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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Case report
Full Version
Anaesthetic Management of Parturient with Severe Mitral Stenosis Planned for Elective Caesarean Section for Safe Confinement
Correspondence Address :
Maitri Patel,
Flat Number 9, Meghe Heights 4, Jawahar Lal Nehru Medical College, Wardha, Maharashtra, India.
E-mail: patelmaitrii26@gmail.com
Perioperative management of pregnant women with cardiac disease is challenging. The physiological cardiac changes that occur during late pregnancy leads to haemodynamic stress to the patient with the cardiac disease during and immediately after parturition. Pregnant women with severe valvular disease do not tolerate haemodynamic changes associated with pregnancy. The choice of anaesthesia technique either general anaesthesia or regional anaesthesia is depending on the haemodynamic goals, cardiac status of the patient, and mode of delivery. A 23-year-old female patient was planned for elective caesarean section for safe confinement. She was an operated case of Balloon Mitral Valvuloplasty (BMV). General anaesthesia was preferred due to the severity of mitral stenosis. Incorporation of epidural analgesia with general anaesthesia provided intraoperatively haemodynamic stability during laryngoscopy, intubation, and extubation. Also, postoperatively analgesia could be achieved due to epidural top-ups. Ultimately, a good perioperative outcome has been achieved due to haemodynamic stability which reduces perioperative morbidity and mortality of the patient.
Haemodynamic changes, Perioperative care, Pregnancy
A 23-year-old G2A1 with 40 weeks of gestation was referred from adistrict hospital. Seven-year-ago, the patient had episodes of haemoptysis and was diagnosed with severe mitral stenosis with a Mitral Valve Area (MVA) of 0.7 cm2 and moderate pulmonary hypertension. The patient underwent BMV. Post BMV echocardiography suggestive of MVA of 1.6 cm2, mitral valve gradient of 6/4 mm of Hg with no mitral regurgitation. A tablet of aspirin 150 mg once a day was advised for 6 weeks. The patient was asymptomatic throughout her current pregnancy. The patient was referred to the pre-anaesthesia clinic for deciding on the perioperative plan of management.
A thorough pre-anaesthetic check-up was done. Her Basal Metabolic Rate (BMI) was of 17.5 kg/cm2 and her Mallampati grade was one. The chest was bilaterally clear and the diastolic murmur was present on auscultation. Preoperative echocardiography was suggestive of severe mitral stenosis (MVA-1.3 cm2), mild mitral and tricuspid regurgitation, left atrial enlargement, and left ventricular ejection fraction was 60%. An elective caesarean section was planned for an American Society of Anaesthesiologist (ASA) class III patient under general anaesthesia with epidural analgesia.
Informed, verbal and written consent was taken. Nil-per-oral was confirmed. Inj. cefotaxime 1 gm was given 30 minutes prior to surgical prophylaxis. Inj. pantoprazole 40 mg was also given. The patient was shifted to the operating room. Monitors were placed and baseline vitals (Heart Rate (HR)- 82/min, Blood Pressure (BP)- 126/78 mm of Hg, and SpO2-100%) were noted. Intravenous access was secured and ringer lactate was started. Urinary catheterisation was done. The invasive arterial was kept ready. Under all aseptic precautions, an epidural catheter of 20G was secured at L3-L4 space and fixed at 9 cm to the skin via using an 18G Tuohy’s needle in the lateral decubitus position. The patient was repositioned slightly by using a left-sided wedge. Inj. Bupivacaine 0.250% of 10 mL was given through an epidural catheter in titrated doses.
Preoxygenation with 100% oxygen was done for 3-4 min. Inj. Glycopyrrolate 0.2 mg was given. Modified rapid sequence induction was performed using inj. Etomidate 22 mg and inj. succinylcholine 100 mcg. The patient was intubated with a 7.0 mm cuffed endotracheal tube. The HR was in the range of 82-90/minutes while BP was in the range of 120/78 to 128/80 mm of Hg during induction of general anaesthesia and intubation. Ringer lactate was given on titrated basis. After the delivery of the baby, oxytocin was started on an intravenous drip slowly at 10 units/hr. The depth of anaesthesia was maintained by oxygen and air 50:50. Inj. fentanyl 100 mcg and inj. atracurium 30 mg was given immediately after delivering the baby. Normocarbia was maintained throughout the period.
At the time of closure, inj. Bupivacaine 0.125% with inj. fentanyl 50 mcg was given for maintaining haemodynamics during and after extubation. At the end of the procedure, the patient started breathing spontaneously. The patient was reversed by using inj. glycopyrrolate 0.04 mg and inj. neostigmine 2 mg i.v. slowly. Extubation was performed without any change in haemodynamics and the patient was shifted to the cardiac care unit for observation with an epidural catheter kept in situ. Postoperatively, inj. bupivacaine 0.125% of 10 mL with inj. fentanyl 25 mcg was given via epidural catheter every 8 hourly for the first 72 hours of the postpartum. The patient was monitored for two days in the cardiac care unit and then transferred to the postnatal ward. The mother and baby were discharged from the hospital on the seventh postoperative day without any perioperative complications.
A normal pregnancy is associated with physiological cardiovascular changes that affect well-being of women with heart disease. If a pregnant patient presented with cardiac disease then the risk of morbidity and maternal mortality is high during the perioperative period. The maternal morbidity and mortality due to cardiac disease depends on the severity of that cardiac disease. Valvular Heart Disease (VHD) in pregnant women can lead to maternal, foetal, and neonatal complications. Pregnant women with severe valvular disease do not tolerate haemodynamic changes associated with pregnancy.
Most of the women who remain asymptomatic throughout their pregnancy can tolerate labour and delivery but, it is poorly tolerated by symptomatic pregnant women with cardiac disease Mitral stenosis contributes to 90% of Rheumatic heart disease in pregnancy (1). In developing countries, due to high prevalence of rheumatic fever cardiac disease complicates 5.9% of pregnancies with high maternal mortality (1). The anaesthesiologist plays an important role in perioperative management because these maternal deaths occur during or immediately following parturition (1).
The choice of anaesthesia technique either general anaesthesia or regional anaesthesia is depending on the haemodynamic goals, the cardiac status of the patient, and the mode of delivery. According to studies, the anaesthetic management of pregnant patients with severe mitral stenosis depends on the cardiovascular status, expertise of an anaesthesiologist, and available treatment options (2). So, there is a need to understand the pathophysiology behind severe mitral stenosis and discuss various anaesthesia techniques to find out a perioperative anaesthetic plan for good maternal and foetal outcomes.
The cardiopulmonary changes in pregnancy during peripartum affect the well-being of women with cardiac disease. The increase in cardiac output during the peripartum period is poorly tolerated by pregnant women with severe mitral stenosis. The heart cannot handle the situations where there is an increase in metabolic demand or blood volume because of the fixed cardiac output state. A pressure gradient that forms between the left atrium and left ventricle during diastole is the key characteristic of mitral stenosis. Pulmonary congestion results from the back pressure on the pulmonary arteries. It can result in pulmonary oedema in extreme circumstances. The risk of pulmonary oedema persists for several days after delivery, irrespective of any mode of delivery due to autotransfusion (3). So, intensive care monitoring is essential during peripartum period. The anaesthetic goals for perioperative management are to maintain normal sinus rhythm, low heart rate, adequate preload and after load, and prevention of factors that lead to pulmonary hypertension like hypoxia, hypothermia, acidosis, and hypercarbia.
The maternal outcome seems to correlate well with the New York Heart Association (NYHA) functional classification (4). The most common maternal complication associated with VHD is heart failure and arrhythmias, while foetal complications are prematurity and intrauterine growth retardation. According to studies, the incidence of maternal cardiac complications correlates with the severity of mitral stenosis (5). Factors like previous history of heart failure, arrhythmia, and transient ischemic attack or stroke, a baseline NYHA class III or more or cyanosis, ejection fraction 40% or less, pulmonary hypertension and severe aortic stenosis are associated with an increase in risk of complications (6).
General anaesthesia was preferred in the index patient due to severity of mitral stenosis. To avoid haemodynamic changes during laryngoscopy and intubation, inj. bupivacaine 0.250% was given via epidural catheter. Etomidate as an induction agent of general anaesthesia is preferred because of its cardioprotective action. For maintaining haemodynamic stability before and during intubation, the short acting beta blockers and opioids can be used. Esmolol is a preferred beta blocking drug but it is associated with foetal bradycardia. Opioids can also be used for stable haemodynamics. However, in one case report, alfentanil provided haemodynamic stability and allowed for immediate postoperative extubation but caused neonatal respiratory depression (7). So, epidural analgesia with general anaesthesia provided haemodynamic stability during laryngoscopy and intubation and the use of opioid and esmolol can be avoided which have effects on foetal outcome.
Adequate depth of anaesthesia was maintained to avoid increase in HR. Inhalation agent was avoided to prevent uterine atony. Oxytocin was given slowly to avoid decrease in Systemic Vascular Resistance (SVR) and Pulse Volume Recording (PVR) that leads to decrease in cardiac output. Ergometrine and prostaglandins analogues were avoided because it is responsible for severe hypertension and tachycardia. For maintaining haemodynamic stability during and after extubation, inj. bupivacaine and inj. fentanyl were given via epidural catheter. Postoperative analgesia was achieved with epidural top ups and the patient was pain free.
Since past two decades, regional anaesthesia in the form of epidural anaesthesia then the spinal anaesthesia proved to be safe technique in cardiac patient came for caesarean section because the total dose of epidural anaesthesia could be titrated to achieve desire sensory level without having noticeable hypotension (6).
Kirti N et al., had used lignocaine and adrenaline to achieve quick onset of epidural blockade in their case study of three patients of severe mitral stenosis (8). Others have used bupivacaine and ropivacaine for epidural anaesthesia (9),(10). Mishra L et al., used lignocaine and adrenaline for both test dose and establishment of epidural block followed by bupivacaine and fentanyl during their case study (11).
Understanding of the physiological changes of pregnancy and the pathological effects of mitral stenosis is necessary for pregnancy with mitral stenosis. The anaesthesiologist an important role for deciding perioperative plan of management. Incorporation of small doses of epidural analgesia to general anaesthesia, avoids the abrupt changes in haemodynamic that normally occurs in pregnancy with mitral stenosis during peripartum period and also provides good anaelgesia. Ultimately, the morbidity and mortality is reduced with good perioperative maternal and neonatal outcome.
DOI: 10.7860/JCDR/2023/61736.17513
Date of Submission: Nov 21, 2022
Date of Peer Review: Dec 23, 2022
Date of Acceptance: Dec 31, 2022
Date of Publishing: Mar 01, 2023
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• 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 CHECKING METHODS:
• Plagiarism X-checker: Nov 28, 2022
• Manual Googling: Dec 28, 2022
• iThenticate Software: Dec 30, 2022 (8%)
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