Background and Aims: Preoperative laboratory testing is done to detect abnormalities in the body not detected by clinical examination. Often a battery of tests is advocated as a routine for patients scheduled for low or intermediate risk surgery. This prospective observational study was aimed to assess agreement of the current practice of preoperative laboratory investigations with the National Institute of Clinical Excellence (NICE) guidelines, and the impact of investigations on patient care and costs. Material and Methods: The study was conducted at a tertiary referral center on 385 patients aged 18-70 years of either gender, posted for elective general surgical, gynaecological or otolaryngological surgery. Sixteen investigations were examined: hemogram, blood urea, serum creatinine, serum electrolytes, coagulation profile, urinalysis, thyroid function tests, electrocardiogram, echocardiogram, chest x-ray, pulmonary function tests, blood sugar, glycosylated hemoglobin, liver function tests, treadmill test and coronary angiogram. The history and physical examination were reviewed to examine for indication for these laboratory investigations. These were compared with NICE guidelines. Impact of these investigations on anesthetic decision-making was noted. Results: There was almost no agreement of the current practice with the NICE guidelines. The total cost of all tests obtained was Rs 5,48,755. Total additional cost of unindicated tests was Rs 5,10,730 (93%). Average amount spent on additional investigations per patient was Rs 1326.57. Conclusion: Most investigations are overprescribed and have minimal agreement with NICE guidelines. None of the tests had any impact on clinical care. Nearly a million rupees is incurred per year in one referral hospital alone, when NICE guidelines are not followed.

ConclusionThe lateral technique of insertion of the Classic TM LMA along either the right border or the left border of the tongue is comparable in terms of the fibreoptic grading and the time taken for successful insertion. However, left side technique is easier as per the operator, requires fewer number of attempts, has lesser incidence of sore throat after 2 hours.

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Peripartum cardiomyopathy (PPCM) is a form of dilated cardiomyopathy which presents unique challenges for anaesthetic management. Here we present a case of PPCM who was given low dose spinal anaesthesia with TAP block for caesarean section which is rarely reported. A 33-year-old multigravida, 35 weeks gestation presented with PPCM with ejection fraction of 24%. Elective caesarean section was planned in view of worsening dyspnoea despite treatment. Graded epidural anaesthesia with invasive monitoring was planned but we encountered a bloody tap whilst securing the epidural catheter, hence switched to low dose spinal anaesthesia (6mg of 0.5% bupivacaine+10mcg of fentanyl). Ultrasound guided bilateral TAP block was given for post-operative analgesia. We observed that the patient had a comfortable and haemodynamically stable experience intra and post operatively. Hence a low dose spinal anaesthesia and TAP block with invasive monitoring can be opted as an anaesthetic technique in PPCM.

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BACKGROUND Pre-operative anxiety is common in children and its relief is an important concern for the anaesthesiologist. Oral midazolam has good sedative and anxiolytic properties. Dexmedetomidine, an alpha-2 agonist, produces sedation like natural sleep, in addition to having analgesic, anxiolytic and anaesthetic-sparing properties, making it a near ideal sedative. Alleviating this anxiety using minimally invasive and painless routes for sedative drugs is of paramount importance. The purpose of this study was to compare the sedation, child-parent separation, and mask acceptance between sublingual atomised dexmedetomidine and oral midazolam, along with the haemodynamic changes associated with these drugs. METHODS This prospective, double-blind, randomised control trial was conducted in a tertiary hospital setting. Using computer-generated randomisation, sixty paediatric patients were divided into one of two groups. Group - D received sublingual dexmedetomidine 1.5 µg/kg using a mucosal atomisation device, and Group - M, oral midazolam 0.5 mg/kg, 45 minutes before anaesthetic induction. Sedation status, child-parent separation, mask acceptance scores, haemodynamics and oxygen saturation were measured at baseline and every 15 minutes till induction. Quantitative data were compared with student’s t-test and repeated measures analysis of variance (ANOVA), and qualitative data using chi-square test. RESULTS Demographic data were comparable between the two groups. Children in Group - D were significantly more sedated (P < 0.0001), with lower heart rate at 30 and 45 minutes (P = 0.003, < 0.0001 respectively) than Group - M. However, mask acceptance score was significantly better (P = 0.007) in Group - M. Child-parent separation score was comparable. CONCLUSIONS Atomised sublingual dexmedetomidine produced significantly greater sedation and low-normal heart rate, but poorer mask acceptance than with oral midazolam. Child-parent separation was comparable. We conclude that sublingual atomised dexmedetomidine 1.5 µg/kg, is not a suitable alternative to oral midazolam 0.5 mg/kg for paediatric premedication. KEY WORDS Anaesthesia, Dexmedetomidine, Midazolam, Anti-Anxiety Agents, Premedication, Paediatric

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