DOI: 10.7860/JCDR/2018/38012.

12348
Original Article

Role of Magnesium as Analgesic Sparing

Anaesthesia Section

Adjuvant to Ropivacaine in Thoracic

Paravertebral Block for Breast Cancer
Surgery: A Prospective, Double-Blinded
Randomised Controlled Study
Sandip RoyBasunia1, Anjan Das2, Tapobrata Mitra3, Nairita Mayur4, Hirak Biswas5,
Anindya Mukherjee6, Chiranjib Bhattacharyya7, Subrata Mandal8

ABSTRACT Intraoperative fentanyl and propofol requirement was compared.

Introduction: Thoracic surgeries are often associated Visual Analogue Scale (VAS) was used for postoperative pain
with intractable pain leading to postoperative pulmonary assessment. Total dose and mean time to administration of
complications. To alleviate this pain in intraoperative and first rescue analgesic paracetamol was noted. Side effects and
postoperative period, Thoracic Paravertebral Block (TPVB) has haemodynamic parameters were also noted.
been proven as an effective mean. Various adjuvants and their Results: Intraoperative fentanyl (153.86 vs. 138.49 µg), propofol
mixtures have been tried to prolong the duration of TPVB. requirement (150.34 vs. 134.23 mg) was significantly less in test
Aim: In this randomised controlled study, we have evaluated (magnesium) group. The requirement of paracetamol was also
the analgesic sparing efficacy of magnesium sulfate; a NMDA significantly less (1592.09 vs. 1149.23 mg) and later (8.44 vs.
receptor antagonist, administered along with ropivacaine for 13.34 hour) in group RM than group RP. Haemodynamics and
TPVB for breast cancer surgery patients. side effects were comparable among two groups.
Materials and Methods: Eighty breast cancer surgery patients, Conclusion: Magnesium provided better intraoperative as well
undergoing General Anaesthesia (GA), were randomly divided as postoperative analgesia than placebo when administered
into group RP and group RM (n=40 each) receiving preoperative with ropivacaine in TPVB prior to breast cancer surgery patients.
TPVB at T3-5 level with 0.5% ropivacaine solution admixture It also renders a lesser analgesic requirement without major
with normal saline and magnesium sulphate, respectively. haemodynamic alteration and side effects.

Keywords: American society of anaesthesiologists, General anaesthesia, Magnesium,

Post anaesthesia care unit, Thoracic paravertebral block

INTRODUCTION Investigators have demonstrated that magnesium administration

Breast cancer surgeries are often associated with moderate during GA reduces anaesthetic requirement and post operative
to severe intensity acute postoperative pain, in the first week, analgesic consumption [17]. Magnesium has long been used for
which is the chief culprit in culminating into chronic postsurgical its analgesic, antihypertensive and anaesthetic sparing effects [18-
pain [1-4]. 21]. Despite its known benefits for pain control, magnesium has
never been studied extensively for its effects as an adjuvant to
Thoracic Paravertebral Block, an excellent analgesic modality for
anaesthetics during thoracic paravertebral block (TPVB).
intra- and postoperative pain management, is used in thoracotomy,
In our study, we had added 1 mL of magnesium sulphate (50%) to
gastrectomy, open cholecystectomy operations with negligible
local anaesthetic solution ropivacaine in the test group to compare
opioid and Nonsteroidal Anti-Inflammatory Drugs (NSAIDS) like
the analgesia with placebo group (ropivacaine with normal saline).
side effects [5-9]. Though general anaesthesia is gold standard
for breast cancer surgeries, TPVB has emerged as an adjunct for The primary objective of this study was to compare the time of
analgesic modality for these patients. rescue analgesic administration with the placebo group. Secondarily,
total dose of rescue analgesics, intraoperative fentanyl, propofol
In TPVB-bupivacaine, lignocaine, levobupivacaine, ropivacaine;
requirement, VAS score and side effects among two groups were
any one or combination of these drugs have been used [10]. Many
compared.
adjuvants have been tried along with the above mentioned local
anaesthetic agents; like clonidine, epinephrine, dexamethasone,
MATERIALS AND METHODS
opioids, dexmedetomidine etc., [11-13].
After planning for this randomised controlled study, we received
Ropivacaine, an amino-amide local anaesthetic, is less approval from Institutional Ethics Committee. The study was
cardiac and central nervous system toxic than other long conducted in an operation theatre of a tertiary care centre
acting local anaesthetics like bupivacaine [14]. Magnesium, (Government Medical College) from December 2014 to December
a plentiful cation of human body and N-methyl D-aspartate 2015. Firstly all patients including other surgical patients had to
(NMDA) receptor antagonist, is necessary for the presynaptic undergo routine preanaesthetic check-up. Among them, female
release of acetylcholine and mimics calcium-entry-blocking patients who were planned for unilateral breast cancer surgery
drugs [15,16]. under general anaesthesia in the age group 40-65 years and met
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 Sandip RoyBasunia et al., Magnesium as Adjuvent in Thoracic Paravertebral Block www.jcdr.net

the eligibility criteria (ASA physical status I and II, Mallampati grade I N2O in O2 and isoflurane up to 1.5 MAC (under guidance of BIS
and II) were counselled regarding the study and those who gave the monitoring). On completion of modified radical mastectomy,
consent were included in the study. inj. glycopyrrolate 0.01 mg/kg and inj. neostigmine 0.05 mg/kg
Exclusion criteria were patients with known allergic to ropivacaine, was used for reversal of anaesthesia and extubation was done
magnesium sulphate; hepatorenal or cardiopulmonary abnormalities, with adequate spontaneous ventilation with Train-of-Four (TOF)
alcohol addict or diabetes, neuropsychiatric or neuromuscular ratio>0.9 and BIS≥70. Ten minutes after extubation, patients
disorders, thrombocytopenia, coagulation or seizure disorders, were all transferred to Post Anaesthesia Care Unit (PACU) for
observation and postoperative pain management.
anatomical anomalies of thoracic spine.
Insufficient analgesia was reflected by the presence of hypertension
The patients were randomised using computer generated
or tachycardia (>20% of baseline) during anaesthesia, {while BIS
random number list and group allocation was done using
was 40-60 (i.e., within desired range)} and fentanyl 1 µg/kg was
sealed envelopes. These opaque envelopes had a paper slip
used to treat the condition. Propofol was supplemented with
inside them indicating either RM or RP group. On the outside
0.2 mg/kg bolus for maximum three successive boluses at an
patient’s registration number was mentioned. When the patient
interval of three to five minutes. This bolus propofol was given when
was received in the OT complex, the numbered envelope was
BIS value exceeds 70. Target BIS was 40-60.
handed over to a resident anaesthesiologist who was not taking
part in the study. He opened the envelope and prepared the drug Hospital discharge (eye opening-discharge from hospital), the time
mixture to be administered in the TPVB route. Patients in group for PACU stay (means time of arrival in PACU to discharge from
RP received 19 mL of 0.5% ropivacaine+1 mL normal saline for PACU) and also the incidence of adverse events were noted. Modified
Aldrete score is based on Consciousness, Respiration (breathing),
TPVB. Group RM received 19 mL 0.5% ropivacaine+500 mg (1
Oxygen saturation, Circulation (BP), Activity. Each parameter has
mL 50% w/v magnesium sulphate) magnesium sulphate for the
score (0-2). The highest cumulative score is 10. Patients were
same block.
considered ready for discharge from the PACU when the modified
In group RP, 19 mL Ropivacaine (0.5%) {Ropin® 0.5%, NEON Aldrete post anaesthesia score was ≥9. After being discharged from
Laboratories Ltd., Mumbai, India} and 1 mL normal saline mixture PACU patients were transferred to the ward. Ondansetron 0.1 mg/
was prepared. In group RM, 19 mL Ropivacaine (0.5%) and 1 mL kg IV was administered for nausea and vomiting. Same surgeon
magnesium sulphate {Magneon® 50% w/v, NEON Laboratories operated all the cases. Vital parameters recording were done every
Ltd., Thane, Maharashtra, India} mixture was prepared. 10 minutes for first two hour, then every half hourly for 12 hour, then
In all cases, preoperative fasting of minimum six hours was ensured every four hourly for two days.
before operation. All patients were given tablet lorazepam 1 mg After operation, efficacy of the paravertebral block was the
and pantoprazole 40 mg orally at the night before surgery as primary outcome of the study which was measured by time of
premedication. rescue analgesic administration among both the groups. The
All baseline parameters like heart rate, Systolic BP (SBP), Diastolic time of administration of first dose of rescue analgesic (Injection
BP (DBP), Mean Arterial BP (MAP), End tidal CO2 (EtCO2) and paracetamol 1000 mg i.v) following performance of paravertebral
Oxygen saturation (SpO2) were noted in the observation room. block was taken as the duration of block. Visual analog scale
Then all patients were transferred to operation theatre and (VAS; 0=“no pain” and 10=“worst possible pain”) was used to
continuously monitored using multipara monitor. In sitting position, assess the magnitude of postoperative pain for 48 hours. Injection
same technique was used for paravertebral block in every patient. paracetamol was given as rescue analgesia if the pain VAS >3.
2% lignocaine was used for skin infiltration at 2.5 cm lateral to Perioperative adverse reactions and haemodynamic changes
the spinous process of third, fourth and fifth thoracic vertebra. were also observed. Sedation was drowsy (not awake) and non-
Through the skin wheal, Tuohy needle (17G) was inserted till it communicative state (spontaneously, but responded when asked
comes in contact with transverse process of the intended thoracic for). Bradycardia was fall in Heart Rate (HR) ≥20% of baseline HR
vertebras. Tuohy needle was then walked off the cephalad edge or HR <60/min or whichever is greater. When HR was <50/min,
of the transverse process and it was further advanced till it enters 0.6 mg i.v atropine was given. Hypotension was fall in Systolic
in paravertebral space which was identified by loss of resistance Blood Pressure (SBP) ≥20% of baseline SBP or SBP<100 mm
technique by using air. Local anaesthetic mixture which was Hg or whichever is greater. When SBP <90 mm of Hg, 5 mg i.v
already prepared by resident doctor (drawn in identical looking mephentermine was given.
syringes) was injected in the desired position. The anaesthesiologist
performing the paravertebral block was completely unaware STATISTICAL ANALYSIS
of the group allocation or composition of the local anaesthetic Sample size was based on a crossover pilot study of 10 patients
mixture. Data collection was done by another resident doctor. The and was selected to detect a projected difference of 10% time
mixture was injected in three spaces in a divided manner in small (i.e., 1.2 hour) for administration of rescue analgesic among two
aliquots with repeated aspiration. This local anaesthetic mixture groups for a type 1 error of 0.05 and a power of 0.8. On the basis
administration was followed by general anaesthesia administration of our previous study assuming within group SD of six hour and
in supine position. we needed to study at least 36 patients per group to be able to
Normal Saline (NS) was started via 18 G i.v cannula done prior to reject the null hypothesis which will be increased to 40 patients
transport of patient to OT. Pre-oxygenation was done with 100% O2 for possible dropouts. Raw data were entered into a MS Excel
for five minutes. Premedication was given with inj. Glycopyrrolate spreadsheet and analysed using standard statistical software SPSS®
(0.2 mg), inj. fentanyl (100 µg), inj ondansetron (8 mg) three statistical package version 18.0 (SPSS Inc., Chicago, IL, USA).
minute before induction. Propofol (2 mg/kg) was used as inducing Categorical variables were analysed using the Pearson’s chi-square
agent. Then laryngoscopy and intubation was done with the test. Normally distributed continuous variables were analysed using
help of atracurium (0.5 mg/kg). After three minutes of atracurium the independent sample t-test and p-value <0.05 was considered
application, less than 20 seconds were taken for laryngoscopy, statistically significant.
intubation, and cuff inflation in all cases. Intraoperative muscle
relaxation was maintained with intermittent intravenous atracurium RESULTS
(0.2 mg/kg) as per requirement. Anaesthesia workstation was Each breast cancer surgery group in our study consisted of
used for controlled ventilation which was maintained with 66% 40 patients which was greater than the calculated sample size. As
2 Journal of Clinical and Diagnostic Research. 2018 Dec, Vol-12(12): UC01-UC05
www.jcdr.net Sandip RoyBasunia et al., Magnesium as Adjuvent in Thoracic Paravertebral Block

the dropout cases were nil, 40 patients were in the control group ipsilateral shoulder movement and here also pain was significantly
(RP) and 40 patients in the magnesium group (RM) were considered low (p<0.05) at 4,6,10 and 12 hours after surgery in magnesium
for effectiveness analysis. group [Table/Fig-6].
From [Table/Fig-1] it is evident that age, body weight, Side effects such as sedation, bradycardia, hypotension,
preoperative haemoglobin level, operative and anaesthetic dry mouth, nausea were all comparable among two groups
duration were all found to be comparable (p>0.05). PACU (p>0.05) [Table/Fig-7]. MAP and HR were found to be
discharge time was comparable among two groups [Table/ quite comparable among two groups (p>0.05) [Table/Fig-
Fig-1]. Baseline heart rate and Mean arterial pressure were 8,9] respectively. The participant flow diagram is shown in
also quite comparable among two groups [Table/Fig-1]. [Table/ [Table/Fig-10].
Fig-2] shows types of different breast surgeries and they were
Postoperative Group RP Group RM 95% confidence
comparable too. Intraoperative mean fentanyl and propofol p-value
Period (Hours) (n=40) (n=40) interval
requirement were compared among two groups and they were VAS0.5 2.25±0.52 2.02±0.61 0.0734 0.0223 to 0.4823
much less in amount and statistically significant (p<0.05) in VAS1 2.35±0.55 2.17±0.42 0.1040 0.0378 to 0.3978
group RM than RP [Table/Fig-3].
VAS2 2.91±0.60 2.70±0.51 0.0957 -0.0379 to 0.4579
Demographic Group RP Group RM 95% confidence VAS4 3.18±0.70 2.89±0.59 0.0486 0.0018 to 0.5782
p-value
­factors (n=40) (n=40) interval
VAS6 3.52±0.80 3.10±0.72 0.0158 0.0812 to 0.7588
Age (years) 48.11±5.60 50.55±6.30 0.0710 -5.0933 to 0.2133 VAS10 3.73±0.91 3.33±0.82 0.0422 0.0144 to 0.7856

Weight (kg) 60.54±9.33 56.92±10.02 0.3552 -0.6897 to 7.9297 VAS12 3.84±1.04 3.39±0.89 0.0409 0.0191 to 0.8809

Haemoglobin (gm%) 11.82±3.6 12.55±3.91 0.3877 -2.4030 to 0.9430 VAS16 3.92±1.43 3.74±0.94 0.5079 -0.3587 to 0.7187

Duration of Surgery 55.93±8.03 59.11±11.13 0.1468 -7.5002 to 1.1402 VAS24 3.82±1.22 3.49±0.83 0.1612 -0.1345 to 0.7945

Duration of Anaesthesia 70.23±11.21 73.11±10.93 0.2482 -7.8084 to 2.0484 VAS36 3.20±0.78 2.89±0.72 0.0685 -0.0241 to 0.6441
Time to reach Aldrete VAS48 2.88±0.78 2.61±0.48 0.0660 -0.0183 to 0.5583
55.02±8.94 58.92±9.10 0.0568 -7.9156 to 0.1156
score ≥9 (minute)
[Table/Fig-5]: Pain score (VAS) at rest in postoperative period.
Baseline Heart rate 68.55±12.43 63.72±11.93 0.0801 -0.5933 to 10.2533
Baseline MAP 79.34±10.55 76.41±9.09 0.1872 -1.4536 to 7.3136 Postoperative Group RP Group RM 95% confidence
p-value
[Table/Fig-1]: Demographic profile and the preoperative hematologic status in Period (Hours) (n=40) (n=40) interval
both groups. VAS0.5 2.68±0.78 2.37±0.81 0.0852 -0.0440 to 0.6640
VAS1 2.70±0.66 2.45±0.53 0.0655 -0.0165 to 0.5165
Group RP Group RM
Types of Surgery in Breast CA p-value VAS2 3.08±0.68 2.85±0.57 0.1052 -0.0493 to 0.5093
(n=40) (n=40)
Simple Mastectomy (SM) 8 (20%) 10 (25%) p=0.604 VAS4 4.15±0.47 3.70±0.76 0.0021 0.1687 to 0.7313

Modified Radical Mastectomy (MRM) 22 (55%) 20 (50%) p=0.7470 VAS6 4.8±0.60 4.45±0.56 0.0086 0.0916 to 0.6084

Partial/Segmental Mastectomy (PM) 7 (17.5%) 8 (20%) VAS10 5.03±0.71 4.62±0.59 0.0063 0.1194 to 0.7006

Lumpectomy 3 (7.5%) 2 (5%) VAS12 5.23±0.83 4.82±0.89 0.0363 0.0269 to 0.7931

[Table/Fig-2]: Types of Surgery in Breast CA for randomised patient groups. VAS16 5.15±0.74 4.89±0.59 0.0862 -0.0379 to 0.5579
Data are presented as n (%).
VAS24 4.81±0.73 4.55±0.51 0.0686 -0.0203 to 0.5403
VAS36 4.17±0.34 3.92±0.46 0.7844 -1.5633 to 2.0633
Group RP Group RM 95% confidence
p-value
(n=40) (n=40) interval VAS48 3.30±0.43 3.52±0.47 0.8304 -2.2577 to 1.8177
Intraoperative -25.2320 to [Table/Fig-6]: Pain on shoulder (ipsilateral) movement in postoperative period.
153.86±25.35 138.49±18.41 0.0027
fentanyl requirement -5.5080
Intraoperative 8.5033 to Group RP Group RM
150.34±18.93 134.23±15.02 0.0001 Parameters p-value
Propofol requirement 23.7167 (n=40) (n=40)
[Table/Fig-3]: Intraoperative fentanyl requirement. Nausea/Vomiting 14 10 0.1441
Sedation 10 12 0.4901
Magnesium group (group RM) received much less paracetamol
(1 gm I.V) than control group (group RP) as rescue analgesic [Table/ Bradycardia (HR <60 bpm) 7 6 0.6570

Fig-4]. The time of administration of rescue analgesic was much Hypotension (SBP <100 mm Hg) 7 6 0.3271
later in group RM than RP. Both the above mentioned results were Dry mouth 5 3 0.2299
statistically significant. [Table/Fig-7]: Side effects.

Group RP Group RM 95% confidence

p-value
(n=40) (n=40) interval
Time of
administration -5.7959 to
8.44±1.91 13.34±2.11 0.0001
of first rescue -4.0041
analgesia (hr)
Total (iv)
Paracetamol 350.2106 to
1592.09±220.12 1149.23±195.39 0.0001
consumption 535.5094
in 24 hrs (mg)
[Table/Fig-4]: Comparison of time of rescue analgesia among two groups.

For detection of pain, VAS score was used at different time interval.
It was significantly low at rest (p<0.05) at 4,6,10 and 12 hours
after surgery with a better pain control in group RM patients than
in group RP patients [Table/Fig-5]. Pain was also assessed with [Table/Fig-8]: Comparison of mean arterial pressure between two groups.

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 Sandip RoyBasunia et al., Magnesium as Adjuvent in Thoracic Paravertebral Block www.jcdr.net

studies greatly helped in framing informed consent and maintaining

confidentiality of each participant.
In this prospective study, we had observed that rescue analgesic
was required much later in magnesium group than control. Gunduz
A et al., in a placebo controlled study on the role of magnesium along
with prilocaine found significant prolongation (304 vs. 253 minutes)
of postoperative analgesia [29]. Ammar AS et al., while performing a
placebo controlled study for the patients undergoing thoracic surgery
found paravertebral magnesium addition has significantly delayed
(388.8±70.6 vs. 222.2±61.6 minutes) the requirement of morphine
as rescue analgesic [30]. On the contrary Lee JH et al., found that
epidural administration of magnesium from before the induction
[Table/Fig-9]: Comparison of mean heart rate between two groups.
of anaesthesia to 48 hours postoperatively did not significantly
decrease the incidence or severity of chronic postoperative pain in
patients undergoing video-assisted thoracic surgery [31].
In this study, we have found that fentanyl requirement (as
intraoperative analgesic) was much less in magnesium group
(RM) as compared with control group (RP) and the outcome was
statistically significant. This result was in accordance with a study
conducted by Kaymak C et al., who found pre-administration of
magnesium sulphate bolus followed by infusion caused a significant
decrease in total consumption of fentanyl and midazolam in
test group in shockwave lithotripsy procedure under monitored
anaesthesia care [32].
In our study, intraoperative propofol requirement was higher in
control group and this finding was very much similar to Choi JC
et al., who found intravenous administration of magnesium sulfate
reduces propofol infusion requirement significantly in the patients
undergoing elective total abdominal hysterectomy [33].
In our study, postoperative paracetamol consumption was
significantly less in magnesium group than control. Similar findings
were observed by Mohamed KS et al., and they found postoperative
analgesic consumption as ketorolac was significantly lower in the
magnesium group (17.00 vs. 30.00 mg) than in the bupivacaine
group [34].
[Table/Fig-10]: Consort diagram showing flow of participants.
We found, VAS score was significantly higher at 4, 6, 10, 12 hours
DISCUSSION in control group. Thus in our study magnesium showed effective
Breast cancer as well as post-mastectomy persistent pain itself analgesic effects. Kaymak C et al., in their study found that
has a negative impact on quality of life in survivors [22-24]. With intravenous magnesium had reduced VAS score significantly at 15,
excellent pain management protocol, breast cancer surgery related 20, 25 minutes time interval [32]. Similar findings were observed by
acute post surgical pain can be alleviated; at the same time anxiety, Mohamed KS et al., who found intrathecal magnesium use caused
morbidity, cost and length of hospital stay in the postoperative a lower VAS score in study group [34].
period can be decreased [25]. In our study, we had found sedation was quite similar and
Different combinations of local anaesthetics and adjuvants have comparable among two groups and the sedation was slightly
been tried in paravertebral block for the patients undergoing higher in magnesium group. But on the contrary, Ammar AS et al.,
found lesser somnolence rate in paravertebral magnesium group
thoracic or breast cancer surgeries to reduce the perioperative pain
than control group [30]. In our study, bradycardia and hypotension
[10-13]. Magnesium sulphate has recently been used in neuraxial
both were comparable among two groups and both the values
anaesthesia, peripheral nerve block and nerve plexus blockade
were slightly less in magnesium group. Similar findings were also
successfully [26-28].
observed by Shabana R et al. They found slightly higher systolic
In this randomised, prospective placebo control trial, we have blood pressure in magnesium group after 24 hours of operation
evaluated the effect of 1 mL magnesium sulphate (500 mg) in but at the same time heart rate was slightly lower in magnesium
thoracic paravertebral block for the patients undergoing breast group [35].
cancer surgery under GA. Here, we measured the time and dose of
Again among side effects in our study nausea, vomiting was quite
administering first dose of rescue analgesic as paracetamol. Total
comparable and magnesium produced slightly lower nausea and
dose of intraoperative analgesic fentanyl; haemodynamics and side vomiting. Mohamed KS et al., also found lesser nausea, vomiting in
effects were also assessed. magnesium group and they were also statistically insignificant [34].
Information regarding various adjuvants in TPVB were available
for conducting this study (like case series, multicentre clinical limitation
trials, meta-analysis of randomised trials, computerised database, Among the study limitations, though we had measured BISS
etc.,), each with specific strengths and weaknesses. This review (bispectral index) for anaesthesia depth assessment, we did not
of literature greatly helped in drawing up the research questions, compare the same among two groups. We did not measure the
identifying the common possible side effects and taking adequate plasma catecholamine concentration which ideally should have
measures for them, devising a data extraction plan, extracting the been decreased by magnesium. In future, a larger study with larger
data, checking for errors, data analysis, and appropriate archiving sample size needs to be conducted to establish author’s point of
and dissemination of the findings. The ethical aspects in such view with solidarity.
4 Journal of Clinical and Diagnostic Research. 2018 Dec, Vol-12(12): UC01-UC05
www.jcdr.net Sandip RoyBasunia et al., Magnesium as Adjuvent in Thoracic Paravertebral Block

CONCLUSION [17] Koinig H, Wallner T, Marhofer P, Andel H, Hörauf K, Mayer N. Magnesium

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administered along with thoracic paravertebral block prior to [18] Panda NB, Bharti N, Prasad S. Minimal effective dose of magnesium sulfate
for attenuation of intubation response in hypertensive patients. J Clin Anesth.
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PARTICULARS OF CONTRIBUTORS:
1. Assistant Professor, Department of Anaesthesiology, Midnapore Medical College, Midnapore, West Bengal, India.
2. Associate Professor, Department of Anaesthesiology, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India.
3. Assistant Professor, Department of Anaesthesiology, Murshidabad Medical College, Berhampore, West Bengal, India.
4. R.M.O cum Clinical Tutor, Department of Anaesthesiology, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India.
5. Assistant Professor, Department of Anaesthesiology, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India.
6. Assistant Professor, Department of Anaesthesiology, N.R.S Medical College, Kolkata, West Bengal, India.
7. Associate Professor, Department of Anaesthesiology, I.P.G.M.E & R, Kolkata, West Bengal, India.
8. Professor, Department of Anaesthesiology, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Anjan Das,
Royal Plaza Apartment, 4th Floor, Flat no-1, 174 Gorakshabashi Road, Kolkata-700028, West Bengal, India. Date of Submission: Jul 26, 2018
E-mail: [email protected] Date of Peer Review: Aug 25, 2018
Date of Acceptance: Sep 29, 2018
Financial OR OTHER COMPETING INTERESTS: None. Date of Publishing: Dec 01, 2018

Journal of Clinical and Diagnostic Research. 2018 Dec, Vol-12(12): UC01-UC05 5