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

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On Sep 2018

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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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"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.
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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,
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
(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)
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.
On April 2011

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
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : September | Volume : 16 | Issue : 9 | Page : UC19 - UC23 Full Version

Effectiveness of Low Dose Dexmedetomidine for an Oligaemic Field in Middle Ear Surgery: A Randomised Control Trial

Published: September 1, 2022 | DOI:
Nitin Agrawal, Smriti Sinha, Reena R Kadni, Shekhar Ramkrishnan

1. Assistant Professor, Department of Anaesthesiology, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India. 2. DrNB Trainee Critical Care Medicine, Department of Critical Care Medicicne, Tata Main Hospital, Jamshedpur, Jharkhand, India. 3. Senior Consultant, Department of Anaesthesiology, Bangalore Baptist Hospial, Bengaluru, Karnataka, India. 4. Senior Consultant, Department of Anaesthesiology, Bangalore Baptist Hospial, Bengaluru, Karnataka, India.

Correspondence Address :
Dr. Smriti Sinha,
312, Dahlia Block, Aashiyana Garden, Sonari, Jamshedpur, Jharkhand, India.


Introduction: Microscopic middle ear surgeries are best done under hypotensive anaesthesia to provide an oligaemic field. Dexmedetomidine is an α2 agonist which produces hypotension by sympathetic response blockade.

Aim: To study the effectiveness of low dose dexmedetomidine in providing an oligaemic field. The additional requirement of inhalational agent required to maintain the oligaemic field in the control group, intubation response and postoperative analgesia were also assessed.

Materials and Methods: The randomised, placebo-controlled double-blind study was conducted by recruiting 48 patients in the study, who were divided into two groups i.e, study group (n=24) and placebo group (n=24). The study group received low dose dexmedetomidine infusion (0.5 μg/kg loading dose followed by 0.2 μg/kg/hr) and placebo group received weight-adjusted saline. The quality of the surgical field was assessed on a score of 0-5. The Minimum Alveolar Concentration (MAC) of inhalational agent needed, postoperative sedation score and pain score were noted. All the data were recorded in Statistical Package for Social Sciences (SPSS) software, version 22.0.

Results: The mean score of quality of the surgical field in the study group was 2.00±0.59, compared to 3.50±0.88 in the placebo group. The mean MAC of isoflurane was 1.32±0.31 in the placebo group and 0.85±0.23 in the study group (p-value=0.03). The study group had a Ramsay sedation score of 3.08±0.65 compared to 2.29±0.75 in the placebo group at 5 minutes after extubation (p-value <0.001). The mean pain score in the dexmedetomidine group in 10 minutes postoperative period was 1.83±2.25, while in placebo group it was 3.25±1.96 (p-value=0.025). However, over the next 20-60 minutes postoperative period the pain score between the two groups were comparable, with no significant difference in analgesia, postoperative shivering and other side-effects.

Conclusion: A low dose dexmedetomidine can effectively provide a bloodless field for middle ear microsurgical procedures.


Bloodless surgical field, Controlled hypotension, Hypotensive anaesthesia

The middle ear microsurgeries need a bloodless surgical field, attention to patient’s head positioning, airway management, facial nerve monitoring, avoidance of nitrous oxide, smooth and calm recovery, and prevention of postoperative nausea and vomiting (1). The bloodless surgical field is preferred for safe tympanic membrane and ossicular reconstruction as blood can obscure the surgical field. Various methods are employed including reverse Trendelenburg position, local infiltration with vasoconstrictors and pharmacological agents to provide controlled hypotension. Controlled hypotension is a method by which arterial blood pressure is decreased predictably and deliberately to decrease blood loss. The level of hypotension is determined by achieving a bloodless field within the safety limits of cerebral and coronary flow. This safety limit is not fixed and generally taken as Mean Arterial Pressure (MAP) as low as 50 mmHg or a 30% drop in MAP in American Society of Anaesthesiologists (ASA) physical status I subject (2). The safety limit of a chronic hypertensive patient will be different and they may not tolerate a drop of more than 25 % of the MAP, due to the shift of cerebral auto regulation limit towards higher blood pressure (2).

Dexmedetomidine is a centrally acting α 2A agonist. It acts by presynaptic activation of α-2 adrenoceptors, thus inhibiting the release of norepinephrine, terminating the propagation of pain signals and postsynaptic activation of α-2 adrenoceptors in the Central Nervous System (CNS), thus inhibiting sympathetic activity. Dexmedetomidine evokes a biphasic blood pressure response. At lower doses, the dominant action of dexmedetomidine is sympatholytic mediated by α-2A adrenergic receptor, and thus is used to provide controlled hypotension by decreasing blood pressure and heart rate, these actions have been put to use, as an infusion, for providing ideal condition for middle ear microsurgical procedure (3).

Under general anaesthesia, dexmedetomidine is commonly used to attenuate sympathoadrenal response, to provide analgesia by reducing the requirement of intraoperative and postoperative opioid requirement, emergence agitation prevention and reducing postoperative shivering (4). The doses used varies from 1 μg/kg to 0.5 μg/kg loading dose with the maintenance of 0.75-0.4 μg/kg/hr (3),(4).

The sympatholytic effect of dexmedetomidine in adults was studied in previous research using dose of 1 μg/kg loading dose followed by 0.4-0.6 μg/kg/hr (5),(6),(7),(8). The adverse effects of dexmedetomidine are hypotension, hypertension, nausea, hypoxia, bradycardia, first and second-degree atrioventricular block as well as atrial fibrillation at higher doses (9). In an attempt to avoid adverse effects of higher doses, in the current study, dexmedetomidine was used at a low dose of 0.5 μg/kg intravenously over 10 minutes as a bolus dose and then infusion at the rate of 0.2 μg/kg/hr. The primary objective was to assess the effectiveness of test drug in lower doses to provide a bloodless field for middle ear microsurgical procedure. The secondary objectives were to assess haemodynamic response to laryngoscopy and intubation, the stress response of surgery by assessing heart rate and MAP and observe any other adverse effects postoperatively.

Material and Methods

The randomised, placebo-controlled double-blinded study was conducted at the Bangalore Baptist Hospital, Bengaluru, Karnataka, India, from January 2013 to December 2013. The approval from Institutional Ethics Committee was taken (BBH/IRB/2012/019). The patients were explained about the procedure and informed consent was taken to include in the study.

Inclusion criteria: The patients scheduled for elective, middle ear surgeries under general anaesthesia in the age group of 16-55 years in American Society of Anesthesiologists (ASA) grade I and II were included in the study if they consented to it.

Exclusion criteria: Pregnant, lactating mothers, patients with renal impairment, hepatic dysfunction, history of allergic drug reactions and on antihypertensive medication with α-2 agonists, α methyldopa were excluded from the study. Patients in whom dexmedetomidine infusion was discontinued due to haemodynamic derangements during the study were also excluded from the study.

Sample size calculation: Based on a pilot study, the surgical field scoring (primary objective) was expected to lower by 30% in patients who received dexmedetomidine compared to the placebo group. The sample size was calculated as 48 (24 patients per group) with 80% power and a significance level of 0.05. The sample size was calculated by the application online “Sample size calculator” (10).

Study group (n=24): Dexmedetomidine 0.5 μg/kg intravenously over 10 minutes as a bolus dose, and then infused at the rate of 0.2 μg/kg/hr (100 μg/50 mL syringe -2 μg/mL, diluted with normal saline) till the end of the surgery.
Placebo group (n=24): Received weight-adjusted normal saline at the same volume (ml) and rate (ml/hr) as in study group (Table/Fig 1).

Allocation process: Patients were randomised by using the block randomisation process, with each size block of 4, to get equal numbers in both study as well as the placebo group. With a block size of 4, there were six possible ways to equally assign participants to a block. Allocation concealment included sequentially structured alphabets of 4 kept in a sealed opaque envelope. The patient and the investigator involved both were blinded. The infusion was prepared by an anaesthesiologist, not involved in the study.


Preoperative assessment was done for all the patients and nil per orally for 6 hours before surgery followed. All patients were pre-medicated with oral alprazolam 0.5 mg at night one day prior and in the morning of the surgery for anxiolysis. The monitors including non-invasive blood pressure monitor, pulse oxymeter, capnography and integrated anaesthetic gas analyser (Aspire 7900 with Philips IntelliVue MP40) were used intraoperatively to monitor Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Mean Arterial Pressure (MAP), Heart Rate (HR), oxygen saturation (SpO2), end-tidal CO2, and Minimum Alveolar Concentration (MAC) throughout the surgery. Two intravenous accesses were secured, one for fluid and the other one dedicated to study drugs. All the patients were pre oxygenated and premedication with glycopyrrolate 0.2 mg intravenously (i.v.) in the operation theatre. The induction of anaesthesia was done with a graded dose of propofol up to 2 mg/kg, fentanyl 2 μg/kg and atracurium 0.5 mg/kg i.v., followed by endotracheal intubation. Intraoperative analgesia was provided by morphine 0.1 mg/kg i.v. as a bolus. Maintenance of anaesthesia was with 50% oxygen, 50% air (FiO2 of 0.5) with low flow anaesthesia, 1% isoflurane and intermittent positive pressure ventilation. The target of induced hypotension was a 30% reduction of MAP from baseline, which was intraoperative done by titrating inhalational agents to the desired effect. Controlled hypotension was provided in all the patients and MAC of isoflurane needed was also noted. Intravenous atracurium 0.1 mg/kg was used for maintenance.

Surgical field: Quality of the surgical field was assessed at the end of the surgery by asking the operating surgeon to score on a scale of 0-5, where ‘0’ meant no bleeding, and ‘5’ stood for severe bleeding which needed continuous suctioning . The desired level was to achieve ≤2 (11).

Sedation score: The sedation score was assessed by Ramsay sedation score recorded preoperatively, after the bolus infusion, before induction and at 30 min postoperatively (12).

Any hypertension and tachycardia more than 20% from preoperative value with MAC level of 1 was considered as inadequate analgesia and i.v. fentanyl 1 μg/kg was given.

Adverse effects:

• Hypotension (MAP <60 mmHg) was treated with intravenous fluids and IV ephedrine 6 mg.
• Severe bradycardia (HR<40/min) was treated by atropine 0.6 mg IV. At the end of the surgery, ondansetron 0.1 mg/kg IV was administered to all patients, residual neuromuscular block was reversed with neostigmine 0.05 mg/kg and glycopyrrolate 0.01 mg/kg IV.

Postoperative period: During the postoperative period nausea, vomiting, respiratory depression, shivering, Visual pain analogue (VAS) scores (0=no pain, 10=worst pain), sedation (Ramsay sedation score) and vitals were recorded.

Recovery: The recovery of all the patients was assessed by Aldrete’s score and shifting from the postoperative ward was done after achieving satisfactory recovery (13).

Statistical Analysis

All the data were recorded in Statistical Package for Social Sciences (SPSS) software (version 22.0). The primary objective, quality of the surgical field was compared by the Mann-Whitney U test. Results on continuous measurements like vitals were presented as Mean±SD (Minimum-Maximum), and an independent student t-test was used to compare between the groups. Significance was assessed at a 5 % level of significance.


The basic characteristics including, age, gender, weight and ASA grade were comparable between the two groups (Table/Fig 2).

The quality of the surgical field was better in the study group (Table/Fig 3). The mean MAC of isoflurane was 1.32±0.31 in the placebo group and 0.85±0.23 in the study group, with p-value of 0.03.

The effect on stress response of intubation assessed by change in HR and MAP at 30 seconds after intubation and the increase in HR was more in placebo group compared to study group. This was statistically significant (p-value <0.001). The MAP in the study group decreased compared to baseline after 30 seconds of intubation while increase in MAP was noted in placebo group. From 30 seconds postintubation to postoperative period, there was a significant difference between the two groups in HR and MAP (Table/Fig 4), (Table/Fig 5).

The SpO2 and EtCO2 did not show significant changes except at 45 minutes and 15 minutes, respectively. The baseline SpO2 was lesser in the study group but not clinically significant (Table/Fig 6).

The Ramsay sedation score was higher in the study group after 10 minutes of bolus dose and immediately postextubation postoperatively (p-value <0.001). After 30 minutes postextubation sedation scores were comparable in both the groups. All the patients in the study group were arousable, comfortable and maintained normal oxygen saturation on room air in Post Anaesthesia Care Unit (PACU) (Table/Fig 7).

The mean VAS pain score was lower in the study group in the immediate postoperative period. However, over the next 20-60 min postoperative period the pain score between the two groups were comparable.

The hypotension and bradycardia were not found in any patient throughout the study, while the incidence of shivering and postoperative nausea and vomiting (PONV) were similar in both groups (Table/Fig 8).


The present study was designed to study the effect of low dose dexmedetomidine in middle ear surgeries, which was found to provide an oligaemic surgical field without clinically significant adverse effects of higher doses. The blunting of intubation response and prolongation of postoperative analgesia was not found with low doses of dexmedetomidine.

Controlled hypotension and oligaemic surgical field: In current study, oligaemic surgical field could be achieved with 0.5 μg/kg loading dose followed by 0.2 μg/kg/hr of dexmedetomidine in middle ear surgery. In children for cochlear implant surgery and nasal surgery, to optimize the surgical field, dexmedetomidine was used in low doses of 0.5 μg/kg followed by 0.2-0.5 μg/kg/hr. Out of 35 patients, 33 patients had bleeding score ≤ 2 in cochlear surgery (14). For nasal surgery in pediatric patients, 97% of patients attained an intraoperative surgical field score of ≤ 2 (15). In another study, a loading dose of 1 μg/kg of dexmedetomidine followed by 0.4-0.8 μg/kg/hr helped in achieving intraoperative surgical field score of ≤2 in Functional Endoscopic Sinus Surgery (FESS) surgery (16). A randomised control trial, conducted with dexmedetomidine with loading dose of 1 μg/kg followed by 0.4-0.8 μg/kg/hr for endoscopic surgery, concluded similar findings of lower Besant’s scale score of intraoperative blood loss (17). Another study by Durums M et al., using dexmedetomidine 1 μg/kg for 10 minutes followed by 0.5 μg/kg/hr, in tympanoplasty surgeries found significantly low blood loss in patients who received dexmedetomidine compared to placebo (5). Other than ENT surgeries, research was done on scoliosis patients where dexmedetomidine was used in a dose of 1 μg/kg followed by 0.2-0.5 μg/kg/hr for spine deformity correction surgery. They concluded that the blood loss was significantly low (18). In the current study, low dose of dexmedetomidine as bolus and maintenance was found to be effective in achieving oligaemic surgical field.

Nasreen F et al., conducted a study in middle ear surgery, intending to maintain a 30% reduction in MAP, comparing dexmedetomidine 1 μg/kg for 10 minutes followed by 0.4 μg/kg/hr with placebo, concluded lower percentage of halothane use in dexmedetomidine group (6). Gupta K et al., also conducted a study in patients requiring middle ear surgery with the goal of a 30% reduction in MAP for the oligaemic surgical field. They used dexmedetomidine in a dose of 0.5 μg/kg/hr, which was started after induction of anesthesia and used isoflurane as an inhalational agent (7). The mean dose of isoflurane in the placebo group was 1.6%, while, in the dexmedetomidine group mean was 0.8%. The use of an inhalational agent to produce controlled hypotension is standard practice, but the anticipated effect to decrease blood loss is controversial as the vasodilation produced by higher doses of inhalational agents can increase the blood loss (19). At a higher concentration of inhalational agents, vasodilatation can increase cerebral circulation and in effect lead to increased intracranial pressure. The cerebral auto regulation gets impaired at higher concentrations of isoflurane (20). In the current study, to achieve oligaemic field in the placebo group, higher MAC of the inhalational agent (isoflurane) was needed, which was comparable to the previous study (7).

The low dose dexmedetomidine decreases the requirement of isoflurane and is an effective adjuvant to decrease blood loss in safer doses of isoflurane. More than 1.3 MAC of isoflurane was found to be MAC of burst suppression which will not be required with dexmedetomidine as an adjuvant (21).

Intubation response: Dexmedetomidine is known to prevent intubation response in a dose of 1 μg/kg and 0.75 μg/kg effectively (22),(23). The lower dose of 0.5 μg/kg used in the current study was effective in preventing any change in MAP, while in HR there was an almost 4% increase. The sympathetic response was prevented but complete abolition was not there.

Sedation, postoperative analgesia and side-effects: In the present study, hypotension and bradycardia were not found in any patient. The oxygen saturation and EtCO2 remained well preserved in both the groups, the difference in sedation score was highly significant between the two groups after the bolus infusion and in the immediate postoperative period. The patients in dexmedetomidine were asleep but arousal in the immediate postop period. These findings were in line with a previous study (24).

Intraoperative dexmedetomidine helps in providing postoperative analgesia and decreasing postoperative shivering (25). These effects were found to be more prominent after loading dose of 0.75μg/kg and 1 μg/kg than 0.5 μg/kg (26). In current study, the mean pain score in dexmedetomidine group was low only in the immediate postoperative period. Any prolonged effect was not noted. In the recovery area, the incidence of PONV and shivering were similar in both groups and comparable. The postoperative effects of dexmedetomidine in form of prolonged analgesia and decrease in shivering (two patients in both groups) were not found with low dose in the current study.


The sample population consisted only adult patients who were relatively healthy (ASA physical status grade I and II). It needs to be determined whether the present findings can be generalised to other age group and ASA status as well.


Dexmedetomidine 0.5 μg/kg bolus infusion over 10 minutes before induction followed by 0.2 μg/kg/hr maintenance infusion can be recommended for all patients of ASA status I and II undergoing middle ear microsurgeries for providing controlled hypotension and better surgical field for the Ear, Nose and Throat surgeon. This technique could also be used for patients undergoing any other surgical procedure safely where the operating field has to be clear and to reduce blood loss.


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DOI and Others

DOI: 10.7860/JCDR/2022/52943.16848

Date of Submission: Oct 20, 2021
Date of Peer Review: Nov 20, 2021
Date of Acceptance: Apr 26, 2022
Date of Publishing: Sep 01, 2022

• 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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