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

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On Sep 2018




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On Sep 2018




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"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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Saraswati Dental College
Lucknow
On Sep 2018




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Calcutta National Medical College & Hospital , Kolkata




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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.
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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.
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.
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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 : June | Volume : 17 | Issue : 6 | Page : UC06 - UC10 Full Version

Comparison of Dexmedetomidine and Fentanyl as an Adjuvant to Ropivacaine in Ultrasound-guided Supraclavicular Brachial Plexus Block: A Prospective Observational Study


Published: June 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/62570.18031
Aavani Sanjeevan, V Rajanigandha, A Harikumar

1. Senior Resident, Department of Anaesthesia, Government Medical College, Kottayam, Kerala, India. 2. Additional Professor, Department of Anaesthesia, Government Medical College, Kottayam, Kerala, India. 3. Associate Professor, Department of Anaesthesia, Government Medical College, Kottayam, Kerala, India.

Correspondence Address :
Dr. Aavani Sanjeevan,
Sreepadmam, Choottayil, Kilimanoor P.O, Thiruvananthapuram-695601, Kerala, India.
E-mail: aavanisanjeevan@gmail.com

Abstract

Introduction: Upper limb surgeries are mostly performed under supraclavicular brachial plexus blocks which provide intraoperative and postoperative analgesia. Ultrasound provides clinicians with real-time images which are useful for better identification of the anatomical structures, safe needle placement, and adequate local anaesthetic spread. Adding adjuvants to local anaesthetic drugs prolong the duration of anaesthesia without concomitantly increasing the risk of complication.

Aim: To compare fentanyl and dexmedetomidine when added as an adjuvant to ropivacaine for Ultrasound-guided supraclavicular brachial plexus block.

Materials and Methods: A prospective observational, double-blinded study was conducted in the Department of Anaesthesia, at Government Medical College, Kottayam, Kerala, India, on 52 patients undergoing orthopaedic upper limb surgeries over a period of one year from April 2019-March 2020. Patients were divided into two groups of 26 subjects each. Group A received ropivacaine 0.5% (20 mL)+dexmedetomidine 1 mcg/kg and group B received ropivacaine 0.5% (20 mL)+Fentanyl 1 mcg/kg. Onset, time to complete sensory and motor block, duration of sensory and motor block, duration of analgesia, adverse effects and haemodynamic status were monitored. Statistical analysis was done using t-test and Chi-square test.

Results: The demographic variables, onset of sensory and motor block were comparable in both the groups. Mean duration of sensory block in group A and B were 638.08±52.001 minutes and 568.85±36.478 minutes, respectively. The mean duration of motor block in group A was 605.77±58.8 minutes and group B was 513.46±14.982 minutes. The mean duration of analgesia in group A and B were 722.3±58.13 and 615.00±48.19 minutes, respectively. Mean duration of sensory block, motor block and analgesia were found more in group A which was statistically significant with p-value ≤0.05. There was no significant difference in haemodynamic parameters.

Conclusion: Dexmedetomidine was a better adjuvant to 0.5% ropivacaine as compared to fentanyl in Ultrasound-guided supraclavicular brachial plexus block in terms of duration of sensory block, motor block and analgesia.

Keywords

Local anaesthetics, Peripheral nerve block, Upper limb

Supraclavicular brachial plexus block is widely used for upper limb surgeries because of the anatomical ease of blocking nerve roots at this level. Brachial plexus block provides distinct advantages over general anaesthesia like maintenance of general body physiology, decreases postoperative pain, shorter stay in postoperative care unit, and decreased incidence of postoperative nausea and vomiting (1). The technique of brachial plexus block has evolved from the classical blind paresthesia technique to the Ultrasound-guided supraclavicular brachial plexus block. The classical approach was associated with a higher failure rate and injury to the nerves and surrounding structures. Ultrasound-guided block offers improved safety and accuracy in identifying the position of nerve to be blocked. Since less total volume of local anaesthetic may be required to produce an effective block, this could reduce the risk of local anaesthetic systemic toxicity (2).

Ropivacaine is a long acting amide with the greatest margin of safety among all local anaesthetics (3). Compared to bupivacaine, ropivacaine is less cardiotoxic. However, the benefits of a brachial plexus block may not persist, if the local anaesthetics used have a limited duration of action. The limited duration of the local anaesthetics used for brachial plexus block may lead to the need for general anaesthesia. This can present difficulties during the surgical procedure, especially, when the patient is positioned laterally. Continuous catheter based nerve blocks provide very good postoperative analgesia, but their placement requires additional time, cost and skill. Drugs like dexmedetomidine and fentanyl were employed as adjuvants for faster onset, denser block and for prolonging peripheral nerve blockade. Dexmedetomidine, a selective centrally acting alpha 2 agonist results in profound prolongation of duration of peripheral nerve blockade (4). Opioids were widely known to have an analgesic effect at the central and spinal cord level. Studies conducted by Rajkhowa T et al., and Magistris L et al., have shown that, the addition of fentanyl can extend the duration of a brachial plexus block (5),(6). There are limited studies comparing the use of fentanyl and dexmedetomidine with ropivacaine. Considering the minimal side-effects and excellent postoperative analgesia of two drugs, it is essential to carry out a comparative evaluation of these drugs as an adjuvant to Ultrasound-guided supraclavicular brachial plexus block. The main objective of the present study was, to compare these drugs in terms of onset time, duration of sensory block, motor block and analgesia, adverse effects and haemodynamic stability.

Material and Methods

A prospective observational, double-blinded study was conducted at Government Medical College, Kottayam, Kerala, India, for a period of one year, from April 2019 to March 2020, after obtaining approval from the Institutional Review Board with IRB No: 42/2019.

Inclusion criteria:

• Patients scheduled for orthopaedic forearm surgeries
• Age 18-60 years
• American Society of Anaesthesiologists (ASA) physical status I and II
• Patient with informed written consent.

Exclusion criteria:

• Patients with hypersensitivity to local anaesthetics
• Pre-existing peripheral neuropathy
• On adrenoreceptor agonist/antagonist therapy;
• Bleeding disorders.

Sample size calculation: By considering alpha error of 0.05 and power of study >80%, the sample size was calculated based on the mean and standard deviation of the parent study by Cham SC et al., using the formula (7):

N=2σ2(Zα+Zβ)/ (μ1-μ2)2

Pooled variance (σ2)=S12(n1-1)+S22(n2-1)/ n1+n2-2

Za=Value of Z at 5% a error=1.96
Zb=Value of Z at 20% b error=0.84
Sample size,

N= 2×(0.13)2×(1.96+0.84)2/ 58
=50.96

Study Procedure

The patients were randomly allocated into two groups of 26 each based on computer generated random number slips. Group A received injection ropivacaine 0.5% (20 mL)+Dexmedetomidine 1 mcg/kg (maximum 50 mcg) and group B received ropivacaine 0.5% (20 mL)+Fentanyl 1 mcg/kg (maximum 50 mcg). Total volume of drug was kept constant (20.5 mL) (8) in both the groups to achieve blinding. The drug solution was prepared by an anaesthesiologist, who was not involved in the conduct of the case and recording the observations. Both the primary assessor and the patient were blinded to the study drug used. During the preanaesthetic check-up, the patients were provided with a detailed explanation of the procedure and the Visual Analogue Scale (VAS) for pain was explained to them in their local language. The patients were instructed to maintain a six hour fast prior to the surgery and premedicated with midazolam 0.02 mg/per/kg intravenously one hour before the commencement of surgery.

On arrival to the operation theatre, baseline pulse rate, blood pressure, peripheral oxygen saturation were recorded, an 18 G canula was inserted and normal saline was started as intravenous (i.v.) fluid. Patient was positioned and brachial plexus identified. Under all aseptic precautions, the injection site was infiltrated with 1 mL of 2% lignocaine intradermally and subcutaneously. Brachial plexus was approached using 22 G stimuplex ultra 55 mm long needle (in plane needle approach) through the lignocaine infiltrated skin. A 20.5 mL drug solution was given according to the group assigned and negative aspiration was performed before every 3 mL to avoid intravascular injection. All patients were supplemented with oxygen at 4 litre/minute via simple face mask throughout the procedure. Heart Rate (HR), Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP) and oxygen saturation (SpO2) was monitored every 15 minutes in the first hour and then every 30 minutes upto four hours. Bradycardia is defined as HR below 50 beats/min and was managed with atropine 0.6 mg. Hypotension is defined as lowering of mean Blood Pressure (BP) below 20% of initial base 7line value. Respiratory depression was defined as respiratory rate <8 breaths/min.

Sensory blockade was assessed by loss of sensation to pinprick over the C5-T1 dermatomes using a three-point scale (0- Normal sensation, 1- loss of sensation of pin prick/analgesia, 2- loss of sensation of touch/anaesthesia), every two minute till the onset of loss of touch and then every 30 minutes till the regain of sensation (9). The sensory onset time refers to the duration from the cessation of local anaesthetic delivery to the point at which a score of 1 is observed on a three-point scale. Time to complete sensory blockade was the interval between local anaesthetic administration and establishment of score 2 on the three-point scale in all dermatomes. Duration of sensory blockade was defined as the time interval between the end of local anaesthetic administration and complete resolution of anaesthesia (score 0 on the three-point scale in all nerve areas) (10).

Motor blockade was assessed using Modified Bromage Scale for upper limb (0- normal motor function with full flexion and extension of elbow, wrist and finger, 1- decreased motor strength with ability to move fingers only, 2- complete motor blockade with inability to move fingers (11). Onset of motor block was the time interval between local anaesthetic administration and establishment of score 1 on bromage scale. Time to complete motor block was defined as the absence of voluntary movements in hand and forearm (score 2 on bromage scale). The period of time between administering the local anaesthetic and recovery of complete motor function of hand and forearm was defined as the duration of the motor block (score 0 on bromage scale). Duration of analgesia was defined as the time interval between supraclavicular brachial plexus block administration and the onset of pain, VAS score >5. VAS-on a scale of 0-10, the patient was asked to quantify postoperative pain (0- no pain, 10- maximum/worst pain). Injection tramadol 50 mg intravenously was administered if VAS score reaches 5. Patients were also observed for any adverse effects, such as nausea, vomiting, hypotension, bradycardia, pruritis, Horner’s syndrome, recurrent laryngeal nerve palsy, pneumothorax, and respiratory depression. However, if any patient had incomplete block (sensory anaesthesia is not achieved within 30 minutes) or complained of discomfort/pain intraoperatively, then they were converted to general anaesthesia and block was considered as inadequate block. The distribution of study participants is shown in (Table/Fig 1).

Statistical Analysis

The data obtained were entered into a Microsoft excel datasheet and analysis done using Statistical Package for the Social Sciences, (SPSS) version 19.0. Categorical variables were represented as number and percentage and continuous variables as mean and standard deviation. Qualitative variables were analysed using Chi-square test and quantitative variables using t-test. The p-value ≤0.05 was considered statistically significant.

Results

Demographic variables like age, gender, weight, ASA were compared in both the groups. In group A, 38.46% of the individuals were females, while in group B, the proportion of females was 42.31%. ASA I patients in group A was 65.38% and group B was 61.54%. Differences in age distribution, gender, ASA physical status and weight distribution in group A and B were not statistically significant (Table/Fig 2).

In the present study, it was found that, duration of sensory block motor block and analgesia was significantly higher in patients who received a combination of ropivacaine and dexmedetomidine than the combination of ropivacaine and fentanyl. Mean duration of sensory block in group A was 638.08±52.00 minutes and in group B was 568.85±36.48 minutes. The mean duration of motor block was prolonged in group A compared to group B. The mean duration of analgesia in group A was 107 minutes higher than group B. All the above differences were statistically significant with a p-value <0.001 (Table/Fig 3).

The onset of sensory block and mean time for onset of sensory block were early in group B compared with group A, but statistically not significant with p-value of 0.785 and 0.690, respectively. The mean time for onset of sensory block was seven minutes prolonged in group A compared to group B. The onset of motor block and mean time to complete motor blockade were early in group B compared with group A but statistically not significant with p-value more than 0.05 (Table/Fig 3). The incidence of side-effects was low and compared between the groups (Table/Fig 4). Incidence of hypotension was 3.8% (1/26) in group A and nil in group B (p-value=0.313). Bradycardia only occurred in group A (7.7%). Nausea and pruritus were seen in 1/26 (3.8%) and 2/26 (7.7%) in group B (p-value >0.05). No major complications like pneumothorax, respiratory depression and Horner’s syndrome and recurrent laryngeal nerve palsy were reported.

Although, the use of dexmedetomidine as an adjuvant resulted in a greater decrease in HR and BP from baseline compared to fentanyl. By comparing heart rate between groups there was statistically significant difference (p-value ≤0.05) in HR in 30, 45, 60, 90, 120, 150, 180 and 210 minutes. At the beginning of surgery HR was comparable among groups. At 240 min, heart again becomes comparable with p-value=0.868 (Table/Fig 5).

By comparing SBP between groups there was statistically significant difference (p-value ≤0.05) only at 210 minute. At the beginning of surgery SBP was comparable among groups. There was no significant difference between SBP during surgery (Table/Fig 6). During entire period of the study, DBP and oxygen saturation were comparable between groups and the difference was not statistically significant with (p-value ≤0.05).

Discussion

Dexmedetomidine 1 mcg/kg, when used as an adjuvant to 0.5% ropivacaine 20 mL in an ultrasound guided supraclavicular brachial plexus block, is superior to fentanyl 1 mcg/kg in terms of sensory block duration, motor block duration, and analgesia. Both groups were similar in terms of demographic variables such as age, gender, weight, and ASA. The study found that, the use of dexmedetomidine as an adjuvant resulted in a significantly longer duration of sensory block compared to the use of fentanyl, with a p-value=0.001. This result was consistent with study by Esmaoglu A et al., (12), using 40 mL levobupivacaine 0.5% and dexmedetomidine 100 mcg compared to plain levobupivacaine in axillary brachial plexus block. Dexmedetomidine 50 mcg with 30 mL bupivacaine 0.33% also showed significantly prolonged duration of sensory block in the study by Ammar AS and Mahmoud KM (13).

A statistically significant difference was observed in the mean duration of motor block between group A and group B. This finding correlates with study done by Kathuria S et al., and Das A et al., using 0.5% ropivacaine 30 mL with or without 50 mcg dexmedetomidine (14),(15). The presence of alpha-2 receptors in the brachial plexus caused a longer duration of sensory and motor block when dexmedetomidine was administered through a block, as opposed to intravenous administration as per Kathuria S et al., (14). Masuki S et al., suggested that dexmedetomidine induces vasoconstriction around the site of injection via alpha-2 receptors in human forearm thus, delaying the absorption of local anaesthetic and hence, prolonging the effect (16). The study results showed similarity to the study conducted by Sahi P et al., in which the use of 30 mL ropivacaine 0.5%, and ropivacaine in combination with fentanyl and dexmedetomidine, were evaluated for their effectiveness in brachial plexus block (17). Both, dexmedetomidine and fentanyl enhances readiness for surgery. In comparison to fentanyl, the use of dexmedetomidine resulted in a significantly longer duration of both motor and sensory block, as well as, improved postoperative analgesia. The difference was particularly noteworthy when compared to ropivacaine, where the results were highly significant. Dar FA et al., evaluated the effect of adding dexmedetomidine to ropivacaine for axillary brachial plexus blockade in 80 patients scheduled for elective forearm and hand surgeries (18). When dexmedetomidine was added sensory and motor block onset times were shorter but sensory and motor blockade durations were longer along with duration of analgesia.

Duration of sensory and motor block was also prolonged in the comparative study of the efficacy of dexmedetomidine and fentanyl as adjuvants to ropivacaine in ultrasound-guided supraclavicular brachial plexus block by Shivalgond P et al., (19). According to the statistical analysis, there was a significant difference in the duration of sensory blockade between the patients who received dexmedetomidine and those who received fentanyl with a p-value=<0.001. Specifically, the duration of sensory blockade was 801.75±46.07 minutes for the dexmedetomidine group, and 590.25±40.41 minutes for the fentanyl group. The duration of motor blockade was also highly statistically significant with 649.56±42.73 minutes in dexmedetomidine group compared to 456.75±32.93 minutes in fentanyl group. Similar results were also obtained by the study by Cham SC et al., in which 30 mL ropivacaine 0.5% alone, 50 mcg fentanyl or 50 mcg dexmedetomidine to ropivacaine were used for supraclavicular brachial plexus block (7). The addition of adjuvant enhanced the onset of block and also increased duration of surgical anaesthesia with prolongation of postoperative analgesia. The total duration of analgesia was significantly increased in dexmedetomidine group (by 2 and half hour) compared to fentanyl group. Wang RD et al., explains the advantages of ropivacaine over bupivacaine which includes greater sensorimotor differential block, increased cardiovascular safety and shorter elimination half life with a lower potential for accumulation (20). Kathuria S et al., found that adding dexmedetomidine to 0.5% ropivacaine in ultrasound-guided brachial plexus block had several effects (14). Specifically, this combination shortened the onset time of both sensory and motor blocks, prolonged the duration of both sensory and motor blocks, and increased the overall duration of analgesia. Esmaoglu A et al., in their study on brachial plexus block described significant bradycardia when 100 mcg dexmedetomidine was added as adjuvant (21). Hence, a dose of 100 mcg was not used for the study. Also, 25 mcg dexmedetomidine showed no sedative effect when used as an adjuvant in brachial plexus block as found by Sudani C et al., (22). Since, the unwanted side-effect of dexmedetomidine (bradycardia) was not desired and also the added advantage of a conscious sedation is desirable, the authors used 1 mcg/kg of dexmeditomidine in the present study.

Farooq N et al., compared the efficacy of fentanyl and dexmedetomidine as adjuvant to ropivacaine among patient undergoing upper limb surgeries in their study (23). Unlike the present study they stated that 3 mg/kg of 0.75% ropivacaine along with 1 μg/kg of fentanyl diluted with normal saline to make a total volume 35 mL were shown to be the most effective combination for brachial plexus block in patients having upper limb orthopaedic surgery. The results were analysed in terms of the onset time for both sensory and motor blockade, duration of sensory and motor blockade and duration of analgesia. While comparing side-effects like hypotension, bradycardia, pruritus, nausea, vomiting, respiratory depression, Horner’s syndrome, pneumothorax and recurrent laryngeal nerve palsy between the groups, no statistically significant difference was there. According to Perlas A et al., ultrasound-guided supraclavicular block is associated with a high rate of successful surgical anaesthesia and low rate of complications like pneumothorax and Horner’s syndrome (24).

Limitation(s)

The study did not follow-up patients with a postoperative chest radiograph to rule out asymptomatic pneumothorax. Study included patients aged 18-60 years and belonging to ASA I and II status, the efficacy of both the adjuvants are not validated in old, as well as, non ASA I and II patients. However, further research is needed to determine the optimal dosing and safety profile of dexmedetomidine for this use, as well as, to compare its efficacy to other adjuvants or local anaesthetics. Overall, dexmedetomidine has potential as a future consideration for improving the efficacy and safety of supraclavicular block in upper limb surgeries.

Conclusion

The supraclavicular block is a reliable and rapid onset method of brachial plexus block for anaesthesia of the upper limb. Dexmedetomidine 1 mcg/kg is a better adjuvant to 0.5% ropivacaine 20 mL in Ultrasound-guided supraclavicular brachial plexus block in terms of duration of sensory block, motor block and analgesia compared to fentanyl. Dexmedetomidine appears to be a promising drug for supraclavicular block in upper limb surgeries.

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DOI and Others

DOI: 10.7860/JCDR/2023/62570.18031

Date of Submission: Jan 01, 2023
Date of Peer Review: Feb 09, 2023
Date of Acceptance: May 02, 2023
Date of Publishing: Jun 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 CHECKING METHODS:
• Plagiarism X-checker: Jan 02, 2023
• Manual Googling: Apr 19, 2023
• iThenticate Software: Apr 28, 2023 (19%)

ETYMOLOGY: Author Origin

EMENDATIONS: 7

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