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

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Dr Mohan Z Mani

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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."



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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.
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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 : June | Volume : 17 | Issue : 6 | Page : UC19 - UC23 Full Version

Postoperative Analgesic Efficacy of Low Dose Intravenous Dexmedetomidine and Intraperitoneal Dexmedetomidine with Bupivacaine in Patients undergoing Laparoscopic Cholecystectomy: A Randomised Prospective Study


Published: June 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/63549.18044
Lakshmi Sowjanya Chandra, Anusha Suntan, Santosh Alalamath, Vijay V Katti

1. Junior Resident, Department of Anaesthesia, Sri BM Patil Medical College and Hospital, BLDE, Vijayapura, Karnataka, India. 2. Assistant Professor, Department of Anaesthesia, Sri BM Patil Medical College and Hospital, BLDE, Vijayapura, Karnataka, India. 3. Assistant Professor, Department of Anaesthesia, Sri BM Patil Medical College and Hospital, BLDE, Vijayapura, Karnataka, India. 4. Associate Professor, Department of Anaesthesia, Sri BM Patil Medical College and Hospital, BLDE, Vijayapura, Karnataka, India.

Correspondence Address :
Dr. Vijay V Katti,
Associate Professor, Department of Anaesthesia, Sri BM Patil Medical College and Hospital, BLDE, Vijayapura-586103, Karnataka, India.
E-mail: drvijaykatti@gmail.com

Abstract

Introduction: Providing a better analgesia in the postoperative period improves the overall outcome in any surgical procedure in terms of better patient satisfaction, early recovery and shorter hospital stay. Multimodal analgesia using α 2 agonists like clonidine and dexmedetomidine along with local anaesthetics via intraperitoneal route had been proved to provide better analgesia in laparoscopic cholecystectomy.

Aim: To evaluate the postoperative analgesic efficacy of low dose 0.5 μg/kg dexmedetomidine via intravenous (i.v.) and intraperitoneal (IP) route in laparoscopic cholecystectomy.

Materials and Methods: This was a randomised prospective study carried out in the Department of Anaesthesiology at BLDE (Deemed to be University) Shri BM Patil Medical College, Hospital, and Research Centre, Vijayapura, Karnataka, India from December 2020 to September 2022. The study comprised of 99 patients of either gender, with American Society of Anaesthesiologists (ASA) Grade-I or II, were randomly allocated into three groups using computer generated randomised slips with 33 in each group (Group IV, Group IP, Group C). Group C (Control) patients received 30 mL of Normal Saline (NS) i.v. and 40 mL of 0.25% bupivacaine IP, Group IV patients received 0.5 μg/kg dexmedetomidine infusion i.v. in 30 mL NS over 10 minutes and 40 mL of 0.25% bupivacaine, IP. Group IP patients received 30 mL NS IV and 0.5 μg/kg dexmedetomidine in 40 mL of 0.25% bupivacaine IP. The time of rescue analgesia, total consumption of diclofenac in 24 hours, Visual Analogue Scale (VAS) pain score at 0.5, 1, 2, 4, 6, 12, 24 hours was compared among the three groups. Side-effects of the study drugs especially hypotension and bradycardia were monitored. All the data was analysed using statistical tests (Independent t-test, Kruskal-Wallis test, Chi-square test). The p-value was found to be statistically significant (p<0.005).

Results: The VAS score was found to be consistently high in control group at all given time intervals, and significantly low in both i.v. and IP groups which were comparable. The Group IV had the longest mean time for rescue analgesia (180.91±41.617 minutes), followed by the Group IP (106.06±8.269 minutes), and the Group C (55.00±6.960 minutes). The consumption of total rescue analgesic (diclofenac) was determined to be highest in the Group C (241.82±30.767 mg) and lowest in the Group IP (115.30± 30.896 mg).

Conclusion: The total consumption of diclofenac and VAS score was less in intraperitoneal dexmedetomidine was found to be effective in producing postoperative analgesia and can be considered as an effective alternative.

Keywords

Adrenergic α-2 receptor agonists, Opioids, Visual analogue scale

In recent times, laparoscopic cholecystectomy has surpassed open operation in terms of popularity, as a result of the numerous benefits that it offers. Despite the fact that it offered a number of benefits, postoperative discomfort had been a major cause for concern, not only for the operating surgeon but also for the patient, in terms of a slow recovery, poor patient satisfaction and an extended stay in the hospital (1). Not only does anaesthesia management involve intraoperative patient care, but it also involves improved postoperative patient care, which makes the recovery phase pain-free and more propitious for the patient (1),(2). In order to accomplish this goal, a wide variety of multimodal analgesia approaches were utilised in the study. Dexmedetomidine is a highly selective α-2 receptor agonist with opioid-sparing, analgesic, sedative, amnestic and sympatholytic properties (3),(4),(5). Recent studies have investigated the use of dexmedetomidine infusions in low dose in laparoscopic cholecystectomy, ranging between 0.2-0.4 μg/kg/hour.

In these investigations, the reduction of postoperative pain was considered as a secondary objective to the primary focus, which was dampening of haemodynamic response. It was established that IP instillation of α 2 agonists such as dexmedetomidine/clonidine and local anaesthetics like bupivacaine/ropivacaine was successful in giving superior postsurgical analgesia after being tried in a large number of patients (1),(2),(3),(4). The efficacy of dexmedetomidine in postoperative analgesia had been successfully demonstrated in other surgical procedures like gynecological laparoscopy (6) postcesarean sections (7), in paravertebral blocks for modified radical mastectomy procedures (8).

The aim of the study was to compare the postoperative analgesic efficacy of a combination of either a low dose i.v. dexmedetomidine (0.5 μg/kg) with IP bupivacaine, or an IP dexmedetomidine (0.5 μg/kg) with bupivacaine with IP bupivacaine alone in patients undergoing laparoscopic cholecystectomy.

Material and Methods

This randomised prospective study was conducted at the Department of Anaesthesiology, BLDE (deemed to be University) Shri BM Patil Medical College, Hospital, and Research Centre, Vijayapura, Karnataka, India from December 2020 to September 2022. The study comprised of a total of 99 patients posted for laparoscopic cholecystectomy. A written informed consent was obtained from all subjects after obtaining approval from the Institutional Ethical Committee (IEC) (IEC/NO-09/2021). This study had been registered with Clinical Trials Registry-India (CTRI/2022/04/041648).

Inclusion criteria: Patients who had been scheduled for laparoscopic cholecystectomy with ASA Grade-I or II, between the age of 18 to 60 years were included in the study.

Exclusion criteria: Patients with impaired kidney or liver functions, neurological and mental illness, heart blocks, Body Mass Index (BMI) >30 kg/m2, patients who were using antihypertensive medication such as α2 agonists like clonidine. If the surgical procedure ends in an open cholecystectomy, such cases were excluded from the study.

Sample size calculation: The formula used to calculate the sample size was

N=2[(zα+zβ)*s/d]2

where Z?=95% which is level of significance,

zb=80% which is power of the study,=clinically significant difference between two parameters, SD=common standard deviation (1). The anticipated Mean±SD of VAS score at 0.5 hour of time interval in the control group was 4.36±2.08 and Group IV was 2.56±1.64, respectively (1). The required minimum sample size was 33 per group (i.e., a total sample size of 99, assuming equal group sizes) to achieve a power of 80% and a level of significance of 1% (two-sided) for detecting a true difference in means between two groups.

Out of 130 patients included in the study based on the inclusion criteria, 106 patients were enrolled and 24 patients who have not met the inclusion criteria were excluded from the study. Out of 106 patients three patients in Group IV, two patients each in Group IP and Group C, since the procedure had been converted to open cholecystectomy were excluded from the study and 99 patients were included with 33 patients in each group (Table/Fig 1).

Study Procedure

Comprehensive patient history, a thorough physical examination, and the patient’s vitals were checked during the preoperative appointment. Inquiries were made regarding the presence of any serious illnesses in the patient’s past. Concerns pertaining to the airway, the respiratory system, and the cardiovascular system were examined thoroughly. A 0.25 milligrams (mg) of alprazolam was given orally the night before surgery to ease the anxiety of the patients. Patients were instructed on how to utilise the VAS during their preanaesthetic evaluation (VAS score 0: none, 1-3: mild pain, 4-6: moderate pain, 7-10: severe pain). All patients were kept nil per oral as per ASA guidelines for six hours prior to the procedure and were explained about its need to be followed-up for atleast 24 hours after surgery. Ninety nine patients recruited for the study were randomly allocated by computer-generated slips into three groups of 33 patients in each group. An i.v. cannula of 18/20 gauge was secured preferably on the right arm or forearm.

After shifting the patient on to operation table, a multi-parameter monitor was attached to record the patient’s Electrocardiogram (ECG), Non Invasive Blood Pressure (NIBP), pulse rate, respiratory rate and oxygen saturation (SpO2) levels. An i.v. infusion of Ringer’s lactate solution at a rate of 10 mL/kg/hour was initiated. Premedication was given using inj. glycopyrrolate 5 μg/kg, inj. ondansetron 0.15 mg/kg, inj. midazolam 0.025 mg/kg and fentanyl 2 μg/kg. Following preoxygenation with 100% oxygen, the patients were induced with propofol 2 mg/kg and to facilitate endotracheal intubation inj. atracurium 0.5 mg/kg was administered. Anaesthesia was maintained with oxygen (O2) 50%, nitrous oxide (N2O) 50%, isoflurane 0.8-1% and bolus doses of atracurium 0.1 mg/kg was administered on an intermittent basis thereafter. Monitoring of the patient’s vitals was performed three minutes after intubation, immediately after the creation of pneumoperitoneum and at regular intervals of 10 minutes thereafter. After the gall bladder was removed, the study solution was administered intravenously and intraperitoneally in respective groups gradually over a period of 10 minutes. In Group C, patients had received 30 mL of NS i.v. and 40 mL of 0.25% bupivacaine IP. Group IV patients were given 0.5 μ μg/kg dexmedetomidine i.v. and 40 mL of 0.25% bupivacaine IP. In Group IP, patients received 30 mL of NS i.v. route and 0.5 μg/kg dexmedetomidine in 40 mL of 0.25% bupivacaine IP (Table/Fig 2).

At every 5-minute interval until tracheal extubation, intraoperative monitoring for haemodynamic parameters like pulse rate, Mean Arterial Blood Pressure (MAP), saturation (SpO2) and End Tidal Carbon Dioxide (ETCO2) were done.

Before the removal of the trocar in Trendelenburg’s position, the respective study solution to be given was injected into the hepato-diaphragmatic space, on the gall bladder bed, near and above the hepatoduodenal ligament. CO2 was evacuated by manual abdomen compression at the end of surgery with open trocars. Patients were extubated after adequate reversal of muscle relaxation with i.v. neostigmine 0.05 mg/kg and glycopyrrolate 0.01 mg/kg.

Any changes in the haemodynamic parameters during intraoperative period, such as hypotension were managed with bolus doses of inj. mephentermine (3-6 mg) i.v. or Ringer lactate solution (100 mL) and incidences of bradycardia were treated with inj. atropine 0.6 mg i.v. The occurrence of any unwanted side-effects, such as nausea, vomiting, pruritis, urine retention was recorded and handled appropriately. Patients were shifted to the post anaesthesia care facility following surgery. Assessment of severity of pain at 0.5, 2, 4, 6,12 and 24 hours was done using VAS score following surgery. When patients complained of pain or VAS ≥4 for the first time after surgery, inj. diclofenac 2 mg/kg was administered as a rescue analgesic. The duration of analgesia and total rescue analgesic usage for the first 24 hours was recorded.

Statistical Analysis

Statistical Package for the Social Sciences (SPSS) version 20.0 was used for the statistical analysis. The data was presented as mean, standard deviation, number, and percentage (%). The post-hoc analysis approach was used to analyse the data. Tukey’s test was used to calculate the intergroup p-value, and Analysis of Variance (ANOVA) was used to calculate the cumulative p-value. Normally distributed data was analysed using an unpaired Student’s t-test. The Chi-square test was used to compare non parametric data, with a p-value provided at 95% confidence level. A p-value <0.05 was regarded as statistically significant.

Results

Upon analysis, all three groups were found to be comparable with respect to the demographic data and the findings were statistically not significant (Table/Fig 3).

The mean time to first rescue analgesia was found to be highest in the Group IV (180.91±41.617) followed by Group IP (106.06±8.269). Upon doing intergroup analysis, this difference was found to be statistically significant between Group C and Group IV and between Group IV and Group IP (Table/Fig 4). The mean diclofenac consumption in 24 hours was found to be lowest in Group IP (115.30±30.896) followed closely by Group IV (119.24±40.372).

In the postoperative period, at 0.5 hours, one hour, six hours, 12 hours and 24 hours the VAS score was found to be significantly low in Group IP (3.48±0.508) and Group IV (4.21±0.696) as compared to the Group C (3.79±0.415). However, at two hours the VAS score was comparable between Group IV and Group IP (3.52±0.508) and at four hours it was slightly high in Group IP (3.58±0.502) than in Group IV (3.36±0.489) (Table/Fig 5)a,b. Upon comparing the intraoperative vital parameters, soon after the removal of gallbladder at an interval of five minutes, thereafter till the release of pneumoperitoneum and after giving study drug, the results were found to be statistically insignificant (Table/Fig 6),(Table/Fig 7),(Table/Fig 8),(Table/Fig 9). With respect to intraoperative haemodynamic parameters Group IV had shown better results, followed closely by IP group.

Two patients in the Group IV had an episode of bradycardia during the intraoperative period which was treated accordingly. No episodes of hypotension, bradycardia, nausea and vomiting were observed in Group IP or Group C.

Discussion

Intraperitoneal instillation of drugs had been in practice for quite some time in laparoscopic surgeries. Most of the studies had emphasised on the role of dexmedetomidine as an i.v. agent but very few literature is available on IP dexmedetomidine. Patients who have had laparoscopic cholecystectomy have more than one mechanism at play when it comes to the production of nociception after the procedure. There are several possible causes, such as trauma from abdominal incisions that destroy somatic free nerve endings, parietal peritoneal distention, disturbance of visceral nerve endings in the gallbladder bed, discharge of endogenous pro-inflammatory molecules, discomfort of the phrenic nerve, irritation of the peritoneum brought on by blood, bile spillage, or carbon-dioxide, and somatoform or psychogenic causes (9),(10). The primary benefits of local instillation may be their rapid nociceptive suppression of free nerve endings injured in the gallbladder bed, their progressive peritoneal uptake into the systemic circulation, and their lack of systemic toxicities associated with direct systemic administration. All these factors combine to produce the preference for local instillation over targeted systemic administration (11),(12),(13),(14).

Dexmedetomidine when used at low dose infusions is effective in reducing the requirements of both i.v. induction agents and inhalational agents (2). It helps in a better postoperative cognitive function in the postoperative period especially in the elderly (3). Park HY et al., and Bhattacharjee DP et al., in their study found that i.v. dexmedetomidine at modest doses of 0.3 and 0.2 μg/kg/hour respectively had better haemodynamics throughout the pneumoperitoneum phase (12),(13). However, neither study assessed the analgesic effectiveness of dexmedetomidine. Swaika S et al., compared the same using IP paracetamol with dexmedetomidine and found better intraoperative haemodynamics and postoperative sedation with dexmedetomidine group (15). In the present study, the intraoperative haemodynamic variables such as pulse rate, blood pressure, SpO2 were found to be statistically insignificant among all the three study groups. The major activity of Alpha2-Adrenergic Receptors (α2AR) agonist effect of dexmedetomidine in the heart is a reduction in tachycardia (through inhibiting cardioaccelerator nerve) and bradycardia (via α2A-AR) (through a vagomimetic action). There is sympatholysis-mediated vasodilation and smooth muscle cell receptor-mediated vasoconstriction in the peripheral vasculature (16).

Chilkoti GT et al., study they used a similar dose (0.5 μg/kg) of dexmedetomidine as used in this study and found that IP dexmedetomidine is equally efficacious as i.v. with no incidence of side-effects like nausea, vomiting, bradycardia or hypotension (1). Current study also had equivalent findings. In similar research by Ahmed B et al., meperidine was compared with dexmedetomidine IP in conjunction with bupivacaine and concluded that not only better analgesia but there was decrease incidence in shoulder tip pain in dexmedetomidine group which was not assessed in present study (17).

Dexmedetomidine when used IP induces local analgesia by enhancing hyperpolarisation-activated cation channels, preventing the neuron from recovering to resting membrane potential (7). The considerable benefit of using local anaesthetics and α 2 agonists, like dexmedetomidine, is that they don’t have the negative side-effects of opioids, which include postoperative nausea, drowsiness, a slow recovery of gastrointestinal motility, and pruritis which can prolong the patient’s recovery and ability to leave the hospital and they aid in early resumption of normal bowel function (9).

In an analysis, Vijayaraghavalu S and Sekar EB they gave bupivacaine and NS IP injections to two separate groups of individuals (18). They discovered that patients who received IP bupivacaine after surgery experienced significantly less postoperative pain for the first six hours (p-value=0.04); additionally, it took longer for patients to request rescue analgesia (p-value=0.04), with considerably less shoulder pain (p-value=0.04) than the other group, however side-effects such as nausea and vomiting were comparable across the two groups (p-value=0.1 and p-value=0.09, respectively). In the present study, participants in control group who received only IP bupivacaine did not experience considerable postoperative analgesia.

The sedative activity of dexmedetomidine is mediated by the locus ceruleus of the brain stem, while the analgesic action is mediated by the spinal cord, both of which work via α2A-Adrenergic Receptors (α2AR). The intergroup analysis revealed that the Group IP had a statistically significant lower VAS pain score than Group C. Mean VAS scores were comparable between Group IV and Group IP at all given time intervals. Chilkoti GT et al., however could not find a particular trend in VAS scores between IP and control group in their study (1).

The mean rescue analgesic consumption in 24 hours in the present study was comparable to that of Fares KM et al., who employed IP dexmedetomidine at a two fold dose (1 μg/kg) (19). Similarly, Shukla U et al., concluded that cumulative rescue analgesia in 24 hours was shown to be significantly lower in the IP dexmedetomidine group when compared to the IP tramadol or control groups in patients following laparoscopic cholecystectomy (20).

The current study demonstrated the efficacy of IP instillation of dexmedetomidine in providing analgesia during the first 24 postoperative hours, as evidenced by reduced diclofenac consumption and a relatively low VAS score.

Limitation(s)

Postoperative pain is subjective hence, it is difficult to quantify the accurate pain in study subjects. As the present study was singlecentre research, multicentric investigations are required.

Conclusion

According to the findings of the current research, dexmedetomidine when administered in a low dose of 0.5 μg/kg together with bupivacaine through IP route, was found to be successful in reducing the postoperative VAS score, and the analgesic demand, and can be considered as an effective and safe alternative for postoperative analgesia. Additionally, it helps to attenuate the haemodynamic changes that are involved with having a laparoscopic procedure done. Hence, IP dexmedetomidine can be used as an effective method for postoperative analgesia with the least possible side-effects.

References

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DOI and Others

DOI: 10.7860/JCDR/2023/63549.18044

Date of Submission: Feb 17, 2023
Date of Peer Review: Mar 18, 2023
Date of Acceptance: May 09, 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. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Feb 23, 2023
• Manual Googling: Apr 19, 2023
• iThenticate Software: May 04, 2023 (14%)

ETYMOLOGY: Author Origin

EMENDATIONS: 6

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