Article in PDF
How to Cite
Citation Manager
Readers' Comments (0)
Audio Visual Article Statistics
Link
to PUBMED
Print this Article
Send to a Friend
Advertisers
Access Statistics Resources
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
Comparing Propofol-Ketamine and Propofol-Fentanyl as Procedural Sedation and Postoperative Analgesia for Total Intravenous Anaesthesia in Adult Patients Undergoing Short Surgical Procedures- A Randomised Clinical Study
Correspondence Address :
Swapnadeep Sengupta,
Calcutta National Medical College, 32, Gorachand Road, Kolkata, West Bengal, India.
E-mail: sdeepcgr@gmail.com
Introduction: Total Intravenous Anaesthesia (TIVA), an immensely popular procedure of recent times is most often conducted using propofol as the main anaesthetic agent. Ketamine or fentanyl has also been regularly used to compliment with their analgesic action, which propofol lacks.
Aim: To compare the induction characteristics, maintenance of anaesthesia, awakening and recovery characteristics while performing TIVA with either propofol-ketamine or propofol-fentanyl combinations.
Materials and Methods: This randomised, single blinded study was conducted, from March 2020 to August 2021, in a tertiary care centre of Kolkata, India. Total of 76 patients of either sex, aged between 18-45 years with an American Society of Anaesthesiologist (ASA) physical status I and II, who were posted for short surgical procedures, with a duration of surgery less than 30 mins were equally divided into two groups. Group A received propofol ketamine (1:1), prepared by mixing 4 mL ketamine (50 mg/mL) with 20 mL of 1% Propofol (10 mL/kg), while group B received propofol-fentanyl solution (1:1) was prepared by mixing 4 mL (50 μg/mL) of fentanyl with 20 mL of 1% propofol (10 mg/mL). Induction was done with ketamine 10 mg/kg+propofol 1 mg/kg in group A and fentanyl 1.5 μg/kg+propofol 1.5 mg/kg while maintenance of anaesthesia was achieved with continuous infusion of the prepared solutions for either group, respectively at a rate of around 20 mL/hour or more, as per required to maintain the Ramsay Sedation Scale (RSS) score of 6. Intraoperative haemodynamic parameters, including respiratory rates, awakening time, recovery time and the possible the side-effects were recorded at regular intervals. Student’s t-test was used for quantitative data and Chi-square test for qualitative data. A p-value of less than 0.05 was considered statistically significant.
Results: Patients of group B developed significantly more incidents of bradycardia (20 in group B and 3 in group A) and hypotension (28 in group B and 2 in group A). Respiratory depression was also significantly more in group B (p-value <0.005). However, recovery, awakening, VAS score and other side-effect profiles were all comparable in the two groups.
Conclusion: Propofol-ketamine provides equipotent analgesia with better haemodynamic control and minimal side-effects in comparison to propofol-fentanyl while used in TIVA for adult patients undergoing short surgical procedures.
Day-care surgery, Hypotension, Visual analog score
Total Intravenous Anaesthesia (TIVA) has gained immense popularity in recent times owing to the gradually increasing practice of office based and day-care surgical procedures. TIVA is popularly used for short surgical procedures including day-care surgeries. The advantages include reduced incidence of postoperative nausea and vomiting, more predictable and rapid recovery, greater haemodynamic stability, preservation of hypoxic pulmonary vasoconstriction and reduced risk of organ toxicity, thereby allowing early patient discharge (1),(2). TIVA can also be used in some cases where the administration of inhaled anaesthetics is impossible or in conditions where traditional anaesthetic delivery systems may be unavailable or impractical.
At present times, TIVA is generally delivered using combination of several short or ultra-short acting drugs, each of which has their individual, specific effects to provide balanced anaesthesia (3). The commonly used drug for this purpose includes short-acting benzodiazepines, propofol, short acting opioids like fentanyl, ketamine etc. This is mainly because no sole anaesthetic agent has shown to have all the requisite properties to fulfil an ideal agent for procedural sedation. However, a combination of these drugs can be effectively used to provide adequate hypnosis, amnesia and analgesia, which are the sole components of a balanced anaesthesia (3).
Propofol, though popular among certain outpatient procedures, because of its short duration of action and antiemetic, amnestic, anticonvulsant and antipruritic properties, it does not cause analgesia (4). Hence, when used for TIVA, it is given along with some potent analgesics like ketamine or fentanyl (5). Ketamine provides excellent analgesia and also aids to maintain the haemodynamic stability when used with propofol. It can also decrease the pain of propofol injection by its local anaesthetic effects (6),(7),(8). Similarly, Fentanyl also has a rapid onset and short duration of action, thus when used as an analgesic with propofol can lead to reduction of dose and thereby, complications related to propofol (9).
Studies have shown that ketamine-propofol combination provides a better option than propofol-fentanyl combination while giving TIVA (2),(10),(11),(12). However, owing to the advantages and overall usage in day-to-day practice, there is always a scope to do further research to compare the efficacies of ketamine and fentanyl when used with propofol for providing TIVA.
This study was conducted to evaluate and compare the efficacy of propofol-ketamine and propofol-fentanyl combinations for TIVA in adult patients undergoing short surgical procedures. The induction characteristics, maintenance of anaesthesia and awakening and recovery characteristics following anaesthesia by the two combinations were primarily studied. Along with that, incidences of any adverse effects were also noted as a secondary study outcome.
This randomised, single blinded clinical study was conducted, from March 2020 to August 2021, in a tertiary care centre of Kolkata, India.The approval from the Institutional Ethics Committee was obtained [No/NMC/681 dated 10/02/2020].
Inclusion criteria: A total of 76 patients of either sex, aged between 18-45 years of age with an ASA physical status I and II, who were posted for short surgical procedures, with a duration of surgery less than 30 mins (like fibroadenoma of breast excision, circumcision, dilatation and curettage, dilatation and evacuation etc.) that require TIVA were included in the study.
Exclusion criteria: Patients refusing to participate in the study, having Basal Metabolic Index (BMI) >35 kg/m2, known allergy or contraindications to either study drugs, patients with head injury, seizure disorder, congestive cardiac failure, haemorrhagic disorder, chronic kidney diseases or neurological disorders were excluded from the study.
Sample size calculation: PS Power and Version 2.1.30, February 2003, was used for sample size calculation. Sample size was calculated taking a difference of wake fulness or recovery score of 0.20 as clinically acceptable margin (3). Sample size thus, required in either arm was estimated to be 34. Taking a 10% attrition, the study subjects recruited in each arm was 38.
Study Procedure
After taking written informed consent from the patients and a detailed preanaesthetic check-up, the patients were randomly divided into two equal groups, each comprising of 38 patients, by opening sealed envelopes.
After receiving the patients in the operation theatre, monitors were attached and an intravenous cannula of 18G secured, following which the patients were preloaded with Lactated Ringer’s Solution @10 mL/kg body weight. All the patients in either of the groups were given supplemental oxygen flow at the rate of 6L/min via face mask and were then premedicated with injections of glycopyrrolate 0.2 mg, midazolam 0.03 mg/kg and ondansetron 4 mg intravenous 2 minutes before induction.
In a single 50 mL syringe, a mixture of propofol-ketamine or propofol-fentanyl was prepared by using an aseptic technique for delivery via an infusion pump. In case of group A (n=38), a propofol-ketamine solution (1:1) was prepared by mixing 4 mL ketamine (50 mg/mL) with 20 mL of 1% propofol (10 mL/kg), a total of 24 mL of solution. In case of group B (n=38), a propofol-fentanyl solution (1:1) was prepared by mixing 4 mL (50 μg/mL) of fentanyl with 20 mL of 1% propofol (10 mg/mL), a total of 24 mL. Induction was done with ketamine 10 mg/kg+propofol 1mg/kg in group A and fentanyl 1.5 μg/kg+propofol 1.5 mg/kg and achievement of induction in both the groups were considered with a Ramsay Sedation Scale (RSS) of 6. In both groups, maintenance of anaesthesia was achieved with continuous infusion of the prepared solutions for either group respectively at a rate of around 20 mL/hour or more, as per required to maintain the RSS score of 6.
Haemodynamic parameters and RSS were observed continuously and recorded at intervals of every five minutes during operation. Neither any muscle relaxant was used nor the patients were intubated. After completion of the surgery or end of the skin closer depending on the type of surgery, infusion was stopped and patients were transferred to the recovery room, Postanaesthesia Care Unit (PACU) with oxygen support at the rate of 6L/min and vitals were monitored for one hour. Duration of surgery, awakening time (define das the time from the first administration of the drug to the opening of eyes to verbal commands after surgery). Total sedation time (awakening time) was defined as the time, from the first administration of the drug to the opening of eyes to verbal commands after surgery. Recovery time was defined as the time taken from stopping the infusion of the study drug to the point when the patients will achieve a Modified Aldrete Score of more than or equal to 8 (13). After ensuring a modified Aldrete score ≥8 patients were shifted to the surgery ward. Postoperative analgesia is assessed by Visual Analogue Scale (VAS).
Statistical Analysis
Statistical Package for Social Sciences software version 20.0 (IBM) was used for statistical analysis and descriptive analysis was done in the form of proportion for categorical variables, mean [Standard Deviation (SD)] or median {Interquartile range (IQR)} for continuous variables. Data were checked for normal distribution using tests (Shapiro-Wilk normality test) for normality and parametric or non parametric test was performed accordingly. Student’s t-test was used for quantitative data and Chi-square test for qualitative data. A p-value of less than 0.05 was considered statistically significant.
(Table/Fig 1) shows that the age and sex difference with ASA distribution were similar.
(Table/Fig 2) shows that the time of awakening and difference of recovery time among the two groups were not statistically different, although both were slightly more among group B. The postoperative pain score was less among the patients of group A than group B, although it was not statistically significant.
(Table/Fig 3),(Table/Fig 4),(Table/Fig 5) show that the mean heart rate, systolic blood pressure, respiratory rate was significantly more among the subjects of group A than group B.
(Table/Fig 6) shows that the occurrence of hypotension and bradycardia were statistically more among the subjects of group B than group A patients. However, the occurrence of nausea among both the groups was similar.
Among the other side-effects, there was no complication like emergence reaction, agitation, increased oral secretions in this study and only one patient in group A and two in group B had nausea but no vomiting.
Total Intravenous Anaesthesia (TIVA), the anaesthestic procedure of choice for short surgical procedures, is generally conducted using propofol based anaesthesia. However, due to lack of its analgesic property, several other drugs have been used as supplemental analgesic, among which ketamine and fentanyl are most commonly used. Few studies have shown propofol-ketamine having a better result than propofol-fentanyl though a definitive conclusion needs further research (2),(10),(11),(12).
This study was thus done to compare the induction, maintenance of anaesthesia, awakening and recovery characteristics following anaesthesia with propofol-ketamine and propofol-fentanyl combinations for TIVA by studying the incidences of any adverse effects in adult patients undergoing short surgical procedures.
In the present study, continuous infusion of propofol-ketamine (group A) and propofol-fentanyl (group B) were used to maintain a steady state sedation level, by achieving a RSS of 6. Intraoperatively, there was not much difference among the total dose of drugs required in either of the groups to maintain a steady state level. Similarly, awakening time, recovery time among the patients of either group were also found to be non significant.
However, regarding haemodynamics, heart rate was found to significantly reduced in group B (after achieving RSS6) at 1 minute, 2 minutes, 3 minutes, 4 minutes, 5 minutes, 10 minutes, 15 minutes; whereas the Systolic Blood Pressure (SBP) also showed significant decrease in patients of group B at those same time intervals. Respiratory Rate (RR) started decreasing more at group B and became statistically significant (p-value <0.05) at 1 minute, 2 minutes, 3 minutes, 4 minutes, 5 minutes, 10 minutes, 15 minutes, 30 minutes as well in this study.
Tajoddini S and Motaghi M, compared the sedative, analgesic effects as well as safety characteristics of ketamine-propofol and fentanyl-propofol combinations in painful emergency procedures (10). They found that the ketamine-propofol group provided superior analgesia and sedation with faster recovery and lesser adverse events in comparison to the fentanyl-propofol group.
Reddy BAP et al., compared the intraoperative haemodynamic responses as well as postoperative spontaneous eye opening and PONV after injection of propofol-ketamine and propofol-fentanyl in 100 patients undergoing short surgical procedures under TIVA (11). They concluded that haemodynamic responses were better in propofol-ketamine group with lesser adverse effects, though patients in propofol-fentanyl had superior postoperative recovery.
El-Rab NAG et al., made a comparative study between propofol-ketamine and propofol-fentanyl combinations in paediatric patients undergoing upper gastrointestinal endoscopy (12). They studied 60 children aged 6-12 years and concluded that propofol-ketamine provided better haemodynamic stability with comparable recovery and adverse effect profiles.
Sharma R et al., did a randomised, double-blind study on 100 adult patients, giving slow bolus of premixed injection of either ketamine-propofol (1 mg/kg) or fentanyl-propofol (1.5 mg/kg) followed by TIVA infusion to a predetermined sedation level using RSS for short orthopaedic procedures (2). They reported a significant decrease (p-value <0.001) in the pulse rate, systolic and diastolic blood pressure in intraoperative and postoperative period in group 2 (fentanyl propofol group) whereas there was significant rise in pulse rate, systolic and diastolic blood pressure in group 1 (ketamine-propofol group). Respiratory depression was more pronounced in group 2. Mean total sedation time as well as recovery time was significantly prolonged in group 2 compared to group 1.
Kurdi MS et al., conducted a prospective randomised double-blind study among 60 adult females scheduled for elective tubal sterilisation by minilaparotomy in which the patients received a slow bolus injection followed by Ketofol containing ketamine: Propofol (1:1) (group A), ketamine: propofol (1:2) (group B), and fentanyl: propofol (group C) to a predetermined sedationlevel using RSS (14). Considering the onset of sedation, intraoperative sedation score, and recovery time, group C (fentanyl-propofol) patients were less sedated than counter parts in group A and B. Considering the verbal rating scale for pain postoperatively, group C patients had poor analgesia compared to group A and B. They found that ketamine-propofol provides better sedation level, better haemodynamic and respiratory stability compared to fentanyl-propofol.
Similarly, Akhondzadeh R et al., in their study, comparing the effects of propofol-fentanyl with propofol-ketamine to sedate patients under going endoscopic retrograde cholangiopancreatography outside the operating room, found that the lower amount of pain and apneain propofol- ketamine group (15).
In another study done by Singh Bajwa SJ et al., propofol-fentanyl combination produced a significantly greater fall in pulse rate and in both systolic and diastolic blood pressures as compared to propofol-ketamine during induction of anaesthesia (3). Propofol-ketamine combination produced stable haemodynamics during maintenance phase.
Similar findings were also found in studies done by Tosun Z et al., Goyal R et al., Nalini KB et al., Khutia SK et al., in all of which haemodynamic status were found to be well maintained in ketofol group with equally acceptable anaesthesia, recovery, analgesia and side-effect profiles (16),(17),(18),(19). The findings of all these studies thus corroborate with the findings of this present study.
Limitation(s)
This was a single centre study carried out in a tertiary care hospital. The population did not include the paediatric and geriatric population and the ASA III and IV patients, where the efficacy and safety may vary.
Thus, from this study we can well conclude that ketamine when combined with propofol can provide better analgesia with adequate haemodynamic stability and minimal side-effects in comparison to Fentanyl during procedural sedation in adult patients undergoing short surgical procedures. Therefore, propofol-ketamine combination provides us with a perfect option for providing TIVA, particularly in daycare procedures.
All the members of the Department of Anaesthesiology and Critical Care, N.R.S. Medical College and Hospital, Kolkata, West Bengal.
DOI: 10.7860/JCDR/2022/58992.17307
Date of Submission: Jul 10, 2022
Date of Peer Review: Aug 17, 2022
Date of Acceptance: Sep 12, 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. NA
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jul 10, 2022
• Manual Googling: Sep 09, 2022
• iThenticate Software: Sep 23, 2022 (25%)
ETYMOLOGY: Author Origin
- Emerging Sources Citation Index (Web of Science, thomsonreuters)
- Index Copernicus ICV 2017: 134.54
- Academic Search Complete Database
- Directory of Open Access Journals (DOAJ)
- Embase
- EBSCOhost
- Google Scholar
- HINARI Access to Research in Health Programme
- Indian Science Abstracts (ISA)
- Journal seek Database
- Popline (reproductive health literature)
- www.omnimedicalsearch.com