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
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On Sep 2018




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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Saraswati Dental College
Lucknow
On Sep 2018




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Calcutta National Medical College & Hospital , Kolkata




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Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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 : 2012 | Month : June | Volume : 6 | Issue : 5 | Page : 870 - 873 Full Version

Comparison of Oral Clonidine and Midazolam as Premedications in Children


Published: June 1, 2012 | DOI: https://doi.org/10.7860/JCDR/2012/.2213
Rubina Khullar Mahajan, Iqbal Singh, Amar Parkash Kataria

1. Anaesthesiology, Government Medical College Amritsar, Punjab, India. 2. Anaesthesiology, Punjab Institute of Medical Sciences, Jalandhar, Punjab, India. 3. Anaesthesiology, Government Medical College, Amritsar, Punjab, India.

Correspondence Address :
Dr. Rubina Khullar Mahajan
100-Dayanand Nagar, Lawrence Road, Amritsar, India.
Phone No. 09585887884
E-mail: khullar.rubina@gmail.com

Abstract

Background: Oral premedication is widely being used in paediatric anaesthesia to reduce the pre-operative anxiety and to ensure a smooth induction. Midazolam is currently the most commonly used premedicant in children. Clonidine, an alpha-2 agonist due to its sedative properties, is also being used.

Aim: The aim of the present study was to compare the clinical effects of oral midazolam and oral clonidine.

Settings and Design: This study was conducted as a single blind trial on 60 children who were in the age group of 2-8 years.

Methods and Material: The children were randomly divided into two groups and they were given either clonidine 4 mcg/kg (Group I, n=30) or midazolam 0.5 mg/kg (Group II, n=30) orally, which were dissolved in honey and water solution, 60 minutes prior to the mask induction. The drug acceptance, pre-operative sedation and anxiolysis, parental separation, quality of induction and mask acceptance, the effect on the haemodynamics and the adverse effects were evaluated.

Statistical Analysis Used: All the values were reported as range and mean±SD. The data analysis for the numerical data was performed by the unpaired Student’s t-test and for the categorical data, the analysis was performed by the Fisher’s exact test or the Chi-Square test. Other data were reported as mean ± SD or frequency (%). A p value of≤ 0.05 was considered as statistically significant.

Results and Conclusions: Oral clonidine tasted significantly better than oral midazolam. The onset of the sedation was significantly faster after the premedication with midazolam (30.5 ± 10.8 minutes) than with clonidine (38.5 ± 12.26 minutes). A satisfactory sedation could be achieved with both the drugs, but the quality of the sedation was significantly better after the premedication with clonidine. The difference in the onset of the anxiolysis was found to be statistically insignificant. A satisfactory anxiolysis was achieved with both, but the quality of the anxiolysis was better with clonidine. The quality of the mask induction was equally satisfactory in both the groups. A steal-induction was performed on 56.7% of the patients of the clonidine group, but on none in the midazolam group. No adverse effects like bradycardia, hypotension, hypoxaemia or apnoea were observed during the peri-operative period in both the clonidine and the midazolam groups. We concluded that oral clonidine is a good alternative to oral midazolam as a premedication in children.

Keywords

Premedication, Clonidine, Midazolam, Paediatric anaesthesia


Anaesthesia induction appears to be the most stressful procedure that children experience during the peri-operative period. It has been associated with many negative behaviours during and after the surgical experience, like post-operative pain, sleeping disturbances, parent child conflict and separation anxiety (1). It also activates the human stress response, leading to increased levels of serum cortisol and epinephrine and natural killer cell activity (2). Children are particularly vulnerable to the global surgical stress response because of the limited energy of the reserves, large brain masses and the obligatory glucose requirements (3).

For reducing the incidence of pre-operative anxiety in children, a number of pharmacological (e.g., sedatives) and non-pharmacological (e.g. parental presence, behavioural preparation programs, music, acupuncture, etc) approaches have proven to be useful.

Midazolam is a benzodiazepine which produces anxiolytic, amnestic, hypnotic and skeletal muscle relaxant effects. It can be administered via the intranasal, sublingual, rectal and the oral routes. It has been the pharmacological agent of choice for pre-operative anxiety in day care surgery because of its rapid onset and short half life. Although midazolam is an effective agent in alleviating anxiety in children, it is not without its own disadvantages. In some investigations, its use has been associated with a delay in either the discharge of the patients from the hospital or in the recovery time. Furthermore, some children, after the premedication with midazolam, experience maladaptive behavioural changes (1).

A number of drugs, other than midazolam, are preferable in the context of paediatric premedication (4).

Clonidine has significant sedative and analgesic properties because of its alpha-2 adrenergic agonism. It was first introduced as a paediatric premedicant in 1993 and although it is less popular than midazolam, its use has been constantly increasing. It has been shown that oral clonidine effectively produces pre-operative sedation and anxiolysis in children, it acts as an analgesic, it decreases the volatile anaesthetic agent requirement and also improves the peri-operative haemodynamic stability. Clonidine can be administered orally (4 mcg/kg) and intranasally (2mcg/kg) (5).

The present study was conducted to compare the efficacy of oral clonidine with oral midazolam as a premedication in children. The effects of the premedication were assessed with regards to the drug acceptance, pre-operative sedation and anxiolysis, parental separation, the mask acceptance for inhalational induction, effect on the haemodynamics and the side effects if any were noted.

Material and Methods

This study was approved by the local ethics committee and an informed parental consent was obtained from the parents of the patients. A pre-anaesthetic check up which included taking a detailed history and a thorough general physical examination of the patients was carried out a day prior to surgery.

60 children, American Society of Anaesthesiology (ASA) Grade I–II, who were aged 2-8 years, who were scheduled for surgery under general anaesthesia, were randomly assigned to receive either oral clonidine 4 mcg/kg (6) (Group I, n = 30) or oral midazolam 0.5 mg/kg (7) (Group II, n = 30), 60 minutes prior to the anaesthesia induction.

Both the drugs were given by dissolving the respective tablets in honey and a water solution. 2 ml of honey and 3 ml of water were mixed and the tablet was dissolved in the solution. This mixture was filled in a 5 ml syringe and the drug solution was then given to the child according to the calculated dose.

The drug acceptance by the children was noted with respect to their tastes on a three point scale: 1 = good, 2 = indifferent and 3 = bitter and unpleasant. The heart rate, blood pressure, respiratory rate, oxygen saturation and the sedation and anxiety levels were noted at the time of administration of the premedication and then they were monitored continuously. The readings were recorded every 15 minutes for upto 60 minutes. The onset of the sedation was defined as the minimum time interval which was necessary for the child to become drowsy or asleep. The level of sedation was assessed by using a 3-point scale: 1 = awake, 2 = drowsy, and 3 = asleep. A sedation score of ≥2 was considered as satisfactory. Anxiety was evaluated by a 4-point scale: 1 = crying, very anxious, 2 = anxious, not crying, 3 = calm, but not cooperative and 4 = calm, cooperative or asleep. The anxiolysis score of ≥3 was considered as satisfactory. The onset of anxiolysis was defined as the minimum time interval necessary to achieve a satisfactory anxiolysis. Any untoward side effect like apnoea, hypoxaemia, bradycardia, hypotension and any other if present, was looked for.

When a sedation score of 2 or 3 was reached, the children were transferred to the induction room. If no satisfactory sedation level was achieved, the children were excluded from further studies. The separation of the children from their parents was evaluated on a three point scale: 1 = Poor: Anxious or combative, 2 = Good: Anxious but easily assured and 3 = Excellent : Calm/Sleeping. If the children came to the induction room while they were already asleep, a steal induction was attempted. All the children received halothane, nitrous oxide and oxygen via a mask to facilitate venous cannulation. The quality of the induction and the mask acceptance was immediately evaluated on a 5-point scale: 1 = combative, crying, 2 = moderate fear of the mask, not easily calmed, 3 = cooperative with reassurance, 4 = calm, cooperative and 5 = asleep, steal induction. A mask induction score of 3–5 was regarded as a successful response to the premedication. An intravenous line was secured and an intravenous infusion was started with Isolyte P. All the children received intravenous atropine 0.02 mg/kg body weight. Anaesthesia was induced by giving propofol 2 mg/kg body weight intravenously, plus 60% nitrous oxide and 40% oxygen with incremental halothane administration from the start of 0.5% induction upto 3%, depending on the requirement. The muscle relaxant, vecuronium 0.1 mg/kg body weight was used to facilitate endotracheal intubation. After the effect of vecuronium wore off, the neuromuscular blockade was supplemented with vecuronium 0.08 mg/kg body weight intravenously and the IPPV was maintained with 0.5% halothane and 60% nitrous oxide in 40% oxygen. No opioids or any other sedatives were administered intra-operatively. All the patients received rectal acetaminophen for post-operative analgesia. At the end, halothane was discontinued and nitrous oxide was switched off. The neuromuscular blockade was reversed with glycopyrrolate 0.01mg/kg and neostigmine 0.04 mg/kg body weight intravenously. The children were extubated after adequate neuromuscular recovery and when they made purposeful movements and had regular respiratory patterns. All the adverse effects including hypotension, bradycardia, respiratory depression, nausea/vomiting and shivering were recorded in the peri-operative period.

STATISTICAL ANALYSIS
All the values were reported as mean plus SD and range. The data analysis for the numerical data was performed by the unpaired Student’s t-test to detect the differences between the groups for age, weight, onset of the anxiolysis and sedation. The data analysis for the categorical data was performed by Fisher’s exact test or by the Chi-Square test to detect the differences for the scores. Other data were reported as mean ± SD or frequency (%). A p value of≤ 0.05 was considered as statistically significant.

Results

The two groups were similar with respect to age, weight, gender, the ASA physical status and duration of the surgery (Table/Fig 1). The children judged the taste of clonidine as significantly better than the taste of midazolam (P<0.05) (Table/Fig 2). The onset of the sedation was 38.5 ± 12.26 (15-60) min in group I and it was 30.5 ± 10.78 (15-45) min in group II. This difference was statistically significant (P<0.05). However, the level of sedation was significantly better in group I than in group II (P<0.05) (Table/Fig 3). A satisfactory sedation with a sedation score of ≥ 2 was achieved in 100% of the children in both the clonidine and the midazolam groups. These results were found to be statistically insignificant (P>0.05).

There was no significant difference in the onset of anxiolysis and in the satisfactory anxiolysis in both the groups (P>0.05). However, the quality of the pre-operative anxiolysis was significantly better with oral clonidine (P<0.05) (Table/Fig 4).

The quality of the parental separation was significantly better in the clonidine group (P<0.05) (Table/Fig 5). The mask acceptance and the quality of the induction were significantly better in the clonidine group as compared to those in the midazolam group (P<0.05). A steal induction could be performed in 56.7% patients of group I, but in no patient of group II. However, a satisfactory quality of induction could be achieved in both the groups (P>0.05) (Table/Fig 6).

No adverse effects like bradycardia, hypotension, hypoxaemia or apnoea were observed during any of the pre-operative, intra-operative or the post-operative periods in both the clonidine and the midazolam groups.

Shivering was not seen in any of the patients in the clonidine group, but it was seen in 13.3% of the patients in the midazolam group. These results were found to be statistically significant.

Post-operative nausea and vomiting (PONV) were seen in 6.67% of the patients in the clonidine group and in 10% of the patients in the midazolam group. These results were found to be statistically insignificant.

Discussion

This study demonstrated that clonidine was a suitable alternative to midazolam as a premedication in children. The children judged the taste of oral clonidine as significantly better than that of oral midazolam, although both the drugs were given with the same sweet tasting honey and water solution. Midazolam has a bitter taste that is difficult to disguise even when it is given in a mixture with grape juice (8). The quality of sedation and anxiolysis was significantly better in the clonidine group, whereas a satisfactory sedation and anxiolysis could be achieved by both. The onset of sedation was significantly slower with oral clonidine, whereas the difference in the onset of anxiolysis was statistically insignificant in both the groups. The quality of the parental separation was significantly better with oral clonidine.

Almenrader et al., conducted a study and they achieved a significantly better level of sedation with oral clonidine than with oral midazolam, but clonidine needed to be administered at least 45 minutes prior to the induction for an optimum sedation, which could be achieved in 30 minutes with oral midazolam. No significant difference in the onset of anxiolysis was found (9).

Another study by Cao et al., demonstrated that the clonidine premedication provided better levels of anti-anxiety in children than midazolam. Clonidine acts as a sedative and analgesic because of its central alpha-2 adrenergic agonism. A significantly higher parental separation score was noted in the clonidine group (10).

Fazi et al., found that the premedication with midazolam was superior than the clonidine premedication. Some differences may explain the different outcomes of their study and our study: firstly, the age of the study population (4–12 years) was different as compared to that of the patients in the present study (2–8 years). Secondly, unlike this study, the patients in Fazi’s study were scheduled only for tonsillectomy. Tonsillectomy can affect the post-operative period more adversely, as the patients may suffer more pain and PONV. Furthermore, in this study, the one major outcome was pre-operative sedation, which was not assessed in the study of Fazi et al., (11).

The qualities of the induction and the mask acceptance in this study were significantly better with oral clonidine and steal induction with the child asleep could be performed in 56.7% patients in the clonidine group. It could be performed in none of the patients in the midazolam group. Clonidine causes a sedation which is similar to that of natural sleep, where the patient can be easily aroused to perform the cognitive tests. The asleep state is essential to perform a steal induction in which the child passes from natural to anaesthetic sleep (12). A satisfactory quality of induction could be achieved in both the groups in our study. The premedication with midazolam was characterized by significant anxiolytic and amnestic effects which could allow a calm mask induction even if the child was awake (9).

No adverse effects like bradycardia, hypotension, hypoxaemia, apnoea or PONV were observed on haemodynamics during the peri-operative period in both the groups. Oral clonidine 4 mcg/kg (6) and oral midazolam 0.5 mg/kg (7) are effective premedications in paediatric surgery, with no clinically significant side effects on the haemodynamics. The incidence of shivering was significantly more in the midazolam group than in the clonidine group. The mechanism of clonidine in preventing shivering was correlated with the inhibition of vasoconstriction and a decrease in the shivering threshold (13).

Conclusion

The premedication with oral clonidine is a suitable alternative to oral midazolam. Although satisfactory levels could be achieved by both, the oral clonidine premedication provided a better sedation, anxiolytic, parental separation and quality of induction and it prevented the post-operative shivering, with few adverse effects.

References

1.
Wright KD, Stewart SH, Finley GA, Susan E, Buffett-Jerrott. Prevention and intervention strategies to alleviate pre-operative anxiety in children. A critical review. Behaviour Modification 2007;31(1):32-79.
2.
McCann ME, Kain ZN. The management of pre-operative anxiety in children: An update. Anesth Analg 2001;93(1):98-105.
3.
Deshpande S, Platt MP, Aynsley-Green A. Patterns of the metabolic and endocrine stress response to surgery and medical illness in infancy and childhood. Crit Care Med 1993; 21 (9 Suppl): S359-61.
4.
Committee on Drugs. Reappraisal of the lytic cocktail/ demerol, phenargan and thorazine for sedation in children. Paediatrics 1995;95:598-602.
5.
Rosebaum A, Kain ZN, Larsson P, Lönnqvist P, Wolf AR. The place of the premedication in the paediatric practice. Paediatric Anesthesia 2009;19:817-28.
6.
Mikawa K, Maekawa N, Nishina K, Takao Y, Yaku H, Obara H. Efficacy of the oral clonidine premedication in children. Anesthesiology 1993;79(5):926-31.
7.
McMillan CO, Spahr-schopfer LA, Sikich N, Hartley E, Lerman J. Premedication of children with oral midazolam. Can J Anaesth 1992;39(6):545-50.
8.
Peterson M. Making oral midazolam palatable for children. Anesthesiology 1990; 73: 1053.
9.
Almenrader N, Passariello M, Coccetti B, Haiberger R, Pietropaoli P. Premedication in children: a comparison of oral midazolam and oral clonidine. Paediatr Anaesth 2007;17(12):1143-49.
10.
Cao J, Shi X, Miao X, Xu J. Effects of the premedication of midazolam or clonidine on the peri-operative anxiety and pain in children. BioScience Trends 2009;3(3):115-18.
11.
Fazi L, Jantzen EC, Rose JB, Kurth CD, Watcha MF. A comparison of oral clonidine and oral midazolam as pre-anesthetic medications in pediatric tonsillectomy patients. Anesth Analg 2001;92(1):56-61.
12.
Hall JE, Uhrich TD, Ebert TJ. The sedative, analgesic and cognitive effects of clonidine infusions in humans. Br J Anaesth 2001; 86:5-11.
13.
Horn EP, Standl T, Sessler DI, von Knobelsdorff G, BĂĽchs C, am Esch J S. Physostigmine prevents post-anesthetic shivering as does meperidine or clonedine. Anesthesiology. 1998; 88:108-13.

DOI and Others

DOI: JCDR/2012/4220:0000

Date of Submission: Mar 02, 2012
Date of Peer Review: Mar 25, 2012
Date of Acceptance: Mar 29, 2012
Date of Publishing: Jun 22, 2012

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