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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
Consequence and Prevention of Haemodynamic Stress Response during Laryngoscopy and Endotracheal Intubation with Oral Ivabradine- A Multicentric Randomised Controlled Study
Correspondence Address :
Ankita Rushik Patel,
12, Tirthnagar Society Part-3, Bhuyangdev Cross Road, Ghatlodia, Ahmedabad, Gujarat-380061, India.
E-mail: drankitapatel30@gmail.com
Introduction: Laryngoscopy and intubation cause lots of haemodynamic changes which adversely affects the patient during the perioperative period. Various methods have been applied to reduce stress response in high risk patients. Ivabradine is a unique cardiotonic drug which reduces the heart rate without compromising blood pressure, specially in debilitating and severely ill patients.
Aim: To evaluate role of oral ivabradine in attenuating the haemodynamic stress response to laryngoscopy, intubation and extubation in patients undergoing surgical procedure under General Anaesthesia (GA) and to note the side-effects and its complications, if any.
Materials and Methods: A randomised controlled multicentric study was conducted in 200 American Society of Anaesthesiologists’ (ASA)-I and II patients undergoing various surgery under general anaesthesia. The patients were randomly divided into two groups: group A (Test group, n=100) received 5 mg oral ivabradine one hour before intubation, group B (Control group, n=100) received placebo. The pulse rate, Systolic Blood Pressure (SBP) and Diastolic Blood Pressure (DBP) and Mean Arterial Pressure (MAP) were recorded at intubation and 10 minutes postintubation along with at extubation and postintubation period till 10 minutes. Patients were monitored for haemodynamic changes as per the protocol. Statistics analysis was done using Statistical Package of Social Science (SPSS) software version 21.0.
Results: Demographic findings were comparable in both groups. Heart rate (84.36±4.11 versus 114.19±12.4), SBP (120±10.5 versus 150±17.5), DBP (76.08±4.29 versus 113.2±10.6), MAP (91.3±6.7 versus 124.4±12.8) at 10 minutes postintubation decreased more in test group as compared to control group from baseline (p-value <0.005). Similarly, heart rate (84.13±2.06 versus 110.58±8.92), SBP (123.4±10.06 versus 150.8±13.1), DBP (84.08±2.02 versus 107±10.2), MAP (97.8±6.47 versus 122.06±9.7) at 10 minutes postintubation decreased significantly in test group as compared to control group from baseline (p-value <0.005).
Conclusion: Oral ivabradine is a very useful cardiotonic drug which facilitates the fluctuation in heart rate during laryngoscopy and endotracheal intubation.
Attenuation, Cardiotonic drug, Diastolic blood pressure, Heart rate, Mean arterial pressure, Systolic blood pressure
Stress response during laryngoscopy and endotracheal intubation leads to increase in heart rate, blood pressure and can cause harmful systemic effects (1). In healthy patients compensatory mechanism is there, however, there are more chances of morbidity and mortality in pre-existing conditions like hypertension, coronary artery disease, recent myocardial infarction, raised intracranial pressure, geriatric population, preeclampsia, aneurismal vascular disorders and ischaemic heart disease (2).
Various techniques help in prevention of stress responses-using intravenous lignocaine, deeper plane of anaesthesia with inhalation agents or opioids, prostaglandins vasodilators, alpha adrenoreceptor antagonists, calcium antagonists, trinitroglycerin, and minimising the duration of laryngoscopy to <15 seconds (3).
Ivabradine inhibits the funny current (“If” channels) in sinoatrial nodal tissue that leads to decrease in the rate of diastolic depolarisation and consequently decreases heart rate without affecting blood pressure (4).
The patients with angina, coronary artery disease, cardiac failure, and obstructive cardiomyopathies are more susceptible to hypoxia.Oral ivabradine drug reduces the heart rate without reducing blood pressure (5),(6). Therefore, the oral ivabradine may be the choice of drug during GA due to its multiple benefits on myocardium. Oral ivabradine can be used in bronchial asthma and diabetic patients due to its advantages over beta blockers (7).
The aim of the present study was to evaluate the role of oral ivabradine in patients scheduled for surgery under GA. The primary outcome measures were the haemodynamic variables (heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure) while the secondary outcome measures were side-effects, if any.
This randomised controlled multicentric study was conducted from December 2021 to June 2022 at the GCS Medical College, Hospital and Research Centre, Ahmedabad and Indira Gandhi Medical College, Research Institute, Puducherry. The ethical approval were obtained from the respective Institutional Ethics Committees, with the following reference numbers- GCSMC/EC/RESEARCH PROJECT/APPROVE/2021/327 (GCS Medical College, Hospital and Research Centre, Ahmedabad), and No386/IEC-33/IGMC&RI/PP-20/2022 (Indira Gandhi Medical College, Research Institute, Puducherry). This Clinical Trial Registry of India registration number is CTRI/2022/04/042188.
Patients written informed consents were obtained. A convenient sampling technique was used. Total 200 patients were enrolled and grouped into two, with 100 in each group (Table/Fig 1). Patients were randomised into group A and group B with the help of computer-generated randomisation in opaque sealed envelopes, prepared by an independent paramedical nursing staff.
• Group-A (Test Group): 100 patients received oral ivabradine (5 mg) one tablet was given an one hour before laryngoscopy and intubation.
• Group-B (Control group): 100 patients received sugar coated tablet (placebo), administered one hour before laryngoscopy and intubation.
Inclusion criteria: Patients in the age group of 20-50 years, undergoing surgeries in GA, ASA grade I and grade II, comprising both sexes were included.
Exclusion criteria: Patients who refused to give consent for this study, with baseline heart rate <60 beats per minute and SBP <100 mmHg, with abnormal electrocardiogram finding, with history of angina, chest pain, palpitations or syncope, with history of any visual disturbances, with liver and kidney dysfunction. Patients who already taking calcium channel blockers, azole antifungals, antiretroviral drugs and macrolide antibiotics and also pregnant and lactating mother were also excluded. Patients with difficult intubation that took more than 20 seconds were also excluded from this study.
Study Procedure
The premedication, induction agent and muscle relaxant were given as per the hospital protocols and following standard fasting guideline. A 18G intravenous cannula taken and intravenous crystalloid 10 mL/kg was started. All ASA basic standard monitoring were applied. Premedication with glycopyrrolate 0.2 mg, inj. midazolam 1 mg i.v. and ondansetron 4 mg were given slowly intravenously before induction. Inj. fentanyl 2 mcg/kg was given for analgesia. All patients were preoxygenated with 100% oxygen for 3 minutes. The patient was induced by injection propofol (2 mg/kg body weight). Intubation was done by using intravenous succinylcholine chloride 2 mg/kg after 60 minutes in ivabradine group-A and placebo in group-B.
Trachea was intubated with portex endotracheal cuffed tube and the time taken for intubation did not exceed 20 seconds. Anaesthesia was maintained with atracurium besaylate 0.5 mg/kg top-up doses; with combination of O2+N2O and inhalational agent. At the end of the surgery, patients were reversed with i.v. neostigmine (0.05 mg/kg) and i.v. glycopyrrolate (0.04 mg/kg) followed by extubation.
Haemodynamic parameters (heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, Oxygen saturation (SpO2) and End-Tidal Carbon Dioxide (ETCO2) were recorded at specific intervals as follows:
1. Preoperatively i.e. after premedication (for baseline values).
2. At the time of induction/intubation, 1 minute after, 3, 5, 8, and 10 minutes after intubation.
3. At the time of extubation, 1 minute after, 3, 5, 8, and 10 minutes after extubation.
All the patients were followed in postoperative period for four hours to check for any adverse effects of oral ivabradine.
Statistical Analysis
Statistics analysis was done using SPSS software version 21.0. Comparison of means between two groups was done using Student t-test or Modified t-test. Else, non parametric data was analysed by Mann Whitney test and categorical data was analysed by Chi-square test. Descriptive statistics was presented in form of numbers and percentages. The p-value <0.05 was taken as statistically significant.
The test and control groups were comparable regarding age, gender, weight, ASA grading, duration of surgery and time of medication, and intubation (Table/Fig 2). SpO2 and EtCO2 were comparable in both groups. There were two patients in test group who developed bradycardia and were excluded from the study.
The mean heart rate in both groups were comparable at baseline, while during intubation and extubation it was significantly less in group A (Table/Fig 3).
Mean SBP in both groups were comparable at baseline. At intubation, postintubation period till 10 minutes, at extubation and postintubation till 10 minutes, mean SBP was significantly less in group A as compared to B (Table/Fig 4).
Mean DBP in test and control group were comparable at baseline. At intubation, postintubation period till 10 minutes, at extubation and postintubation till 10 minutes, mean DBP was significantly less in group A as compared to B (Table/Fig 5).
Mean arterial pressure in test and control group were comparable at baseline, while during intubation and extubation it was significantly less in group A (Table/Fig 6).
There were no major side-effects of oral ivabradine but two patients had developed bradycardia and were managed adequately.
Cardiac and haemodynamic changes were first reported by Reid and Brace in 1940 during laryngoscopy and endotracheal intubation with conventionally used anaesthetic techniques. The sympathetic reflex including increase in heart rate and blood pressure in anaesthetised patients were usually peak after 30-45 seconds of laryngoscope and intubation. These transient changes may be serious and life threatening in patients with cardiovascular and cerebral disorder (2).
Ivabradine was approved by the European Medicines Agency in 2005 and by the United States Food and Drug Administration in 2005 (8). However, ivabradine is indicated for symptomatic treatment of chronic stable angina pectoris with normal sinus rhythm in patients who can not take beta blocker and also it’s being used off label in the treatment of inappropriate sinus tachycardia (9). Initial oral ivabradine doses of 2.5 mg twice a day started and maximum up to 7.5 mg daily is acceptable. However, in several randomised controlled trials, ivabradine can administered 5-10 mg twice daily (10). Ivabradine reduce heart rate in patients who have HR >70 bpm and also incidence of coronary artery disease (11).
Surgery was not allowed to start till period of 10 minutes after intubation for the recording of baseline haemodynamic parameters. In the present study, after intubation all haemodynamic parameters of mean heart rate, SBP, DBP and MAP till period of 10 minutes were significantly less in oral ivabradine group as compared to the placebo group. Also, theses changes in haemodynamic parameters after extubation till period of 10 minutes were found to be significantly less in oral ivabradine group as compared to control group (p-value <0.005).
Ibrahim AN and Atallah RY observed that the haemodynamic parameters (heart rate, SBP, DBP and MAP) had mild changes after intubation and extubation compared to propranol group, in microlaryngoscopic surgeries (12). A similar study by Mohamed MAL et al., concluded that both premedication with oral propranol (10 mg) and oral ivabradine (5 mg) in the evening before the day of surgery another 5 mg tablet one hour before anaesthesia induction was safe and effective in reducing reflex tachycardia that occurs during controlled nitroglycerine induced hypotensive anaesthesia in Functional Endoscopic Sinus Surgery (FESS). However, ivabradine compared to propranol was more effective with high safety margin in patients (13).
Kunwer R et al., also found that haemodynamic parameters during intubation and after 10 minutes of intubation were significantly lower in oral ivabradine group as compared to placebo group (14). Similar to this study, haemodynamic parameters at extubation till period of 10 minutes also were stable compared to placebo group.
Similarly, Raghuram CG et al., found that oral ivabradine have reduced reflex tachycardia and haemodynamic parameters (15). The authors compared the efficacy of oral ivabradine 5 mg at 6 p.m. on evening before the day of surgery and another 5 mg tablet one hour before intubation versus a placebo group. It was concluded that ivabradine is an excellent drug for preventing both increase in heart rate and, to a lesser extent blood pressure. Similar to this study, haemodynamic parameters at extubation till period of 10 minutes also were stable compared to placebo group. The fact of oral ivabradine have larger safety margin in view of reduced the heart rate without affecting haemodynamic instability (16).
The study concluded that ivabradine is simple, safe, cheap (Rs. 21.1 per tablet) and easy to use drug that gives adequate and satisfactory haemodynamic stability during induction, laryngoscopy, intubation and perioperative period. It also minimises the extent of high blood pressure seen during laryngoscopy and endotracheal intubation and help in return of blood pressure to the baseline values within a shorter period (around 3 min after endotracheal intubation) (17).
Limitation(s)
Compromised myocardium condition, clinically significant hypotension and bradycardia, uncontrolled diabetic mellitus, sick sinus syndrome, severe hepatic impairment, pacemaker dependency patients were not taken in this study.
It is concluded that ivabradine is an useful drug to prevent abnormal rise in heart rate during laryngoscopy and intubation. It’s stabilising effect of haemodynamic also extends up to extubation and immediate postoperative period. This study has shown no serious side-effects.
The authors extended their sincere thanks to Mr. Vasu Rathod statistician for his help and support in data collection and analysis.
DOI: 10.7860/JCDR/2022/59965.17226
Date of Submission: Sep 02, 2022
Date of Peer Review: Sep 30, 2022
Date of Acceptance: Nov 06, 2022
Date of Publishing: Dec 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. No
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