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

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Dr Mohan Z Mani

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Professor & Head,
Department of Dermatolgy,
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."



Dr Kalyani R
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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I wish JCDR a great success and I hope that journal will soar higher with the passing time."



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 : 2012 | Month : May | Volume : 6 | Issue : 3 | Page : 418 - 422 Full Version

A Comparative Study of Ketorolac with Lornoxicam as Pre-emptive Analgesics in Patients Who were Undergoing Elective Abdominal Surgery under General Anaesthesia


Published: May 1, 2012 | DOI: https://doi.org/10.7860/JCDR/2012/.2068
Girish Babu Narasimha Murthy, Girish M. Bengalorkar, Ravi Madhusudhana

1. Assistant Professor, Anaesthesiology 2. Associate Professor, Pharmacology 3. Associate Professor, Anaesthesiology NAME OF DEPARTME NT(S)/INSTITUTION(S) TO WHICH THE WORK IS ATTRIBUTED: Sri Devaraj Urs Medical College, Tamaka, Kolar 563101, Karnataka, India.

Correspondence Address :
Ravi Madhusudhana
Associate Professor, Anaesthesiology,
R.L. Jalappa Hospital & Research Center
Sri Devaraj Urs Medical College, Tamaka, Kolar- 563 101
Karnataka, India.
Phone: +919845287591
E-mail: ravijaggu@hotmail.com

Abstract

Introduction: NSAIDs and opioids are the drugs which are commonly used in the post-operative pain management. The purpose of the present study was to determine the pre-emptive analgesic effects of lornoxicam, and ketorolac and the reduction in the opioid consumption post operatively.

Materials and Methods: Ninety patients of ASA class I-II, who were undergoing abdominal surgeries under general anaesthesia, were assigned in a randomized manner into three groups. Group K received a single IV injection of Ketorolac 30 mg (1ml), Group L received a single IV injection of lornoxicam 8mg (1ml) and Group P received IV saline (1ml) 1 hour before surgery.

Results: The post-operative pain scores were evaluated at 2, 4, 8, 12 and 24 hours by using a Visual Analogue Scale (VAS). The time taken to administer the first dose of rescue analgesic was significantly delayed in the Groups K and L as compared to Group P (291 min for gp K, 302 min for gp L as compared to P of 107 min, p<0.001). The pain scores between the Groups K and L were significantly lower as compared to those in Group P at 2,4, 8 ,12 and 24 hours. The twenty four hour analgesic consumption was significantly lower in Groups K and L as compared to that in Group P (p<0.05). The 24 hr total opioid consumption was 47 % and 54 % less in the lornoxicam and the ketorolac groups as compared to that in the placebo group. The degree of satisfaction with the post-operative pain management was excellent in 15 % and 40 % of the patients in Groups K and L respectively. Nausea and vomiting were seen more in Group P due to increased tramadol consumption.

Conclusion: Lornoxicam decreased the VAS score and the need for opioids as compared to ketorolac, by its pre-emptive administration. It was found to be an equally effective analgesic like ketorolac in abdominal surgeries.

Keywords

Pre-emptive analgesia, Abdominal surgeries, Lornoxicam, Ketorolac, Tramadol

Introduction
Pain relief during the post-operative period is usually inadequate, and the conventional approaches do not take into account the underlying mechanism. A new approach which provides adequate relief from pain during the post-operative period is the administration of an analgesic agent, either an opioid or an NSAID before the surgery. This concept is called pre-emptive analgesia, wherein the development of pain in the post-operative period is prevented. Pre-operatively administered analgesics prevent the nociceptive sensation which is generated during surgery due to the sensitizing of the central neurons in the spinal cord (1). Thus, it prevents the post-operative pain from getting established, which is difficult to treat. Opioids are the gold standard for the post-operative pain management and they are commonly used but they are associated with respiratory depression, sedation, cardiovascular instability, nausea, and vomiting. NSAIDs lack these adverse effects and are used as alternatives to the opioids. Ketorolac is one of the NSAIDs which are commonly used for pre-emptive analgesia (1). Lornoxicam is a newer oxicam class NSAID with a potent analgesic and anti-inflammatory activity, which is available as oral and parental formulations (2). Hence, this study was aimed at determining the efficacy and safety of lornoxicam and ketorolac as pre-emptive analgesics in patients who were undergoing elective abdominal surgeries.

Material and Methods

This was a randomized, single dose, double blind, placebo controlled, comparative study. Patients who were aged between 20 to 50 years, of either sex, of ASA (American Society of Anaesthesiologists) grade 1 and 2, who were undergoing elective open abdominal surgery under general anaesthesia, were enrolled. The patients who had received analgesic drugs within 2 weeks of surgery, those who were taking anti-platelet drugs (drug interaction), those who had a history of alcohol abuse, allergy to NSAIDs and gastric ulcer, pregnant women, children and those with hepatic, renal and cardiac impairment were excluded from the study. The institutional ethical clearance was obtained and informed consent was taken from all the patients.

Preoperative Examination
The routine pre-anaesthetic examinations and investigations of all the patients were done on the previous day of the surgery. All the patients received tab. alprazolam 0.25 mg and ranitidine 150 mg, the night before the operation. The patients were randomized to3 groups of 30 patients each. The randomization was done by random numbers table into 3 groups. • Group K received a single IV injection of Ketorolac 30 mg (1ml), • Group L received a single IV injection of Lornoxicam 8mg (1ml) and • Group P was taken as the control and it received IV saline (1ml). The test drugs were administered approximately one hour before the induction of the anaesthesia. The patients were explained about how to describe the pain intensity on a visual analog scale (VAS) of 0 to 10.

Anaesthetic Technique
The patients in the 3 groups were pre-medicated with injection glycopyrrolate 0.2 mg IV, 15 minutes before the induction of the anaesthesia. All the patients were pre-oxygenated for 3 minutes with 100% oxygen. Fentanyl 2μg/kg was administered to all the patients before the induction and it was continued to be administered intra-operatively. The patients were induced with thiopentone sodium (4-7mg/kg, 2.5%), followed by injection suxamethonium chloride 2mg/kg, to facilitate endotracheal intubation. After adequate relaxation, laryngoscopy was performed and the intubation was done. The anaesthesia was maintained with nitrous oxide, oxygen and isoflurane. Injection vecuronium was used as muscle relaxant. Injection neostigmine and injection glycopyrrolate were used for the reversal of the neuromuscular blockade. The patients were administered a rescue medication, injection tramadol 2mg/kg post-operatively, when the VAS score was more than 3.

The primary measurement of the efficacy was the pain intensity score which was measured on a Visual Analog Scale from 0 (no pain) to 10 (severe pain) at 2, 4, 8, 12 and 24 hours. The total VAS score at the end of 24 hours was assessed to compare the analgesic efficacy of these drugs. The above parameters were assessed by a trained nurse observer who was unaware of the study medication. Neither the patient nor the observer knew which drug was administered to them. The analgesic duration, which is the duration of the analgesia between the time of the end of the surgery and the time of the first rescue dose of analgesia which was given, was noted. In addition, the total amount of the rescue medication which was given was noted. Adverse effects like nausea and vomiting were observed and ondansetron was administered to the patients who complained of vomiting.

The patient’s satisfaction (global efficacy) was assessed at the 24th hour by patients on a 4-point Likert’s scale, in which 1. Poor 2. Fair 3. Good and 4. Excellent The patients were withdrawn from the study if the tramadol requirement was more than 3 doses during the first 4 hours, if they demanded analgesia more than 2 times during the 2 hours period following the initial 4hours or if they consumed the total daily dose allowance before the end of the 24 hours observation period.

Statistical and Analysis Methods
The sample size was determined by power analysis with power of 0.95 and it was found to be 30 in each group. The demographic data which was obtained was analyzed by using descriptive statistics which was expressed as mean ± standard deviation. For comparing the continuous variables such as weight, age, duration of the surgery and the time for the first analgesia, the ANOVA test was performed. The VAS pain scores were analyzed by using ANOVA and the Bonferroni adjustment was used for comparing the intragroup VAS values. The total analgesic consumption of the groups was compared by using the Kruskal Wallis test and between the groups, it was compared by the Mann-Whitney U-test. The sex, ASA grade, patient satisfaction (global efficacy score) between the groups and the incidence of the side effects were analyzed by using the Chi square test. A probability (p) value of <0.05 was considered as statistically significant. The statistical analysis was performed by using SPSS, version16.0 (SPSS Inc, Chicago, IL, April 2008).

Results

There were no significant differences between the groups with regards to the demographic variables (age, gender, weight and ASA physical status) or the mean duration of the surgery in minutes (Table/Fig 1). The most common abdominal operations included acute appendectomy, cholecystectomy, hernia repair, hysterectomy and laprotomy. The changes in the post-operative VAS pain scores are shown in (Table/Fig 2). The VAS pain scores which were recorded at 2, 4, 8, 12 and 24 hrs after the operation were higher in Group P, as compared to those in Groups K and L (p=0.0001).

The pain scores were significantly lower in the lornoxicam group as compared to those in the placebo group at 2, 4, 8, 12 and 24 hrs (p=0.0001). The pain scores were significantly lower in the ketorolac group at 2, 4, 12 and 24 hrs as compared to those in the placebo group. There was no difference in the pain score between the ketorolac and the lornoxicam groups (p>0.05).

Within the groups, the pain scores at 8 hours were significantly lower (p=0.004) as compared to those at 2 hours in the ketorolac group, whereas in the lornoxicam group, the pain scores were lower at 4, 8 and 12 hours as compared to those at 2 hours (p =0.033, 0.0001 and 0.005 respectively). There was a significant difference with respect to the first analgesic requirement time between the three groups. The time for the first analgesic requirement was longer in the lornoxicam (302.75 ± 92.57 min) and the ketorolac groups (291.25 ± 100.34 min) as compared to that in the placebo group (107.50 ± 50.71 min) (p=0.0001) (Table/Fig 3). The amount of analgesic consumption was significant between the groups and it was less in the ketorolac (47%) and the lornoxicam (54%) groups as compared to that in the placebo group (p=0.0001). There was no statistical difference in the analgesic consumption between the lornoxicam and the ketorolac groups. Tramadol was used in all the patients who received placebo and lornoxicam and in 96.6% of the patients who received ketorolac (Table/Fig 3).

The degree of satisfaction with the post-operative pain management was excellent in 15 % and 40% of the patients who received ketorolac and lornoxicam (p=0.0001) respectively (Table/Fig 4). The most frequent side effects in both the groups were nausea and vomiting and their incidence was significantly higher in the placebo group as compared to those in Group L (p<0.05).

Discussion

Based on the mechanism pain can be divided into nociceptive, inflammatory and neurogenic pain. Nociceptive pain is often regarded as the key feature of the acute post-operative pain, the most common form of the acute pain symptoms. However, in addition to the incisional damage to the skin and various other tissues, the nociceptive barrage during surgery is followed by a protracted inflammatory state which is mediated by prostaglandins in the post-operative period. The transmission of the pain signals which are evoked by tissue damage during surgery leads to the sensitization of the peripheral and the central pain pathways. The only way to prevent the sensitization of the nociceptive system is to block completely any pain signal which originates from the surgical wound from the time of the incision until the final wound healing (3), (4). Thus, the concept of pre-emptive analgesia was postulated.

The present study demonstrated that that pre-emptive administration of the test drugs produced a significant decrease in the VAS score at (2),(4),(8) hours and 24 hours, which was suggestive of the effectiveness of the analgesic drugs as compared to the placebo. (Table/Fig 3). The findings of this study confirmed those of other studies, wherein the VAS score was significant at 12 and 24 hours in the active comparator groups (lumiracoxib, rofecoxib) as compared to placebo till 30 hours
(Table/Fig 5) (5), (6). The surgical damage produced the upregulation of PGE2, IL-6 and IL-8 in CSF and the surgical sites (upto 25 to 30 hours), that amplified the post-operative pain because of hyperalgesia (6). Hence, it can be explained that the pre-operative administration of NSAIDs decreased the PGE2 and the IL-6 in the CSF and the surgical sites upto 30 hours, which was correlated with a decreased VAS score (7).

The 24 hours total opioid consumption was 47% and 53.5% less in the lornoxicam and the ketorolac groups as compared to that in the placebo group and the time for the first tramadol administration for the pain was more in the lornoxicam and the ketorolac groups. This indicated that NSAIDs had an opioid sparing effect and that they could be used for pre-emptive analgesia. The advantages of reducing the narcotic usage were evident as the patients were more alert and cooperative and as they could ambulate more rapidly. Besides their analgesic effects, the anti-inflammatory properties of NSAIDs decrease the inflammatory mediators in the post-operative period, thus contributing significantly to the recovery of the patients as compared to opioids in the post-operative period.

Lornoxicam has been successfully used in the prevention and treatment of post-operative pain (8),(9). Lornoxicam provides an alternative to morphine and tramadol for the treatment of post-operative pain, with fewer adverse events after hysterectomy (10). Lornoxicam suppresses the inflammatory mediators like the prostagland in production at the time of the surgical trauma. Ketorolac, as a pre-emptive analgesia for laporoscopic surgeries, has been demonstrated to reduce the need for narcotic medication in the post-operative period (11). Previous studies have established the pre-emptive analgesic effects at a dose of 8mg for lornoxicam and at a dose of 30mg for ketorolac (12),(13). The pre-operative administration of lornoxicam 8 mg had a greater analgesic efficacy in the prevention of the post-operative pain than its post-operative administration in male patients who were undergoing varicocelectomy (Table/Fig 6) (14). Intravenous ketorolac, as pre-emptive analgesia, had a longer pain free time interval and the request for the first analgesic supplement was made after 90 minutes as compared to a shorter interval of 60 minutes in the intra-muscular diclofenac sodium group, in laparoscopic surgeries (15). Thus, pre-emptively, its administration improved the quality of the post-operative analgesia. Intravenous lornoxicam 8 mg was found to be equianalgesic to 20 mg of morphine, 50 mg of pethidine and 50 mg of tramadol (16). The objective data from the present study revealed that the analgesic consumption was lower and that the time for first tramadol use was more in the lornoxicam than in the ketorolac group, even though it was insignificant.

The total VAS score was less in Group L as compared to that in Group K. The quality of the post-operative analgesia was excellent in 40% of the patients in the lornoxicam group as compared to 15% in the ketorolac group. This indicated that lornoxicam had an advantage over ketorolac. Studies have shown that lornoxicam releases endogenous dynorphin and beta endorphin in the spinal cord, thus providing a central analgesic effect apart from the anti-inflammatory, peripheral analgesic action through prostaglandin synthesis inhibition at the site of the surgery (16). Lornoxicam has a time-to-peak effect of approximately 20–30 min and an elimination half-time of 3–5 h in healthy young volunteers (17). The 5′-hydroxy metabolite has a mean terminal elimination t 1⁄2 of about 11 hours with a range of 6 to 24 hours for a single 4mg dose, and a range of 8.5 to 9 hours after a parenteral single or twice daily doses (18).

The biological activity of Ketorolac tromethamine is associated with the S-form. The peak analgesic effect of Ketorolac tromethamine occurs within 2 to 3 hours. The half-life of the Ketorolac S-enantiomer was approximately 2.5 hours as compared to the 5 hours of the R-enantiomer. The half-life for the racemate has been reported to lie within the range of 5 to 6 hours. Whereas the major metabolites of ketorolac are glucuronide conjugate , which may also be formed in the kidney, and p-hydroxy ketorolac. Neither metabolite has a significant analgesic activity (19).

The most frequent side effects were nausea and vomiting in the placebo group. Visceral and pelvic pains were the frequent causes of the post-operative nausea and vomiting. Studies reported the improvement of the nausea after the treatment of the pain (20).The reason for a high incidence of nausea and vomiting in Group P may be visceral and pelvic pains and a higher consumption of opioids in the post-operative period. Hypotension can be caused by opioid use. NSAIDs are known for their tendency to cause bleeding, as a result of the inhibition of cyclooxygenase and thereby, platelet aggregation. But a meta-analysis of 1368 patients who were undergoing tonsillectomy reported that the incidence of the post-operative bleeding was not affected by the NSAID consumption (21). In the present study, none of the patients had significant post-operative bleeding in the lornoxicam and the ketorolac groups.

Another aspect was the outcomes like the shorter time in physical therapy and the early mobility and rehabilitation which were seen in patients who received NSAIDs pre-emptively. This could be because of the decreased VAS score in those groups, which was correlated with a decrease in PGE2 and IL-6 at the site of the operation (7).

Thus, pre-emptive analgesia may prevent the nociceptive input which is generated during surgery via the sensitizing central neurons. Owing to this ‘protective’ effect on the nociceptive system, pre-emptive analgesia has the potential to be more effective than a similar analgesic treatment which is initiated after the surgery. It has been suggested that pre-emptive analgesia may reduce the risk of developing chronic post-operative pain (1). In a study on patients who were undergoing limb amputation, who were allocated pre and intra-operative epidural blockade or an intra-operative blockade alone, the occurrence of phantom limb pain for the subsequent 12 months was assessed. The results showed a significant reduction in the phantom limb pain 6 months post-operatively in the pre- and the intra-operative groups (1). Post-operative lornoxicam should also be compared to pre-emptive lornoxicam to unlock its true pre-emptive analgesic effect. The follow up of the patients should have been made beyond 24 hours in order to assess the effect of the pre-emptive analgesics, the post-operative recovery, and the early rehabilitation.

Conclusion

Lornoxicam and ketorolac are useful pre-emptive analgesics which are used for the post-operative pain, especially in patients who undergo abdominal surgeries and have a significant opioid sparing effect. This minimises the related adverse effects of the opioids and at the same time, improves the quality of the post-operative analgesia. Lornoxicam appears to be better than the ketorolac analgesic, as was seen by a lesser VAS score, a better quality of analgesia and less tramadol requirement which were related to its use. Hence, lornoxicam is an equally effective a pre emptive analgesic as compared to ketorolac.

Acknowledgement

We, the authors, sincerely appreciate the contributions of Dr Dinesh K, Professor Anaesthesiology, Dr.T.N.Kumar, Professor and Head Pharmacology, Dr.Somasekharam P, Professor and Head Anesthesiology, SDUMC, Kolar in all aspects of the study.

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DOI and Others

DOI: JCDR/2012/4026:2068

Financial OR OTHER COMPETING INTERESTS:
None.

Date of Submission: Oct 07, 2011
Date of Peer Review: Jan 14, 2012
Date of Acceptance: Jan 23, 2012
Date of Publishing: May 01, 2012

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