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 : 2024 | Month : November | Volume : 18 | Issue : 11 | Page : UC06 - UC12 Full Version

Comparison of Intravenous Lignocaine and Dexmedetomidine in Attenuating the Haemodynamic Response to Laryngoscopy and Intubation: A Randomised Double-blind Clinical Study


Published: November 1, 2024 | DOI: https://doi.org/10.7860/JCDR/2024/71081.20252
Deepika Seelwal, Nidhi Bangarwa, Ankit Tyagi, Manisha Manohar, Sanjay Johar, Preeti Gehlaut

1. Associate Professor, Department of Anaesthesiology, Pt. B.D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India. 2. Associate Professor, Department of Anaesthesiology, Pt. B.D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India. 3. Junior Resident, Department of Anaesthesiology, Pt. B.D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India. 4. Associate Professor, Department of Anaesthesiology, Pt. B.D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India. 5. Professor, Department of Anaesthesiology, Pt. B.D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India. 6. Professor, Department of Anaesthesiology, Pt. B.D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India.

Correspondence Address :
Manisha Manohar,
Flat E1103, Sector 36 A, Ladhot Road, Suncity Heights, Rohtak-124001, Haryana, India.
E-mail: manishamb123@gmail.com

Abstract

Introduction: Endotracheal intubation often triggers a sympathetic response, leading to an increase in Heart Rate (HR) and blood pressure. Dexmedetomidine (DEX) and lignocaine have shown the potential to mitigate cardiovascular changes secondary to intubation.

Aim: To compare the efficacy of 0.25 mcg/kg and 0.5 mcg/kg DEX with 1.5 mg/kg lignocaine in attenuating haemodynamic responses during the peri-intubation period.

Materials and Methods: This randomised double-blind study included 90 patients classified as American Society of Anaesthesiologists (ASA) I and II, aged 16-65 years. Patients were divided into three groups: Group A received lignocaine (1.5 mg/kg); Group B received DEX (0.25 mcg/kg); and Group C received DEX (0.5 mcg/kg). Haemodynamic parameters were recorded at various intervals before and after laryngoscopy. Data were checked for normality before statistical analysis using the Shapiro-Wilk test. Normally distributed continuous variables were compared using Analysis of Variance (ANOVA), while categorical variables were analysed using the Chi-square test. For all statistical tests, a p-value of less than 0.05 was considered indicative of a significant difference.

Results: All groups were found to be comparable in terms of age, weight, and gender distribution. The mean age in Group A was 36.10±12.60 years, in Group B was 36.10±13.47 years, and in Group C was 37.37±11.49 years. Inter-group comparisons between Group A and Group C showed statistically significant lower HR values in Group C (79.23±10.37 vs. 90.7±17.68) at T0 as well as T1 (90.07±14.65 vs. 99.93±17.02, p-value 0.019). The comparison between Groups A and C revealed significantly lower Systolic Blood Pressure (SBP) values in Group C at T0, T1, T3, and T5. Inter-group comparisons between Groups A and B showed that Diastolic Blood Pressure (DBP) values were significantly lower at T5 in Group B (69.33±10.09 vs. 62.33±9.11, p-value 0.006). Between Groups A and C, significant differences were noted at T0, T1, T3, and T5 in Mean Arterial Pressure (MAP).

Conclusion: DEX at a dose of 0.5 mcg/kg appears to be a more effective option for managing haemodynamic responses compared to lignocaine. Nevertheless, the haemodynamic stability achieved with 0.25 mcg/kg of DEX is nearly equivalent to that observed with both 0.5 mcg/kg of DEX and 1.5 mg/kg of lignocaine.

Keywords

Adrenergic alpha-2 receptor agonist, Airway management, Blood pressure, General anaesthesia, Heart rate, Sympathetic nervous system

Endotracheal intubation is a common procedure in operating rooms to establish a secure airway. However, it often triggers a sympathetic response, leading to undesirable effects like increased HR and elevated blood pressure. DEX, an alpha-2 adrenergic agonist, is shorter-acting than clonidine and has a higher selectivity for alpha-2 receptors. It produces sedation by acting on these receptors, resulting in decreased sympathetic nervous system activity and reduced levels of arousal. Due to its sympatholytic effect, DEX has demonstrated potential in mitigating the cardiovascular changes associated with intubation (1),(2),(3).

Lignocaine is an amide local anaesthetic that is also used to control ventricular tachyarrhythmias by blocking sodium channels. It has been demonstrated to attenuate the haemodynamic response to laryngoscopy (4),(5),(6). While existing studies have explored varying doses of DEX, ranging from 0.5 micrograms/kg to 1 microgram/kg (1),(2),(3),(7),(8),(9),(10),(11),(12),(13),(14), there is a notable knowledge gap regarding a direct comparison between lower doses of DEX (0.25 mcg/kg and 0.5 mcg/kg) and lignocaine. This randomised controlled trial aims to bridge this gap by providing insights into the comparative efficacy of these medications in managing haemodynamic responses during the crucial peri-intubation period.

The present study aimed to determine whether using a lower dose of DEX (0.25 mcg/kg) can provide the same stability as the standard 0.5 mcg/kg dose or 1.5 mg/kg of lignocaine during intubation. This exploration could help optimise drug dosages for better patient care. The primary objective is to compare the effects of intravenous lignocaine with two different doses of DEX on HR, SBP, DBP, and MAP during laryngoscopy and intubation. The secondary objective is to compare the side effects of both drugs.

Material and Methods

This randomised double-blind study was conducted in the Department of Anaesthesiology and Critical Care at Pt. BD Sharma PGIMS, Rohtak, Haryana, India, from September 2021 to August 2022.

Sample size calculation: The sample size was determined using the mean and standard deviation values of HR from the study conducted by Gulabani M et al., (7).

The mean values used were 83.20 and 74.63, while the standard deviation values were 12.46 (rounded to 12.5) and 7.78 (rounded to 7.8). The pooled standard deviation was calculated to be 10.42.

N= 2 (Zα+ Zβ)2 (s)22

Where,

N: sample size
Zα: 1.96
Zβ: 0.84
S2: 10.42=108.57
Δ2: Difference between means: 83.20-74.63= (8.57)2

Where, Zα is the z variate of alpha error i.e., a constant with a value of 1.96, Zβ is the z variate of beta error i.e., a constant with a value of 0.84.

Approximate estimates: 80% power, Type I error to be 5%, Type II error to be 20%,

Substituting the values,

N= 2 (1.96+0.84)2 (108.57)/73.44
= 2 (2.8)2 (108.57)/73.44
=23.18

Approximately, 23 subjects/patients per group.

Considering the drop rate/attrition, the authors included 30 patients in each group, resulting in a total sample size of 90 patients, with 30 patients in each group. Ethical clearance was obtained from the Institutional Ethical Committee (BREC/Th/20/Anaesth./23). The study was registered with the Central Trial Registry of India (CTRI number: CTRI/2022/04/041867). Informed written consent was obtained from all participants.

Inclusion criteria: Patients classified as ASA I and II of either sex, aged between 16 and 65 years, who were scheduled for surgery under general anaesthesia, were included in the study.

Exclusion criteria: Patients with anticipated difficult intubation, those with oropharyngeal pathology, or a history of cardiovascular problems (e.g., ischemic heart disease, cerebrovascular accident)were excluded from the study.

Out of the 100 patients assessed, 90 patients were included, while 10 patients (8 did not meet the criteria and 2 declined participation) were excluded from the study (Table/Fig 1).

Procedure

After taking the medical history, all patients were subjected to a general physical and systemic examination during the pre-operative visit, which took place the day before surgery. Routine relevant investigations were carried out.

All patients enrolled in the study were advised to fast for six hours for solids and two hours for clear liquids before the scheduled time of surgery. They were pre-medicated with a tablet of alprazolam 0.25 mg and a tablet of pantoprazole 40 mg, taken orally the night before surgery. Upon arrival in the operating room, routine monitors, including HR, Electrocardiography (ECG), pulse oximetry (SpO2), Non Invasive Blood Pressure (NIBP), and End-Tidal CO2 (EtCO2), were established, and baseline readings of vital parameters (B1) were recorded. An intravenous line was secured.

Patients were randomly allocated into three groups of 30 patients each using a computer-generated random number table (Table/Fig 1). Participants were not informed about the medications they were receiving to ensure blinding. Each group received the following medications intravenously:

Group A (n=30): Received 10 mL of normal saline via an infusion pump over 10 minutes before induction, followed by a bolus of 1.5 mg/kg lignocaine diluted to 5 mL of normal saline, administered 90 seconds before direct laryngoscopy.

Group B (n=30): Received DEX 0.25 mcg/kg diluted to 10 mL in normal saline via an infusion pump 10 minutes before induction of general anaesthesia, followed by a bolus of 5 mL of normal saline, administered 90 seconds before direct laryngoscopy.

Group C (n=30): Received DEX 0.5 mcg/kg diluted to 10 mL in normal saline via an infusion pump 10 minutes before induction of general anaesthesia, followed by a bolus of 5 mL of normal saline, administered 90 seconds before direct laryngoscopy.

Anaesthesiologists involved in the intraoperative management were not part of the data collection and processing.

Ten minutes before the induction of anaesthesia, patients received the respective infusions of drugs as per their allocated group. All patients were pre-oxygenated for three minutes. A standard anaesthetic technique was used in all three groups. Anaesthesia induction was performed with injection (inj.) fentanyl 2 mcg/kg and inj. thiopentone sodium 5 mg/kg. The ability to mask ventilate the patient was confirmed before administering inj. vecuronium 0.1 mg/kg intravenously. All patients were manually ventilated for three minutes. Ninety seconds before laryngoscopy, the patients received the respective drugs according to their allocated group. Laryngoscopy and orotracheal intubation using an appropriately sized cuffed Endotracheal Tube (ETT) were performed. The time taken for laryngoscopy and intubation was noted in seconds, measuring the time from picking up the laryngoscope to obtaining an EtCO2 tracing on the monitor to confirm successful intubation.

Thereafter, anaesthesia was maintained with nitrous oxide in oxygen (50:50) and sevoflurane titrated to 1 MAC. Additional doses of muscle relaxant were administered as required to maintain adequate neuromuscular blockade. At the end of the surgery, anaesthesia was discontinued, and after observing spontaneous respiratory efforts, residual neuromuscular blockade was reversed with inj. glycopyrrolate and inj. neostigmine (0.05 mg/kg), and the patient was extubated. Once fully awake, the patients were shifted to the post-anaesthesia care unit and observed for any side effects like bradycardia, hypotension, and post-operative Nausea and Vomiting (PONV) for one hour at 15-minute intervals.

The following parameters were recorded: haemodynamic parameters like HR in beats per minute (bpm), SBP in mmHg, DBP in mmHg, MAP in mmHg, and oxygen saturation (SpO2) in percentage (%). These parameters were recorded using an automatic multi-parameter monitor at the following intervals: before administering the study drug (B1), just before laryngoscopy (B2), just after intubation (T0), and after intubation at one minute, three minutes, and five minutes (T1, T3, T5).

Any side effects, including bradycardia, hypotension, PONV, and dysrhythmias, were noted. Hypotension (defined as SBP <25% below baseline) was treated in a stepwise manner with intravenous fluids and inj. mephentermine 3 mg. Bradycardia (defined as HR <40/min) was treated with inj. atropine 0.6 mg i.v. increments until the desired effect was achieved.

Statistical Analysis

Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS) program for Windows, version 28.0. Continuous variables are presented as mean±SD, and categorical variables are presented as absolute numbers and percentages. Data were checked for normality before statistical analysis using the Shapiro-Wilk test. Normally distributed continuous variables were compared using Analysis of Variance (ANOVA). If the F value was significant and variance was homogeneous, the Tukey multiple comparison test was used to assess the differences between the individual groups. Categorical variables were analysed using the Chi-square test. For haemodynamic variables, values from baseline to various time points were analysed using paired t-tests for each group, respectively, and mean percentage change±SD was reported. For all statistical tests, a p-value of less than 0.05 was considered indicative of a significant difference.

Results

All three groups were found to be similar in terms of age distribution, gender distribution, and American Society of Anaesthesiologists (ASA) class, with no statistically significant differences (Table/Fig 2). The mean age in Group A was 36.10±12.60 years, in Group B was 36.10±13.47 years, and in Group C was 37.37±11.49 years. The mean weight was 61.37±13.40 kg in Group A, 59.97±12.69 kg in Group B, and 59.33±13.37 kg in Group C. In Group A, 43.3% of the patients were female, while 56.7% were male; in Group B, 40.0% of the patients were female, while 60.0% were male. In Group C, 53.3% of the patients were female, while 46.7% were male. The time taken for laryngoscopy and intubation was also found to be similar in all three groups (Table/Fig 2).

The mean HR in Group A increased significantly at T1; however, the values returned to below baseline at T5. Group B patients did not show any significant change in HR values when compared to baseline. Patients in Group C showed statistically significant lower HR values at B2 and T0 (Table/Fig 3). There was no significant difference in HR values between Groups A and B. However, inter-group comparison between Groups A and C showed statistically significant lower HR values in Group C at T0 as well as T1. An inter-group comparison between Groups B and C showed a statistically significant difference at T0 only (Table/Fig 4).

A significant decrease in mean SBP was noted in Group A at B2, followed by an increase at T1. However, the SBP values persistently decreased thereafter at T3 and T5. A highly significant drop in blood pressure was observed in Group B at B2 and T5 when compared to baseline. The mean SBP baseline in Group C was 130.83±14.23 mm of Hg. There was a statistically significant decrease in SBP readings at all time points in the study for Group C (Table/Fig 5). Inter-group comparison between Groups A and B showed that the mean values were insignificantly different, except at T5. However, the comparison between Groups A and C revealed significantly lower blood pressure values in Group C at T0, T1, T3, and T5. Among Groups B and C, no statistically significant differences were noted (Table/Fig 6).

A statistically significant decrease in DBP was observed at B2 and T1, while a highly significant decrease was noted at T5 in Group A. Patients in Group C experienced a consistent decline in DBP, except at T1. A significant decrease in DBP was recorded at B2, T0, T3, and T5 in Group C (Table/Fig 7). Inter-group comparisons between Group A and Group B revealed that diastolic values were significantly lower at T5 in Group B. A significant difference between Group A and Group C was observed at T1, T3, and T5, as shown in (Table/Fig 8). However, no significant differences were found when comparing Group B and Group C at B1, B2, T1, T3, and T5.

A significant decrease in mean blood pressure was noted at B2 and T1 in Group A. Patients in Group B exhibited significantly lower blood pressure at B2, T3, and T5 (Table/Fig 9). When comparing Group A to Group B, a statistically significant difference was observed at T5. Significant differences between Group A and Group C were noted at T0, T1, T3, and T5. Consistent with the findings regarding diastolic blood pressure, inter-group comparisons between Group B and Group C did not reveal any significant differences in mean blood pressure (Table/Fig 10).

No episodes of bradycardia, hypotension, PONV were observed during the postoperative observation period. A comparison of oxygen saturation among the three groups showed no significant differences (Table/Fig 11). Additionally, no abnormalities were noted in the ECG for any of the groups.

Discussion

Endotracheal intubation is a routine procedure in operating theatres for establishing a secure airway. However, it often elicits a sympathetic response, resulting in undesired effects such as tachycardia and hypertension. Notably, the elevation in arterial pressure parallels an increase in plasma noradrenaline concentration, implying a notable surge in sympathetic nerve activity associated with the process of intubation (12). An anaesthesiologist's dual objective during laryngoscopy is to secure the airway effectively and mitigate the associated haemodynamic perturbations. Various pharmacological agents have been employed to dampen the haemodynamic response to laryngoscopy, and among them, DEX, an alpha-2 adrenergic agonist, has shown promise in reducing these cardiovascular changes. While some researchers have investigated the use of DEX in doses of 0.5 mcg/kg (2),(7),(8),(9),(10),(15),(16), 0.75 mcg/kg (13), 1 mcg/kg (1),(3),(7),(10),(11),(15),(16),(17), 0.2 mcg/kg/hr, and 0.4 mcg/kg/hr (18) to attenuate the haemodynamic responses associated with laryngoscopy, the efficacy of a lower dose, specifically 0.25 mcg/kg, remains unexplored in this context.

As a highly selective alpha-2 receptor agonist, DEX exhibits eight times greater selectivity for alpha-2 receptors compared to clonidine. DEX acts by inhibiting the release of noradrenaline at the locus coeruleus in the pons. The cardiovascular effects of DEX follow a biphasic pattern: initially causing hypertension through the activation of alpha-2B receptors on vascular smooth muscle, and subsequently leading to hypotension due to reduced central noradrenaline release (19).

Heart Rate (HR): The present study elucidates the significant impact of DEX dosage on HR values during intubation procedures. Specifically, the administration of DEX at 0.5 mcg/kg emerged as a key determinant in achieving the lowest HR values compared to both lignocaine and a lower DEX dose (0.25 mcg/kg). When examining lignocaine in comparison to lower doses of DEX, the authors did not observe any statistically significant difference in HR values. This finding suggests that within the spectrum of lower DEX dosages, lignocaine may not exhibit a distinct advantage in modulating HR responses during the intubation process.

The comparison between the lower dose (0.25 mcg/kg) and the higher dose (0.5 mcg/kg) of DEX reveals a dose-dependent relationship in the attenuation of HR. Notably, the higher dose of DEX resulted in lower HR values during intubation. In summary, present findings highlight the dosage-dependent influence of DEX on HR responses during intubation. While lignocaine may not demonstrate a statistical advantage over lower doses of DEX, the impact of a higher DEX dose emphasises the importance of dosage precision in achieving desired haemodynamic outcomes.

In the study conducted by Gulabani M et al., the comparison between lignocaine (1.5 mg/kg) and two different doses of DEX (0.5 and 1 mcg/kg) revealed that the higher DEX dose of 1 mcg/kg exhibits a greater reduction in HR values at 1, 3, and 5 minutes after intubation compared to both the 0.5 mcg/kg dose of DEX and lignocaine (7). Additionally, Zhan-Ying G et al., concluded in their comparative evaluation of three different doses of DEX in elderly patients that a dose of 0.25 mcg/kg DEX does not serve as a very useful anaesthesia adjuvant to control haemodynamic stress response to intubation in this population (15). They noted a greater reduction in HR with 1.00 mcg/kg DEX as compared to 0.5 mcg/kg of DEX at the time of intubation (67.2±16.3 vs. 59.1±10.9) as well as five minutes after intubation (63.7±12.5 vs. 59.8±11.6). The authors also noted that 0.50 mcg/kg of DEX was associated with fewer cardiovascular effects but was still sufficient to prevent the tracheal intubation-evoked haemodynamic response in elderly patients (15).

Systolic Blood Pressure (SBP): This research demonstrated that the benefits of 0.5 mcg/kg DEX extended beyond the intubation period. Notably, 0.5 mcg/kg DEX consistently maintained low SBP values not only during intubation but also at one minute, three minutes, and five minutes post-intubation. This sustained effect suggests that DEX at 0.5 mcg/kg may offer prolonged haemodynamic stability during the critical post-intubation period.

In direct comparison to lignocaine, 0.5 mcg/kg of DEX demonstrated a noteworthy advantage, revealing substantially reduced SBP readings during and after intubation. This underscores the superior performance of DEX over lignocaine in mitigating the haemodynamic response, particularly in maintaining lower SBP levels. A significant decline in SBP with both 0.5 and 1 mcg/kg DEX was also reported by Sharma N and Mehta N (16). Kumari K et al., observed a significant difference in blood pressure values in patients who received DEX, with lower SBP noted in the DEX group up to five minutes post-intubation (8).

Diastolic Blood Pressure (DBP): The present findings show that the haemodynamic effects of DEX at a dose of 0.5 mcg/kg also encompass diastolic pressure dynamics. In comparison to lignocaine, DEX at 0.5 mcg/kg exhibited lower diastolic pressure values, with a more pronounced impact observed during the post-intubation period. Interestingly, when contrasted with the lower dose of DEX (0.25 mcg/kg), DBPs were not found to be statistically different, except at the time of intubation. This nuanced understanding of the DBP responses to varying DEX doses adds a layer of complexity to the present findings. While the 0.5 mcg/kg dosage demonstrates a clear advantage over lignocaine in terms of lower diastolic pressure values, the absence of statistically significant differences after intubation when compared to the lower DEX dose suggests that even a lower dose can provide similar haemodynamic stability. Kumari K et al., reported that the maximum percentage increase in DBP was lower in patients who received 0.5 mcg/kg DEX compared to those who received a placebo (19.36% vs. 60.36%) (8).

Administering DEX through an infusion at a loading dose of 0.5 mcg/kg has been found to be as therapeutically effective as a 1.0 mcg/kg dose. This effectiveness extends not only to decreasing the propofol induction dose but also to ensuring favourable intubating conditions and mitigating the haemodynamic response to intubation. Choosing the lower dose was associated with a reduced occurrence of adverse effects, including hypotension and bradycardia (16). The present study results suggest that doses as low as 0.25 mcg/kg could provide similar advantages in controlling the pressor response. As compared to lignocaine (1.5 mg/kg) and fentanyl (2 micrograms/kg), DEX (1 mcg/kg) led to a greater reduction in the SBP and DBP in the 3rd, 5th, and 10th minutes after intubation in the trial conducted by Mahjoubifard M et al., (17).

Mean Arterial Pressure (MAP): The reduction in MAP was also found to be greater in the DEX group than in the two other groups during the 3rd, 5th, and 10th minutes. The present investigation into MAP also revealed statistically significant differences between the lignocaine group and the subset receiving 0.5 mcg/kg of DEX. Notably, consistently lower MAP values were observed with the administration of 0.5 mcg/kg of DEX compared to lignocaine during and after intubation. This finding underscores the potential haemodynamic advantage associated with the 0.5 mcg/kg DEX dosage, suggesting its efficacy in maintaining a more favourable MAP during the observed period. The observed statistical significance between the lignocaine and 0.5 mcg/kg DEX groups indicates a noteworthy clinical impact, supporting the consideration of DEX as a preferred agent for haemodynamic control in specific contexts.

Interestingly, the present study did not reveal any significant difference in MAP between the groups receiving 0.25 mcg/kg of DEX and 0.5 mcg/kg of DEX. This suggests that, within the parameters of the present investigation, the incremental increase from 0.25 to 0.5 mcg/kg did not yield a discernible difference in MAP. The absence of significant variance in this comparison prompts further exploration into the optimal dosage range of DEX for achieving specific haemodynamic goals without undue fluctuations.

In contrast to present findings, Manne GR et al., observed a different outcome when comparing 0.2 mcg/kg/hr and 0.4 mcg/kg/hr doses of DEX in patients undergoing laparoscopic cholecystectomy (18). They reported that in both DEX groups, there was a significant decrease in MAP in the DEX 0.2 group and a highly significant decrease in the DEX 0.4 group after initiating the infusion. Following intubation and extubation, the pulse rate and MAP increased significantly above the pre-infusion level in the DEX 0.2 group, while in the DEX 0.4 group, they remained below the pre-infusion level. It is worth noting that the difference in findings between our study and that of Manne GR et al., could be attributed to the continuous infusion of DEX used in their study, which was not employed in our investigation (18).

In conclusion, the present findings highlight the significance of dosage precision in the administration of DEX, with the 0.5 mcg/kg dosage demonstrating superiority over lignocaine in maintaining consistently lower MAP values.

Elevated doses of DEX are linked to occurrences of bradycardia and hypotension. In the present study, the authors observed no instances of hypotension or bradycardia when employing doses of 0.25 mcg/kg and 0.5 mcg/kg of DEX. As expected, there was no statistically significant difference in the values of oxygen saturation when comparing lignocaine and DEX. Singh G et al., also reported no side effects in their study comparing 1 mcg/kg of DEX with 1.5 mg/kg of lignocaine (20). However, Mahjoubifard M et al., reported a higher incidence of hypotension and bradycardia with a dose of 1 mcg/kg of DEX (17). The administration of a single dose of 0.5 mcg/kg of DEX leads to a notable reduction in the elevation of HR, SBP, DBP, and MAP lasting up to five minutes after intubation, as indicated by various studies (8),(10),(14). However, the present results demonstrate that even a lower dose of DEX at 0.25 mcg/kg achieves nearly equivalent haemodynamic stability in terms of SBP, MAP, DBP, and HR, except for an increase in DBP and HR at the time of intubation.

Limitation(s)

The study was conducted at a single institute involving ASA 1 and 2 adult patients. As a result, the findings may not be applicable to different settings and cannot be generalised to paediatric, obstetric, or geriatric cohorts. Excluding patients with cardiovascular diseases limits the applicability of the study to high-risk groups. Additionally, the study does not account for genetic differences in drug metabolism, which could influence the findings.

Conducting studies across multiple centres and involving diverse cohorts would improve the generalisability of the results. This approach would provide a more varied patient population, thereby enhancing the understanding of how well the interventions work in different clinical environments. Furthermore, it would be beneficial for future research to focus on the analysis of cost-effectiveness, evaluating the economic implications of incorporating lignocaine or DEX into standard clinical procedures, taking into account both the costs of the drugs and the potential reduction in postoperative complications.

Conclusion

The present study demonstrates the significant haemodynamic advantages of using DEX, particularly at a dose of 0.5 mcg/kg, for managing cardiovascular responses during endotracheal intubation. This dosage not only effectively attenuates HR and blood pressure spikes but also maintains haemodynamic stability in the critical post-intubation period. Compared to lignocaine, DEX at 0.5 mcg/kg shows superior performance in reducing systolic, diastolic, and MAP without the associated risk of hypotension or bradycardia observed with higher doses.

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DOI and Others

DOI: 10.7860/JCDR/2024/71081.20252

Date of Submission: Apr 09, 2024
Date of Peer Review: Jun 11, 2024
Date of Acceptance: Aug 02, 2024
Date of Publishing: Nov 01, 2024

Author declaration:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. No

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