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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
Original article / research
Full Version
Intraperitoneal Instillation of Magnesium Sulphate and Dexmedetomidine for Postoperative Analgesia after Laparoscopic Cholecystectomy- A Randomised Clinical Study
Correspondence Address :
Dr. Manju Lata Shakya,
Bhajanjeet Colony, Near Holy Cross Ashram School, Datia, Madhya Pradesh, India.
E-mail: dr.manjushakya@gmail.com
Introduction: Magnesium sulphate and dexmedetomidine can decrease the duration and intensity of postoperative pain due to their antinociceptive effects. Magnesium sulphate blocks N-methyl-D-aspartate receptor (NMDA) channel in a voltage dependant way, while dexmedetomidine acts on dorsal root neurons.
Aim: To compare the analgesic efficacy and duration of postoperative analgesia after intraperitoneal instillation of magnesium sulphate and dexmedetomidine in laparoscopic cholecystectomy.
Materials and Methods: The present study was a randomised clinical study, in which 90 patients of age 18-60 years, belonging to American Society of Anaesthesiologists (ASA) grade I or II were randomly selected and divided in three groups. Group M received magnesium sulphate 50 mg/kg with 0.25% bupivacaine 30 mL, group D received dexmedetomidine 1 µg/kg with 0.25% bupivacaine 30 mL, and group B received 0.25% of plain bupivacaine 30 mL. Pain was assessed using Visual Analog Scale (VAS) score as primary outcome, recorded at 0, 2, 4, 6, 8, 10, 12 and 24 hours after surgery. Time to rescue analgesia (VAS ≥4 or on demand) and patients satisfaction score were the secondary outcomes. All recorded data were analysed by statistical test (Analysis of Variance (ANOVA), post-hoc Tukey’s HSD (Honest Significant Difference) test and Chi-square test).
Results: The mean VAS score was 2.40±0.84, 2.57±0.78 and 2.88±0.92 in group M, group D and group B, respectively (p<0.05). The total analgesic requirement (Paracetamol) in first 24 hours postoperatively was lower in group M (1.73±0.58 gm), and group D (2.17±0.53 gm), than group B (2.70±0.47 gm). Highly satisfied patients in group M were 10, group D were 03, and none in group C. There were 14 highly dissatisfied patients in group B. The difference in the patient satisfaction score between groups was statistically significant (p=0.0002). Time to first rescue analgesia was highest in group M then group D.
Conclusion: Intraperitoneal instillation of magnesium sulphate was found to be superior for postoperative analgesia in first 24 hours after laparoscopic cholecystectomy as reflected by a lower VAS score and longer duration of analgesia.
Bupivacaine, Patient satisfaction, Visual analogue scale score
Laparoscopic cholecystectomy is a common day care procedure. The pain after open cholecystectomy is mostly parietal whereas it is more of visceral following laparoscopic cholecystectomy (1). The pain occurs due to stretching of the abdominal wall during the pneumoperitoneum and release of inflammatory mediators, local dissection and irritation of the peritoneum, or CO2 used for pneumoperitoneum (2). The pain can be prevented or reduced by blocking the nociceptor before their stimulation via use of local anaesthetics (3). Many studies have demonstrated the effectiveness of local anaesthetics instilled intraperitoneal, alone or mixed with other drugs for postoperative analgesia in laparoscopic cholecystectomy but, there is no consensus regarding the dose, concentration, site and manner of administration (4),(5),(6).
The antinociceptive effect of magnesium sulphate relieves chronic pain and it can also decrease the duration and intensity of postoperative pain (7). The postoperative pain free period is longer after intraperitoneal instillation of bupivacaine additive with magnesium sulphate (7).
Dexmedetomidine, used in combination with local anaesthetic, is associated with prolonged analgesic effects. Studies on the role of intraperitoneal instillation of dexmedetomidine for postoperative analgesia, suggest its role in prolonging the duration of analgesia in Transversus Abdominis Plane (TAP) block in various surgeries (8),(9).
There is need for multimodal postoperative analgesia for laparoscopic procedure. Comparative studies have not been done between magnesium sulphate and dexmedetomidine for postoperative analgesia in laparoscopic cholecystectomy. This study was designed to compare, duration of analgesia after intraperitoneal instillation of magnesium sulphate with bupivacaine to dexmedetomidine with bupivacaine. Primary outcome was VAS score, and secondary outcomes were time to first resque analgesia, patient’s satisfaction score and side effect (if any).
This randomised clinical study was carried out in the Department of Anaesthesia, Government Medical College, Rewa, Madhya Pradesh, India, from April 2018 to March 2019. After getting clearance from Institutional Ethics Committee (IEC) (91/19) and informed consent from every patient, this study was carried out on 90 patients.
Inclusion criteria: Patients between 18-60 years of age, ASA grade I and II, of either sex, posted for laparoscopic cholecystectomy under general anaesthesia.
Exclusion criteria: Patients with allergy to study drugs, chronic alcoholism, systemic diseases like severe heart disease, lung disease, diabetes mellitus etc., renal dysfunction, and patients who refused to consent.
Sample size calculation: After considering power of study by 90% and level of significance with 5%, calculated sample size came out 28 patients in each group, so decided to select total 90 patients after randomisation (n=30) using computer based randomisation software, “Random Allocation Software 1.0” (Copyright © 2017 Informer Technologies, INC) as under (Table/Fig 1).
Group M- Received intraperitoneal instillation of 30 mL, inj. bupivacaine 0.25% and inj. magnesium sulphate 50 mg/kg b.w.
Group D- Received intraperitoneal instillation of 30 mL, inj. bupivacaine 0.25% and inj. dexmedetomidine 1 µg/kg b.w.
Group B- Received intraperitoneal instillation of 30 mL of inj. bupivacaine 0.25%.
Procedure
All patients were kept nil by mouth for at least six hours prior to surgery. After shifting them to the operation theatre, monitors were attached and baseline parameters (heart rate, non invasive blood pressure, and Oxygen Saturation (SpO2) and End Tidal Carbon Dioxide (ETCO2) values) were recorded. Intravenous access secured with 18 G i.v. (intravenous) cannula. All the patients were premedicated with Inj. glycopyrrolate 0.01 mg/kg, Inj. midazolam 0.03 mg/kg and Inj. fentanyl 2 µg/kg. After preoxygenation for 3 minutes, patients were induced with Inj. propofol 2.5 mg/kg and Inj. succinylcholine 1.5 mg/kg, laryngoscopy was performed and orotracheal intubation was done. The correct placement of endotracheal tube was confirmed by five point auscultation and ETCO2. Anaesthesia was maintained with O2 40%, N2O 60%, isoflurane and intermittent Inj. atracurium i.v.
After cholecystectomy and achievement of haemostasis, abdomen was thoroughly washed to remove the blood clots and debris. The surgeon instilled 10 mL of study solution in the subdiaphragmatic space and 10 mL at suprahepatic surface of liver and remaining drug in the gallbladder fossa under vision, which was prepared by investigator. Patients who required intraperitoneal drain after surgery were excluded from this study. All the patients received inj. diclofenac 75 mg IV at the end of surgery and same dose was repeated after 12 hours, as per institutional protocol.
All the patients were reversed with Inj. neostimine 0.05 mg/kg and Inj. glycopyrrolate 0.01 mg/kg. Patients were extubated after absence of residual neuromuscular deficit.
After surgery, patients were transferred to the postanaesthesia care unit. Pain severity was assessed using a VAS at 0, 2, 4, 6, 8, 10, 12 and 24 hours after surgery. When patients complained of pain or VAS ≥4 for first time in postoperative period, paracetamol 1 gm i.v. infusion (max 4 gm in 24 hours) was given as rescue analgesic. The duration of analgesia and total paracetamol consumption in first 24 hours were duly noted.
Patient’s satisfaction score was assessed and noted at 24 hours after surgery, using a 5-point patient’s satisfaction score to evaluate the level of postoperative analgesic satisfaction.
Statistical Analysis
All recorded data were tabulated and statistically analysed by appropriate statistical test (ANOVA, post-hoc tukey’s HSD test and Chi-square test). Mean values were compared for normally distributed parameters by using ANOVA. Post-hoc (tukey’s HSD) test was used if statistically significant difference was found with ANOVA to assess pair wise comparisons. Categorical outcomes were compared using Chi-square test between study groups. The p-value <0.05 was considered statistically significant. All statistical calculations were performed using Statistical Package for the Social Sciences (SPSS) software version 22.0.
All the three groups were comparable with respect to demographic profiles and there was no statistically significant difference found in between the groups (Table/Fig 2).
The duration of analgesia was longest in patients of group M, and shortest in patients of group B (4.93±1.14 hrs). Duration of analgesia was significantly different between all the three groups. Paracetamol requirement was lower in group M (1.73±0.58 gm) (Table/Fig 3).
Immediately after surgery, VAS was zero in all patients. After 2 hours and 4 hours of surgery, no statistical difference was noted between group M and group D. After 6 hours of surgery, VAS was significantly lower (p-value <0.0001) in patients of group M (2.53±0.86) and (p-value=0.0338) in patients of group D (3.00±0.95) as compared to patients of group B (3.53±0.90). However, no statistical difference noted between group M and group D. After 8 hours of surgery, VAS was significantly lower in patients of group M as compared to patients of group D (3.57±0.86) and patients of group B (3.00±0.79). However, no statistical difference (p-value=0.0805) was noted between groups D and group B. The patients of group D have received rescue analgesia at mean time 7.60±1.22 hours which led to lower VAS at subsequent points of time. After 10 hours of surgery, VAS was not statistically comparable (p-value >0.05) between patients of all the three groups. The patients of group M received rescue analgesia at mean time 9.30±1.64 hours which led to decreased VAS at subsequent point of times (Table/Fig 4).
According to patients’ satisfaction score, group M patients were highly satisfied (33.33%) by pain relief procedure than patients of group D and group B at any point of time. Group B patients were highly dissatisfied patients (46.67%). The difference in the patient satisfaction score between groups was statistically significant (Table/Fig 5).
Bradycardia (Heart rate <60/Min.) was seen in six patients of group D. The incidence of nausea was seen in six patients of group M, four patients of group D and six patients of group B. Vomiting was not seen in any of the patients of all the three groups. No incidence of sedation, hypotension or hypertension was seen in any of the group in first 24 hours postoperatively (Table/Fig 6).
Intraperitoneal instillation of analgesics drugs is a single-shot technique and provides a substantial period of postoperative analgesia with negligible side-effects. The present randomised and controlled study shows that intraperitoneal instillation of magnesium sulphate and dexmedetomidine both provide postoperative analgesia after laparoscopic cholecystectomy however, magnesium sulphate prolongs the duration of analgesia more than the dexmedetomidine.
The dose of magnesium sulphate used in this study was based on previous studies (10). Maharjan S and Shrestha S, in their randomised study on 60 patients found that magnesium sulphate adjuvant with bupivacaine prolonged the duration of postoperative analgesia after laparoscopic cholecystectomy in comparison to bupivacaine alone but they did not compared it with any other additive (11).Similar results were also found in a study done by Yadava A et al., when they compared bupivacaine-magnesium sulphate (MB) with tramadol (7). In the present study, duration of analgesia was also high with magnesium sulphate as in previous studies (11),(12).
Magnesium reduces calcium influx to the cell, and also antagonises NMDA receptors blocking pain processing in the central nervous system (13). Due to blockade of this receptor, magnesium sulphate decreases postoperative pain.
Rapolu S et al., evaluated the intraperitoneal instillation of dexmedetomidine adjuvant with bupivacaine for postoperative analgesia in 100 patients in two groups following laparoscopic cholecystectomy (14). Similarly, they found the mean duration of analgesia was more in dexmedetomidine group as compared to control group. Ali U et al., compared the intraperitoneal instillation of bupivacaine alone with dexmedetomidine or tramadol for postoperative analgesia following laparoscopic cholecystectomy (8). They concluded that intraperitoneal instillation of dexmedetomidine 1 mcg/kg in combination with bupivacaine after laparoscopic cholecystectomy significantly increases the duration of postoperative analgesia and significantly reduces the analgesic requirement in postoperative period, as compared to bupivacaine alone and may be better than bupivacaine combined with tramadol. Present study also found long duration of analgesia as previous studies but, it was lower than magnesium sulphate (14),(15).
Several studies has been done using intraperitoneal instillation of magnesium sulphate (12),(13),(16) and dexmedetomidine (17),(18),(19) but not compared their analgesic efficacy which was compared in this study.
The total analgesic requirements (paracetamol) in first 24 hours postoperatively were lower in group M and group D than group B which was statistically significant, and the results were in concordance with a study done by Yadava A et al., where they have compared magnesium sulphate with tramadol (7). Pati BK, observed the total analgesic consumption was lower in group BD (Bupivacaine with Dexmedetomidine) compared to group B (Bupivacaine), which was statistically significant (15).
Mean VAS score increased till 8 hours in group M in present study. Similarly, Yadava A et al., was also found lower mean VAS score in MB (magnesium sulphate+bupivacaine) group then TB (tramadol+bupivacaine) group, which was statistically significant (p<0.05) (7). In some previous studies (19),(20), lower mean VAS score was also evaluated with dexmedetomidine in comparisons to control group but this VAS score was more than the VAS with magnesium sulphate as with present study.
This study assessed patient’s satisfaction score at 24 hours after surgery, and revealed number of highly satisfied patients in group M, group D and group B were 10, 3 and nil respectively. Fourteen patients in group B were dissatisfied. The difference in the patient satisfaction score between the groups was statistically significant (p=0.0002).
In this study, postoperative bradycardia (Heart rate <60/min) was 20% among group D and it was easily manageable, while patients of group M have no such episode. The mechanism of dexmedetomidine induced bradycardia is activation of the alpha-2 adrenergic receptors, results in a decrease in the discharge of the sympathetic signals and a rise in the parasympathetic activity. Similarly, Elnabtity AM and Ibrahim M reported bradycardia among patients of group BD (bupivacaine with dexmedetomidine), with an incidence of 11.5 (9).
Shukla U et al., found 3 cases having nausea in postoperative period with dexmedetomidine (17) and Ali U et al., found the incidence of nausea in 80% patients with magnesium sulphate group (8). This may be due to opioids used for rescue analgesia. In present study, nausea was seen in six cases in group M and four cases in group D. No episode of vomiting was observed in any patients of all the three groups.
In present study, authors did not found other side-effects like sedation or hypotension in any of the study group in first 24 hours postoperatively; similar results were concluded in study conducted by Rapolu S et al., and Oza VP et al., (14),(20). This was due to intraperitoneal instillation of drugs not by intravenous route.
Present study showed the superiority of intraperitoneal instillation of magnesium sulphate over dexmedetomidine in providing analgesia in first 24 postoperative hours, as evident by longer duration of analgesia along with lesser consumption of paracetamol and lower VAS score.
Limitation(s)
Postoperative pain is a subjective experience and can be difficult to quantify and compares objectively. As it was a single centre study, there is a need for multicentric studies for more conclusive results.
It can be concluded that intraperitoneal instillation of magnesium sulphate was found to be superior for postoperative analgesia in first 24 hours after laparoscopic cholecystectomy as reflected by a lower VAS score and longer duration of analgesia along with lesser consumption of paracetamol. Intraperitoneal instillation can be considered as a part of multimodal analgesia technique for laparoscopic surgeries in future. An optimal dose finding study is also the need of hour with using large number of patients.
DOI: 10.7860/JCDR/2022/51536.15849
Date of Submission: Jul 24, 2021
Date of Peer Review: Sep 08, 2021
Date of Acceptance: Nov 19, 2021
Date of Publishing: Jan 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
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