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

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On Sep 2018




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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
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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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Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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




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Best regards,
C.S. Ramesh Babu,
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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 : UC58 - UC62 Full Version

Spinal Anaesthesia for Ambulatory Perianal Surgeries: A Comparison between Short Acting and Long Acting Local Anaesthetics


Published: June 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/60319.18123
Navin Gandhi, Mohan Sundaram, Ashok Kulasekhar, Subramaniam Anand, Arun Kumar

1. Postgraduate, Department of Anaesthesia, Chettinad Hospital and Research Institute, Chennai, Tamil Nadu, India. 2. Postgraduate, Department of Anaesthesia, Chettinad Hospital and Research Institute, Chennai, Tamil Nadu, India. 3. Head, Department of Anaesthesia, Chettinad Hospital and Research Institute, Chennai, Tamil Nadu, India. 4. Professor, Department of Anaesthesia, Chettinad Hospital and Research Institute, Chennai, Tamil Nadu, India. 5. Professor, Department of Anaesthesia, Chettinad Hospital and Research Institute, Chennai, Tamil Nadu, India.

Correspondence Address :
Dr. Mohan Sundaram,
No. 16A, Kumar Street, Kanchipuram-631501, Tamil Nadu, India.
E-mail: mohanvinoth96@gmail.com

Abstract

Introduction: Chloroprocaine (ester group) is a preservative-free local anaesthetic which is available as isobaric solution. It is being recently popularised in spinal anaesthesia for its shorter duration of action which plays a significant role in the early ambulation and voiding functions, which is the primary essence in ambulatory surgery. Intrathecal Bupivacaine is the most commonly used drug for its block characteristics, taking into account not only the fast initiation of sensory and motor blockade but also faster sensory and motor regression.

Aim: To compare the block characteristics between 1% Chloroprocaine and 0.5% Bupivacaine in patients undergoing perianal surgeries under spinal anaesthesia.

Materials and Methods: This randomised, interventional double blinded study was carried out in Chettinad Hospital and Research Institute, Kelambakkam, Chennai, Tamil Nadu, India, from April 2020 to August 2021. The patients were split into two groups of 34 each. Group 1: Patients received 30 mg of 1% Chloroprocaine intrathecally. Group 2: Patients received 10 mg of 0.5% Bupivacaine intrathecally. In both the groups the onset, duration of both sensory and motor blocks, intraoperative haemodynamic, two segment regression time, time to ambulation and micturition, the time to eligibility for discharge from hospital was evaluated. Independent sample t-test, Chi-square test and Fisher’s-Exact test were employed to compare the distribution of qualitative variables between the groups.

Results: Total of 68 participants 31 (45.6%) males and 37 (54.4%) females), 34 in each group 1 and group 2 were analysed. Both groups contained maximum patients in >45 years age group, 12 (35.2%) in each group. Demographic and anthropometric parameters of patients in both the groups were comparable. Mean time of ambulation after spinal anaesthesia in the Group 1 was 137.65±9.15 minutes and in Group 2 was 193.38±8.14 minutes (p-value <0.05). Mean time taken to return of voiding function the Group 1 was 157.06±16.05 minutes and in Group 2 was 213.53±10.26 minutes (p-value <0.05). Mean time taken for Post-Anaesthetic Discharge Scoring System (PADSS) score >9 in Group 1 was significantly less (165.29±13.59 minutes) than Group 2 (219.41±9.52 minutes). Mean time duration for request of first rescue analgesic in Group 1 was significantly faster (104.71±8.69 minutes) than Group 2 (157.79±8.81 minutes). There was no significant difference in haemodynamic changes between the study groups.

Conclusion: Chloroprocaine has proved to be better than Bupivacaine. It has proven to provide adequate surgical anaesthesia, it leads to early regression of motor and sensory blocks, faster un-assisted ambulation and micturition. Time to rescue analgesia was earlier in the Group 1 when compared to Group 2.

Keywords

Bupivacaine, Chloroprocaine, Day care surgeries, Subarachnoid block

The incidence of perianal surgeries varies among institutions, accounting for more than 5% of General surgical procedures. Commonly done perianal surgeries like lateral sphincterotomy, haemorrhoidectomy, fistulectomy are of short duration (less than one hour) (1). However, in terms of effective recovery and airway management, regional anaesthesia has massive benefits over general anaesthesia. Frequent post-operative negative impacts of general anaesthesia, such as post-operative nausea and vomiting, giddiness might be mitigated by confining the anaesthetised region to the surgical field (2). Because it delivers a stable anaesthetic action with a quick onset of effect, spinal anaesthesia is an appropriate anaesthetic choice for ambulatory procedures of the infraumbilical region (3).

Duration of spinal anaesthesia with 15-20 mg of hyperbaric Bupivacaine ranges from 90 to 200 min (4). In order to reduce the duration of surgical anaesthesia for day care surgeries lower dose of 10 mg of 0.5% hyperbaric Bupivacaine is routinely used. However, a few of their properties, such as delayed ambulation and the likelihood of retention of urine, may restrict it being used for ambulatory surgery (5). The perfect anaesthetic should have a rapid onset as well as offset of its action in order to enable rapid patient discharge with the least number of adverse effects possible. Therefore, in the ambulatory context, determining the correct local anaesthetic for spinal anaesthesia is essential (6).

Chloroprocaine (ester group) preservative free local anaesthetic with a very short half-life, available as isobaric solution has been recently used in spinal anaesthesia for its shorter duration of action. This drug was first made available in 1952 and has since been widely used for spinal anaesthesia. It wasn’t until 1956 that sodium bisulfite was put into commercial chloroprocaine formulation as a preservative (7). For obstetric patients, the medication was administered as an epidural anaesthetic. Several instances of neurologic impairments linked to inadvertent intrathecal injections of high volumes of chloroprocaine during labour analgesia were described in the 1980s (8).

Considering this and the paucity of studies in the Indian set-up, intrathecal 1% preservative free chloroprocaine has been used in this study for short duration perianal surgeries lasting less than one hour. These preservatives resemble para-aminobenzoic acid. Because of this, allergic reactions may be due to preservative stimulation of antibody formation rather than a response to the local anaesthetic (9).

The purpose of this study was to evaluate the efficacy of 1% Chloroprocaine 30 mg over 0.5% hyperbaric Bupivacaine 10 mg intrathecally in perianal surgeries. The primary outcome measures were the time taken to reach eligibility for discharge from Post Anaesthesia Care Unit (PACU). The secondary outcomes were the block characteristics (onset and regression of sensory and motor block), the haemodynamic changes and the time taken to request of first rescue analgesic.

Material and Methods

It was a, randomised, interventional double blinded study carried out at Chettinad Hospital and Research Institute in Kelambakkam, Chennai, Tamil Nadu, India, from April 2020 to August 2021, under the Department of Anaesthesiology. The Institutional Human Ethical Committee reviewed and approved the study- IHEC No: 009/IHEC /Feb.2020, dated 22-03-2020, CTRI/2021/07/034845. Prior to enrolment all study participants were explained the risks and benefits associated with the study in a language they understand, following which an informed written consent was obtained. Anonymity was maintained with regards to information of study participant.

The enrolled 68 participants were randomly allocated into two groups (34 patients in each group) using a computer-generated randomisation code. Group 1 (n=34): Patients received 30 mg of 1% Chloroprocaine (3 mL) intrathecally. Group 2 (n=34): Patients received 10 mg of 0.5% Bupivacaine (2 mL) intrathecally (Table/Fig 1).

Inclusion criteria: American Society of Anaesthesiology (ASA) Grade-I and ASA Grade-II, age 18-65 years, Body Mass Index (BMI) of the patient <35, both elective and emergency surgeries, duration of surgery < 60 minutes.

Exclusion criteria: Coagulopathy and other bleeding disorder, increased intracranial pressure, patient allergic/sensitive to local anaesthetic agents, pregnant and lactating patients, patients with peripheral neuropathy were excluded from the study.

Study Procedure

All patients underwent routine pre-operative assessment in the pre-anaesthetic assessment clinic and were assessed again the day before surgery. Those who fulfilled the eligibility criteria were enrolled, after explaining the study and the risks associated with the interventions in the language they understood.

The patients were advised fasting of six hours for a light meal, two hours for clear liquids prior to surgery and pre-medicated with Tablet Ranitidine 150 mg the night before surgery and 6 am on the day of surgery. On arrival, in the pre-anaesthetic room, one hour prior to wheeling inside the operation theatre, all patients were encouraged to void the bladder, the consent forms were re-checked, an 18 Gauge (G) intravenous (i.v.) access secured and the patients were pre-loaded with 500 mL of ringer lactate solution.

Once the patient was shifted inside the operating room, routine monitors for haemodynamic monitoring (3-lead Electrocardiogram (ECG) monitoring, heart rate, blood pressure, oxygen saturation) were attached and baseline vital signs were recorded. The appropriate study drug according to the randomised code was pre-loaded and kept in a sterile syringe by anaesthesiologist not involved in the study.

All patients were made to sit, with arms hugging a pillow, their neck flexed and both legs stretched out on the operation table. Their lumbar region was painted with antiseptic solution and draped. The intervertebral space to which the drug to be given was identified and 1-2 mL of 2% lignocaine local anaesthetic was infiltrated in the skin and subcutaneous tissue and after that subarachnoid block was performed with 26 G Quincke needle using median approach. After the lumbar puncture, the continuous flow of cerebrospinal fluid was ascertained.

Each of the 68 patients was given the study drug intrathecally over 10-15 seconds. The patients were placed in supine position immediately after the injection, and this time was defined as ‘zero’. The patients were placed in supine position for a minimum of at least three minutes before any positional change. All patients were given a hot air forced convective warmer blanket with a temperature of 40ºC. Thereafter, investigator assessed all of the following parameters. An anaesthesiologist who was not involved in the trial prepared pre-filled marked syringes with the study drug. The composition of the injections and the group allocation were unknown to the anaesthesiologist who performed the intervention and recorded the observations.

Level of sensory blockade was assessed by loss of cold sensation, using cotton swab dipped in cold saline.

The grading used for sensory blockade-

• Grade-0: Normal Sensation to cold cotton swab.
• Grade-1: Dull sensation to cold cotton swab.
• Grade-2: Sensation felt.

Time taken for onset of sensory block (level L1), time taken for sensory block to level T10 and maximum level of sensory blockade and time taken for it are duly noted. Level of motor blockade was assessed using Modified Bromage score. Time taken to onset of complete motor block (score 1) was duly noted.

All haemodynamic parameters such as heart rate, blood pressure {Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Mean Arterial Pressure (MAP)}, SpO2, were monitored every three minutes for first 15 minutes and then every five minutes for first one hour and then every 15 minutes for 90 minutes. In the event of failed subarachnoid block or inadequate anaesthesia duration during procedure, the patient will be given general anaesthesia and excluded from the study group. Any hypotension due to spinal anaesthesia was managed with intravenous fluids or injection Ephedrine as needed.

Patients were put in lithotomy position and surgery started and duration of surgery was noted. Postoperatively, patients were shifted to PACU for further monitoring. Time taken to request of first rescue analgesic was noted. Patients were asked to rate their pain using a 100 mm Visual Analogue Scale (VAS) till they reported a VAS >3 and the patient was given rescue analgesic (Inj. Paracetamol 1 g intravenously). Time taken to un-assisted ambulation was noted. Time to spontaneous voiding of urine was noted. Patients were observed in the PACU till micturition.

Patients were started on liquids and soft solid diet from 180 minutes from starting of anaesthesia, provided there was no contraindication to start oral diet on a surgical aspect. Common side effects like nausea, bradycardia, vomiting, hypotension, shivering, urticaria, if any, were noted. Postoperatively, eligibility to discharge from hospital was calculated based on Post Anaesthesia Discharge Scoring System (PADSS) (10). A score >9 is fit for discharge. PADSS has been modified to ensure a higher level of safety, thus the “vital signs” criteria must never score lower than two, and none of the other five criteria must ever be equal to 0, even if the total score reaches nine.

Degree of sensory regression, motor regression was recorded every five minutes till one hour and every 15 minutes till four hours. Time for two-segment sensory regression, complete sensory regression to level S2 and complete motor regression (score 6) were noted.

Statistical Analysis

Independent sample t-test was used in order to compare two means. Chi-square test and Fisher’s-Exact test was employed to compare the distribution of qualitative variables between the groups. In case if one characteristic is measured multiple times along the timeline, two way Repeated Measures Analysis Of Variance (RMANOVA) was used as inferential statistic. All tests were two tailed and results were considered statistically significant if the p-value is <0.05. Continuous variables were expressed as mean and standard deviation. Description of categorical variables were expressed as frequency and proportion. The data were entered using Microsoft Office Excel 2010 and analysed using Statistical Package for Social Sciences (SPSS) software version 24.0.

Results

Demographic and anthropometric parameters of patients in both the groups were comparable. In both the groups’ females were more than males (Table/Fig 2). Mean time of ambulation after spinal anaesthesia in the Group 1 was 137.65±9.15 minutes and in Group 2 was 193.38±8.14 minutes (p-value <0.05). Mean time taken to return of voiding function the Group 1 was 157.06±16.05 minutes and in Group 2 was 213.53±10.26 minutes (p-value <0.05).

Mean time taken for PADSS score >9 was found to be significantly low in Group 1 when compared to Group 2 (Table/Fig 3).

Onset of sensory block among the Group 1 was longer than that of the Bupivacaine Group 2. Mean time to attain Sensory level T10 among the Group 1 was faster than that of the Group 2 (Table/Fig 4).

Mean time to attain complete motor block among the Group 1 was faster than that of the Group 2, though not statistically significant (Table/Fig 5).

Mean time for two-segment regression from peak block and time for sensory regression to level S2 among the Group 1 was significantly faster than that of the Group 2 (Table/Fig 6).

The mean duration of motor block was significantly low in Group 1 when compared to Group 2 (Table/Fig 7).

Mean heart rate of study participants both the groups showed a declining trend. The change in heart rate in both the groups was found to be similar over the surgical process (Table/Fig 8).

MAP of study participants both the groups showed a declining trend. The change in MAP in both the groups was found to be similar over the surgical process (Table/Fig 9).

Mean time duration to request of first rescue analgesic was significantly lesser in Group 1 when compared to Group 2 (Table/Fig 10).

In this study the only complication reported was shivering. Other complications like nausea, bradycardia, vomiting, hypotension and urticaria were not reported in both the group.

Discussion

The present randomised interventional double-blinded study carried out with an aim to evaluate the block characteristics between 1% Chloroprocaine versus 0.5% hyperbaric Bupivacaine in spinal anaesthesia for short duration perianal surgeries. Outcome of the study Chloroprocaine for perianal surgeries of short duration resulted in an adequate surgical anaesthesia and at the same time quicker recovery from anaesthesia and early hospital discharge when compared with 10 mg of hyperbaric 0.5% Bupivacaine. Few previous studies also discuss the comparative toxicities and side effects, useful for deciding the anaesthetic agents [11-13]. Mean time of ambulation after spinal anaesthesia in the Chloroprocaine group was faster than the Bupivacaine group. This was similar to the study done by Gys B et. al. Their study also concluded faster motor and sensory regression as compared to prilocaine. (14).

Lacasse MA et al., who studied the effect of 30 mg chloroprocaine and 10 mg Bupivacaine in healthy volunteers and found that mean time to ambulation was 225+56 minutes and 265+65 in respective groups and stated mean time to ambulation was earlier in chloroprocaine group. This proves that patients who were given Chloroprocaine can be ambulated early than Bupivacaine group patients (15).

Mean time taken to return of voiding function the Chloroprocaine group was faster than Bupivacaine group This was similar to the study done by Smith KN et al., who found the mean time to micturition in 30 mg Chloroprocaine group was 167+47 minutes and Prabhakar A et. al., found that 10 mg Bupivacaine in spinal had mean time to micturition of 241+14 minutes [4,5]. Lacasse MA et al., stated that mean time of voiding after spinal anaesthesia was earlier in Chloroprocaine group than Bupivacaine similar which was analogous with our study (15).

Rescue analgesic: The mean time duration to request for first rescue analgesic was found to be low in Chloroprocaine Group when compared to Bupivacaine group. Patients required analgesics earlier in Chloroprocaine Group. This was similar to study conducted by Lacasse MA et al., who stated patients in 30 mg Chloroprocaine group experienced more pain, earlier in PACU and required rescue analgesic faster than Bupivacaine group as the level regressed faster (15). The association of anaesthetists from various countries all together explained the skin antisepsis for central neuraxial blockade, in their previous literature (16).

PADSS scoring: The mean time taken for PADSS score >9 was found to be low in Chloroprocaine Group when compared to Bupivacaine group This was similar to the results of Lacasse MA et al., Campbell JP et. al. and Camponov C et. al. who stated that readiness to home discharge was earlier with chloroprocaine group when compared to Bupivacaine group (15),(16),(17). In this study the only complication reported was shivering.. Other complications like nausea, bradycardia, vomiting, hypotension and urticaria were not reported in both the group. In contrast to various other previous studies depicting toxicities in their literature [8,9,16].

Limitation(s)

One of the limitations of this study is that Chloroprocaine is an ultra short acting drug so even though blinded we can predict the drug given to each patient by the time taken for the regression of block. The selection and information bias due to the above limitation was avoided by randomisation and collecting data under supervision of guide. An additional limitation of this study was determining the precision of the sensory level of the block within two dermatomal levels. This was reduced by having the same blinded observer responsible for collecting data all the time during the entire study.

Conclusion

Intrathecal administration of 30 mg of 1% 2-Chloroprocaine for perianal surgeries of short duration resulted in an adequate surgical anaesthesia and at the same time quicker recovery from anaesthesia and early hospital discharge when compared with 10 mg of hyperbaric 0.5% Bupivacaine. So, it can be effectively used for ambulatory perianal surgeries of shorter duration.

Declaration

This research was a thesis project done in Chettinad Hospital and Research Institute, Chennai.

1. Dr. Navin Gandhi, was the principal investigator of this study.
2. Dr. Mohana Sundaram had the chief role in manuscript preparation, visualisation and data presentation.
3. Dr. Ashok Kulasekhar was the guide for this study. He provided resources and helped with study conception and data curation
4. Dr. S Anand was the co-guide for this study and helped in methodology and formal analysis of the study.
5. Dr. Arun Kumar supervised the overall study and helped in computation.

References

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Singh B, Anand A, Attri JP. A prospective open-label randomized controlled trial to compare intrathecal 1% 2-chloroprocaine versus 0.5% bupivacaine in ambulatory elective surgeries. Anesthesia, Essays and Researches. 2020;14(2):266. [crossref][PubMed]
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Prabhakar A, Lambert T, Kaye RJ, Gaignard SM, Ragusa J, Wheat S, et al. Adjuvants in clinical regional anesthesia practice: A comprehensive review. Best Practice & Research Clinical Anaesthesiology. 2019;33(4):415-23. [crossref][PubMed]
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Barrington MJ, Uda Y. Did ultrasound fulfill the promise of safety in regional anesthesia? Current Opinion in Anesthesiology. 2018;31(5):649-55. [crossref][PubMed]
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Li J, Duan R, Zhang Y, Zhao X, Cheng Y, Chen Y, et al. Beta-adrenergic activation induces cardiac collapse by aggravating cardiomyocyte contractile dysfunction in bupivacaine intoxication. PloS one. 2018;13(10):e0203602. [crossref][PubMed]
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Wong GK, Pehora C, Crawford MW. L-carnitine reduces susceptibility to bupivacaine-induced cardiotoxicity: An experimental study in rats. Canadian Journal of Anesthesia/Journal Canadien D’anesthésie. 2017;64(3):270-79. [crossref][PubMed]
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Gys B, Lafullarde T, Gys T, Janssen L. Intrathecal prilocaine, 2-chloroprocaine and bupivacaine for ambulatory abdominal wall herniorrhaphy: A prospective observational study. Ambul Surg. 2017;23:08-12.
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Lacasse MA, Roy DJ, Forget J, Vandenbroucke F, Seal RF, Beaulieu D. Comparison of bupivacaine and 2-chloroprocaine for spinal anaesthesia for outpatient surgery: A double-blind randomized trial. J Can Anesth 2011;58:384-391. [crossref][PubMed]
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Membership of the Working Party; Campbell JP, Plaat F, Checketts MR, Bogod D, Tighe S, Moriarty A, Koerner R. Safety guideline: Skin antisepsis for central neuraxial blockade: Association of Anaesthetists of Great Britain and Ireland Obstetric Anaesthetists’ Association Regional Anaesthesia UK Association of Paediatric Anaesthetists of Great Britain and Ireland. Anaesthesia. 2014;69(11):1279-86. [crossref][PubMed]
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Camponovo C, Wulf H, Ghisi D, Fanelli A, Riva T, Cristina D, et al. Intrathecal 1% 2-chloroprocaine vs 0.5% bupivacaine in ambulatory surgery: A prospective, observerblinded, randomized, controlled trial. Acta Anaesthesiol Scand. 2014;58(5):560-566.[crossref][PubMed]

DOI and Others

DOI: 10.7860/JCDR/2023/60319.18123

Date of Submission: Sep 19, 2022
Date of Peer Review: Dec 10, 2022
Date of Acceptance: Feb 11, 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: Sep 22, 2022
• Manual Googling: Jan 24, 2023
• iThenticate Software: Feb 07, 2023 (12%)

ETYMOLOGY: Author Origin

EMENDATIONS: 8

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