.

Following a patient centred explanation of the operation, signed informed consent was obtained. An 18-gauge intravenous cannula was placed under local anaesthetic infiltration as soon as the patient entered the operating room, and an infusion of Ringer’s lactate 20 mL/kg preloading was commenced. The patients were hooked up to a multiparameter monitor that recorded oxygen saturation, heart rate, non invasive assessments of blood pressure, mean arterial pressure, and continuous ECG. Both the heart rate and the average systolic blood pressure were noted. A continuous visual ECG from lead II was used to assess the heart rate and rhythm.

The L2-3 or L3-4 epidural space was identified by the loss of resistance technique with an 18G Tuohy needle under aseptic conditions after local anaesthetic infiltration of the skin. A multi-orifice catheter was placed up to 4cm in the epidural space. A test dose of 3 mL of epidural lignocaine 2% with adrenaline confirmed the epidural catheter’s proper insertion (1:200,000). Epidural medication was administered following proper epidural catheter insertion. Time to reach the highest dermatomal level, time to reach T10 sensory level, mean pulse rate and mean arterial pressure were recorded at the time of drug delivery, at 5 min intervals for the first 20 min then 10 min and 15 min intervals up to 60 minute, regression from Bromage level 3, need for a first epidural top-up, and perioperative complications like bradycardia, hypotension, nausea, vomiting, shivering, and sedation based on Ramsay sedation score were all factors that were evaluated. Patients were monitored for any delayed problems for 72 hours.

Statistical Analysis

Data were collected, and statistical analysis was done by SPSS version 17.0, and presented as tables, figures, graphs, and diagrams. An independent samples t-test was employed to compare the means for the two groups. ANOVA with repeated measurements and the contingency coefficient test were both used. All information was displayed as mean±SD (standard deviation). The student’s t-test was used to assess the demographic data. Results were shown in table and figure as numbers and percentages for each parameter for discrete data and as an average (mean±SD) for continuous data. The statistically significant difference in the parameters measured between the study groups was determined using the student’s t-test. A p-value of less than 0.05 was considered statistically significant in all the tests mentioned above.

Results

Between the three groups, there were no significant statistical variations in terms of gender, height, or weight (Table/Fig 2). Most of the patients were over the age of 40; 43.3% of patients in group M and 56.7% in groups C and D had no concomitant diseases (Table/Fig 3).

For groups C, D, and M, respectively, the times required to reach the sensory block to the T10 level were 16.9±1.2, 13.1±1.3, and 15.4±1.3 min respectively. The time for onset of sensory block in group D was considerably shorter than that of the other two groups. In all three groups, the maximum dermatomal level obtained was comparable (Table/Fig 4).

The duration between the initial epidural bolus to the first epidural top-up was the longest (307.3±77.3 min) in the group D and then the group M (195.9±33.1min) and the shortest (144.2±22.4 min) in the group C of patients. The differences among groups were highly significant (p-value <0.001) (Table/Fig 5).

The group D experienced the longest time for regression from modified Bromage level 3 (228.0±49.8 min), followed by the group M (149.9±25.1 min), and the group C (102.6±16.3 min) (Table/Fig 4).

When the patient’s pulse rates were taken, there was a statistically significant difference between the three groups’ mean pulse rates (p-value < 0.001). After 20 minutes the medication was administered, the mean pulse rate in group D decreased (Table/Fig 6).

The patient’s Mean Arterial Pressure (MAP) was monitored at multiple time intervals (Table/Fig 7), and there was no statistically significant difference (p-value>0.05) in the MAPs of the three groups (Table/Fig 8).

During and after surgery, adverse effects such as hypotension, bradycardia, nausea, vomiting, sedation, and shivering were observed. The group D experienced statistically significant bradycardia episodes. In all three groups, hypotension, nausea, and vomiting were comparable. The group receiving dexmedetomidine had a higher sedation score and was graded per Ramsay sedation score. The prevalence of shivering was more in the control group (Table/Fig 9).

Discussion

The epidural local anaesthetic injection is a common and effective method of anaesthesia and postoperative analgesia for abdominal and lower limb procedures. To prevent monopharmacy related adverse effects and to improve the quality of anaesthesia and postoperative analgesia, a variety of pharmacological substances are utilised as adjuvants to local anaesthetic drugs.

The effects of the addition of dexmedetomidine vs. magnesium sulphate to epidural bupivacaine were compared for sedation, onset and duration of motor and sensory block, maximum sensory block, analgesic efficacy in the perioperative period, haemodynamic variables, and side effects along with a control group. It was found that dexmedetomidine be a better agent in prolonging the motor and sensory block intraoperatively and the duration of effective postoperative analgesia with good arousable sedation. Neuraxial adjuvants are used to improve the quality, lengthen the duration, and accelerate the neural blockade’s onset (lower latency). Examples include opioids, vasoconstrictors, alpha-2 adrenoreceptor agonists, cholinergic agonists, NMDA antagonists, and GABA receptor agonists. It produces analgesia by hyperpolarising, which prevents the release of C-fiber transmitters and postsynaptic horn neurons. Adjuvant properties of magnesium sulphate have been mentioned in recent study research in combination with a local anaesthetic. It blocks NMDA channels in a voltage-dependent way and produces a reduction of NMDA-induced currents (18).

Most of the patient population was above 40 years of age with a higher incidence of the orthopaedic lower limb and gynaecological surgeries in those above 40 years.The time taken for the sensory level to reach the T10 block was significantly lower with group D compared to the other two groups. Similar findings were seen in the study by Shahi V et al., magnesium sulphate and dexmedetomidine were used as an adjuvant with the epidural (15).

Compared to the control and magnesium group, 0.5 mcg/kg of dexmedetomidine when used as an additive to epidural bupivacaine prolonged the duration of sensory blockage, so the time taken for the first epidural top-up was significant. The dexmedetomidine group had the longest interval followed by the magnesium group while the control group of patients had the shortest interval. Zhang X et al., did a systematic review and meta-analysis of 12 randomised controlled trials and found that epidural dexmedetomidine administration prolonged the duration of analgesia (19). The study by Kaur S et al., showed that 1mcg/kg dexmedetomidine along with 0.75%ropivacaine, prolonged sensory analgesia with a time duration of (496.56±16.086 min while in our study it was 307.3±77.3 min probably as the dose taken was 0.5mcg/kg dexmedetomidine (20). Comparable values were found in the study done by Karhade SS et al., (21). The rescue analgesia requirement was proven to be less which is supported by Elhakim M et al., where in one lung ventilation for thoracic surgeries epidural dexmedetomidine was used and found that the requirement of paracetamol was minimal (22). The analgesic sparing effect has been proven in several studies (17).

The motor blockade was assessed by the Modified Bromage scale. Dexmedetomidine has a visible edge over magnesium sulphate as it enables the establishment of prolonged motor block. The time for regression from modified Bromage level 3 was longest in the group D followed by the group M and shortest in the group C. It correlates with the study by Gupta K et al., where motor blocks were more pronounced in the dexmedetomidine group with 25 mcg given epidurally along with 0.5% levo bupivacaine (23). The delayed recovery of motor function proves to be a disadvantage for its use in daycare surgeries this was supported Shahi V et al., (15) where prolongation of motor block was observed. The prolongation of motor block may be due to the binding of alpha-2 adrenoreceptor agonist to the motor neuron of the dorsal horn (24),(25).

In the present study, heart rate and mean arterial pressure were recorded. A mean pulse rate of 59.7 at 20 minutes was observed in the group D but it did not require any intervention in the intraoperative period, hence it was clinically insignificant. This is in accordance with a meta-analysis conducted in 2021 by Li N et al., (26) where maternal bradycardia was observed in the 8 randomised control trials were studied. It was found that there was no foetal compromise and hence no intervention was required. Maternal bradycardia was observed from 15 mins to 2 hour time period when dexmedetomidine was given in a fixed range of 50 mcg to all patients by Afandy ME et al., who conducted a study to see the effect of dexmedetomidine when administered in labour analgesia (27).

Group D had the highest sedation score compared to the other two groups but patients showed arousable sedation. It was assessed by sedation scale used in study conducted by Bajwa SJ et al.,(28). Hence occurrence of respiratory depression was minimal. Shivering was observed more in the group C than the other two groups as known dexmedetomidine inhibits neuroendocrine and haemodynamic response at the central and spinal levels. Magnesium also decreases shivering but the mechanism is still under research. The most probable mechanism being after administration of epidural, the vasoconstriction developed is counteracted by the vasodilatory property of magnesium (29),(30).

Limitation(s)

ASA I and II patients were included and hence the effect of dexmedetomidine in elderly with severe cardiovascular co-morbidity has yet to be studied. Magnesium was used on a fixed dose and dose variability and the impact was not studied.

Conclusion

To conclude, 0.5 mcg/kg of dexmedetomidine added to epidural bupivacaine has shown to be a better agent in prolonging the motor and sensory block intraoperatively. It also prolonged the the duration of effective postoperative analgesia with good arousable sedation and clinically insignificant bradycardia as side effects compared to magnesium sulphate.

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DOI and Others

DOI: 10.7860/JCDR/2023/60381.17401

Date of Submission: Sep 22, 2022
Date of Peer Review: Nov 18, 2022
Date of Acceptance: Dec 24, 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. No

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Sep 28, 2022
• Manual Googling: Dec 03, 2022
• iThenticate Software: Dec 20, 2022 (20%)

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