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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
Case Series
Full Version
A Combination of Ultrasound-guided Popliteal Sciatic Nerve Block and Adductor Canal Block as a Sole Anaesthetic Technique for below Knee Amputation in High-risk Patients: A Case Series
Correspondence Address :
Dr. MK Sandhya,
Associate Professor, Department of Anaesthesiology, Kanachur Institute of Medical Sciences, University Road, Natekal, Mangalore, Karnataka, India.
E-mail: sandhyamohanmk@gmail.com
Below-knee amputation in high-risk patients is associated with significant mortality and morbidity. Spinal anaesthesia is linked to an increased incidence of hypotension and bradycardia, and it is relatively contraindicated in patients with coagulation abnormalities. General anaesthesia is used as an alternative when spinal anaesthesia is contraindicated, but it is associated with a considerable increase in perioperative morbidity and the need for postoperative ventilatory support and Intensive Care Unit (ICU) care. A combination of sciatic nerve block and femoral block has been employed for below-knee surgeries as it provides complete anaesthesia below the knee. Adductor canal block, compared to femoral nerve block, is motor-sparing and, when combined with popliteal sciatic nerve block, offers complete anaesthesia below the knee. Below-knee amputation requires complete motor and sensory blockage, making regional block for below-knee amputation more challenging for the anaesthesiologist. Present case series is of five cases of below-knee amputation performed under a combination of ultrasound-guided popliteal sciatic nerve block and adductor canal block. Ultrasound-guided popliteal sciatic nerve block was administered with a combination of 10 mL of bupivacaine 0.5% and 5 mL of lignocaine 2% with adrenaline (1:200,000) diluted with 5 mL of distilled water to a total volume of 20 mL. Ultrasound-guided adductor canal block was performed with 8 mL of bupivacaine 0.5% and 4 mL of lignocaine 2% with adrenaline (1:200,000), diluted with 4 mL of distilled water to a total volume of 16 mL. All patients achieved adequate surgical anaesthesia, and none experienced any anaesthesia-related complications.
Regional nerve block, Saphenous nerve block, Subsartorial block
A combination of femoral and sciatic nerve block has been employed as an anaesthetic technique for below-knee surgeries. The sciatic nerve is blocked at the popliteal region, providing anaesthesia below the knee joint, except for the medial aspect of the leg. Adductor canal block is used to block the terminal branches of the femoral nerve and has been utilised to provide analgesia for knee surgeries. It has also been used in combination with popliteal sciatic nerve block to provide analgesia and complete anaesthesia for below-knee surgeries (1),(2),(3). Present case series is of five below-knee amputation cases performed using a combination of adductor canal block and popliteal sciatic nerve block (Table/Fig 1).
Case-1
A 57-year-old female patient was scheduled for a right below-knee amputation due to right diabetic foot gangrene. The patient had a medical history of coronary artery disease for five years, diabetes for five years (treated with insulin), and hypertension for five years. The patient was on amlodipine 5 mg, a combination of losartan/hydrochlorothiazide, and rosuvastatin 10 mg at night. The patient was also taking aspirin 150 mg and clopidogrel 75 mg, which were discontinued before two days. The patient’s vital signs were stable, and a systemic examination revealed no abnormalities. The investigation reports were as follows: haemoglobin level was 9.6 gm%, total leukocyte count was 14,100 cells/mm3. Renal function tests were normal. An Electrocardiography (ECG) showed T-wave inversion in the lateral leads. An Echocardiogram (ECHO) showed left ventricular hypertrophy, an ejection fraction of 35%, Grade-I diastolic dysfunction, and regional wall motion abnormality in the left anterior descending artery territory. The patient was instructed to be Nil Per Oral (NPO) and posted for surgery under American Society of Anaesthesiologists (ASA) III risk.
Case-2
A 60-year-old male patient presented with left diabetic foot with gangrene and sepsis, requiring emergency left below-knee amputation. The patient had been NPO for four hours. He had history of diabetes for 15 years and was on insulin. Additionally, he had acute-on-Chronic Kidney Disease (CKD) and he was on conservative management for the same. On examination, the patient was febrile, with a heart rate of 120/min and blood pressure of 160/90 mmHg. Systemic examination revealed no abnormalities. The investigation results were as follows: haemoglobin level was 8.2 gm%, total leukocyte count was 13,430 cells/mm3, serum creatinine was 3.9 mg/dL, and serum urea was 36 mg/dL. The remaining blood investigation reports were within normal limits. His ECG showed sinus tachycardia, and chest X-ray was normal. The patient was classified as ASA III and taken up for surgery.
Case-3
A 58-year-old male patient presented with left diabetic foot gangrene. The patient had history of diabetes for 21 years and was on insulin. Additionally, he had been diagnosed with Chronic Kidney Disease (CKD) three years ago and had been undergoing dialysis for the past three months. The patient’s last dialysis session was one week ago. Vital signs were stable, and systemic examination revealed no abnormalities. The investigation reports were as follows: haemoglobin level was 8.2 gm%, total leukocyte count was 18,540 cells/mm3, urea level was 78 mg/dL, and serum creatinine was 2.9 mg/dL. The remaining blood investigations were within normal limits. The patient was classified as ASA III and taken up for the procedure.
Case-4
A 76-year-old female patient with gangrene in the right lower limb due to peripheral vascular disease was scheduled for below-knee amputation. The patient was diabetic for 30 years on diet control. Patient was also hypertensive for 30 years, on treatment with amlodipine 5 mg twice daily. On examination, the patient was afebrile. Her heart rate was 108 beats per minute, blood pressure was 110/70 mmHg, and respiratory rate was 16 breaths per minute. Systemic examination revealed no abnormalities. Haemoglobin level was 13 mg/dL, total leukocyte count was 11,000, and ECG showed left ventricular hypertrophy. All other investigations were within normal limits. The patient was classified as ASA II, but a high-risk consent was obtained considering her age.
Case-5
A 66-year-old male patient with peripheral vascular disease in the right diabetic foot was scheduled for below-knee amputation. He had history of diabetes for 25 years and was on insulin. Additionally, he had CKD for four years and was managed conservatively. The patient’s vital signs were stable, and systemic examination revealed no abnormalities. The investigation reports were as follows: haemoglobin level was 8.9 gm%, total leukocyte count was 15,540 cells/mm3, urea level was 50 mg/dL, and creatinine level was 3 mg/dL. The remaining blood investigations were within normal limits. The patient was instructed to be NPO for six hours and was classified as ASA III. Informed consent was obtained prior to the procedure.
Routine monitoring, including pulse oximetry, non Invasive Blood Pressure (NIBP), and ECG, was applied to all patients. Popliteal sciatic nerve block was performed with the patient in lateral position. An antiseptic solution was applied to the area around the popliteal crease, and sterile drapes were used. A high-frequency linear probe was placed at the popliteal crease to identify the popliteal artery and vein in the transverse axis. The common peroneal and posterior tibial nerves were also identified. These nerves were traced proximally until the vloka’s sheath was identified (Table/Fig 2). After anaesthetising the skin and subcutaneous tissue, a 23-gauge spinal needle was inserted using an in-plane technique from the lateral side, directed towards the sciatic nerve (Table/Fig 3). Once the positioning of the needle within the nerve sac was confirmed, a local anaesthetic solution consisting of 10 mL of 0.5% bupivacaine and 5 mL of 2% lignocaine with adrenaline (1:200,000), diluted with 5 mL of distilled water to a total volume of 20 mL, was injected. A post scan was performed confirm the spread of the local anaesthetic along the common peroneal and posterior tibial nerves. Following the popliteal sciatic nerve block, the adductor canal block was performed. The patient was placed in supine position, and the affected limb was abducted and externally rotated at the hip joint.
A high-frequency linear probe was placed on the medial aspect of the thigh, 10 centimeters above the knee joint, in the transverse axis. The femur, vastus medialis muscle, and sartorius muscle were identified (Table/Fig 4). The saphenous nerve and femoral artery were visualised. A needle was inserted using an in-plane technique from lateral to medial, confirming the position of the needle tip in the adductor canal below the sartorius muscle (Table/Fig 5). A local anaesthetic solution consisting of 8 mL of 0.5% bupivacaine and 4 mL of 2% lignocaine with adrenaline (1:200,000), diluted with distilled water to a total volume of 16 mL, was injected. All patients achieved adequate surgical anaesthesia within 20 to 25 minutes after the block. Tourniquet was not required in any of the patients due to their peripheral vascular disease. After the procedure, all patients were observed in the recovery room for 24 hours, and their vital parameters remained within normal limits. All patients, except for patient four, received one pint of blood transfusion in the postoperative recovery room. Additionally, all patients received 1 gm paracetamol as an infusion three times a day. According to institutional protocols, all patients received intravenous tramadol at a dose of 2 mg/kg when they complained of pain (VAS >4). The time to the first dose of tramadol after the block was 10 hours for Case-1, eight hours for Case-2, six hours for Case-3, seven hours for Case-4 and eight hours for Case-5. None of the patients developed hypotension, bradycardia, or any anaesthesia-related complications.
Patients requiring emergency below-knee amputation often present with sepsis, Multiple Organ Dysfunction Syndrome (MODS), and other co-morbid conditions. A combination of femoral nerve block/adductor canal block, along with sciatic nerve block (subgluteal or popliteal approach), has been successfully used for below-knee surgeries and postoperative analgesia (1),(2),(3). Descriptive studies and case reports have been published regarding the combined use of adductor canal and popliteal sciatic nerve block for below-knee 3surgeries (1),(2),(3). Studies conducted by Arjun BK et al., and Ara M et al., included patients undergoing below-knee surgeries, such as below-knee amputation, diabetic foot debridement, and distal tibial plating. Both studies concluded that ultrasound-guided combined popliteal sciatic nerve block and adductor canal block offer a safe and effective alternative to spinal anaesthesia for below-knee surgeries (1),(2). Below-knee amputation requires anaesthesia below the knee, and there are a few published articles on below-knee amputation under femoral and popliteal sciatic nerve block (4),(5),(6),(7),(8). Choi YS et al., published a case report on below-knee amputation under combined ultrasound-guided popliteal sciatic and femoral block in a patient with a recent history of myocardial infarction while on anticoagulants (5). In adductor canal block, the local anaesthetic solution is deposited in the adductor canal, which contains the saphenous nerve and nerve to vastus medialis (9). Branches of the anterior obturator nerve may also be present in the adductor canal (10). The local anaesthetic injected in the adductor canal is known to spread proximally and provide anaesthesia over the medial aspect of the leg (10),(11). Combined popliteal sciatic nerve block produces complete anaesthesia of the lower limb below the knee joint. While sensory innervation of the lower leg is attributed to the saphenous and sciatic nerves, the posterior femoral cutaneous nerve may also play a role in sensory innervation of the lower leg (12),(13). However, all patients in present case series experienced complete anaesthesia below the knee. A combination of bupivacaine and lignocaine with adrenaline was used as the combination is associated with faster onset and longer duration of action (14). This case series affirms that below knee amputation can be safely performed under a combination of adductor canal block and popliteal sciatic nerve block in high-risk patients. Further studies are required to compare adductor canal block with femoral block, in addition to popliteal sciatic nerve block, in patients undergoing below-knee amputation.
The combination of ultrasound-guided popliteal sciatic nerve block and adductor canal block provides complete surgical anaesthesia below the knee joint without any haemodynamic complications. It can be used as a sole anaesthetic technique in high-risk patients undergoing below-knee amputation.
DOI: 10.7860/JCDR/2023/66221.18436
Date of Submission: Jun 26, 2023
Date of Peer Review: Aug 01, 2023
Date of Acceptance: Aug 29, 2023
Date of Publishing: Sep 01, 2023
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
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ETYMOLOGY: Author Origin
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