Patient Satisfaction With, and Outcomes of, Ultrasound-Guided Regional Anesthesia at a Referral Hospital in Tanzania: A Cross-Sectional Study.

BACKGROUND: Regional anesthesia techniques are increasingly used in high-income countries (HICs) for both surgical anesthesia and postoperative analgesia. However, regional anesthesia has not been utilized to the same degree in low- to middle-income countries (LMICs) due to a lack of resources and trained personnel. This study evaluates patient satisfaction with, and outcomes of, ultrasound-guided regional anesthesia for extremity surgery at Kilimanjaro Christian Medical Center (KCMC) in the Northeastern zone of Tanzania. METHODS: Study patients were ≥18 years of age; American Society of Anesthesiologists (ASA) physical status I, II, or III; and underwent extremity surgery under peripheral nerve block with ultrasound guidance at KCMC. After placement, blocks were assessed for effectiveness intraoperatively, as demonstrated by the need for supplemental analgesic or sedative medication or conversion to a general anesthetic. Postoperatively, patients were assessed for satisfaction with their nerve block and pain at 12 and 24 hours. Adverse events related to regional anesthesia were assessed immediately, 45 minutes after block placement, and at 12 and 24 hours postoperatively. The primary outcome was patient satisfaction at 12 hours. Secondary outcomes were block success rate and analgesia at 12 and 24 hours postoperatively. RESULTS: A convenience sample of 170 patients was included in the study, of whom 156 (95% confidence interval [CI], 87-95) were either satisfied or very satisfied with their block. Block placement was highly successful with only 8 of 170 participants (95% CI, 2.4-8.3), requiring conversion to a general anesthetic. Analgesia continued in the postoperative period, with 164 of 170 (95% CI, 93-98) patients and 145 of 170 (95% CI, 80-90) patients reporting acceptable analgesia at 12 and 24 hours, respectively. No major adverse events, such as local anesthetic toxicity, infection, bleeding, nerve injury, or pneumothorax, were observed. CONCLUSIONS: Our study found that ultrasound-guided regional anesthesia in a resource-constrained setting was effective for extremity surgery and resulted in high patient satisfaction. No complications occurred. The use of ultrasound-guided regional anesthesia shows promise for the safe and effective care of patients undergoing extremity surgery in LMICs.

Ultrasound-guided, continuous erector spinae plane (ESP) block in minimally invasive thoracic surgery-comparing programmed intermittent bolus (PIB) vs continuous infusion on quality of recovery and postoperative respiratory function: a double-blinded randomised controlled trial.

BACKGROUND: Minimally invasive thoracic surgery (MITS) has been shown to reduce postoperative pain and contribute to better postoperative quality of life as compared to open thoracic surgery (Bendixen et al., Lancet Oncol 17:836-44, 2016). However, it still causes significant post-operative pain. Regional anaesthesia techniques including fascial plane blocks such as the erector spinae plane block (ESP) have been shown to contribute to post-operative pain control after MITS (Finnerty et al., Br J Anaesth 125:802-10, 2020). Case reports relating to ESP catheters have described improved quality of pain relief using programmed intermittent boluses (PIB) instead of continuous infusion (Bendixen et al., Lancet Oncol 17:836-44, 2016). It is suggested that larger, repeated bolus dose may provide superior pain relief, possibly because of improved spread of the local anaesthetic medications (Ilfeld and Gabriel, Reg Anesth Pain Med 44:285-86, 2019). Evidence for improved spread of local anaesthetic may be found in one study which demonstrated that PIB increased the spread of local anaesthetic medication compared to continuous infusions for continuous paravertebral blocks, which are another type of regional anaesthesia technique for the chest wall (Hida et al., Reg Anesth Pain Med 44:326-32, 2019). Similarly, regarding labour epidural analgesia, the weight of evidence is in favour of PIB providing better pain relief compared with continuous infusion (Onuoha, Anesthesiol Clin 35:1-14, 2017). Since fascial plane blocks, such as ESP, rely on the spread of local anaesthetic medication between muscle layers of the chest wall, intermittent boluses may be particularly useful for this group of blocks. However, until recently, pumps capable of providing automated boluses in addition to patient-controlled boluses were not widely available. To best of our knowledge, there are no randomised controlled trials comparing continuous infusion versus intermittent bolus strategies for erector spinae plane block for MITS in terms of patient centred outcomes such as quality of recovery. METHODS: This trial will be a prospective, double-blinded, randomised controlled superiority trial. A total of 60 eligible patients will be randomly assigned to receive an intermittent bolus regime of local anaesthetic vs a continuous infusion of local anaesthetic. The medication will be delivered via an ultrasound-guided erector spinae plane block catheter which will be inserted by an anaesthesiologist while the patient is under general anaesthetic before their MITS surgery begins. The primary outcome being measured is the Quality of Recovery (QoR-15) score between the two groups 24 h after surgery. Secondary outcomes include respiratory testing of maximal inspiratory volume measured with a calibrated incentive spirometer, area under the curve for Verbal Rating Score for pain at rest and on deep inspiration versus time over 48 h, total opioid consumption over 48 h, QoR-15 score at 48 h and time to first mobilisation. DISCUSSION: Despite surgical advancements in thoracic surgery, severe acute post-operative pain following MITS is still prevalent. This study will provide new knowledge and possible recommendations about the efficacy of programmed intermittent bolus regimen of local anaesthetic vs a continuous infusion of local anaesthetic via an ultrasound-guided erector spinae plane catheter for patients undergoing MITS. TRIAL REGISTRATION: This trial was pre-registered on ClinicalTrials.gov Identifier: NCT05181371 . Registered on 6 January 2022. All item from the World Health Organization Trial Registration Data set have been included.

Re-intervention and patient satisfaction rates following office radiofrequency endometrial ablation: a comparative retrospective study of 408 cases.

This retrospective study assessed the efficacy and long-term satisfaction of radiofrequency endometrial ablation outside the context of clinical trials in 408 women, and compared the outcome between office-setting (211, 52%) and day-case procedures under general anaesthetics (197, 48%). The Kaplan Meir time-to-event analysis showed that the cumulative number of women undergoing surgical re-intervention was 32 with a probability of 9.4% (95% CI: 6.3 - 12.5%) at 2-years, and 45 with a probability of 14.5% (95% CI: 10.3 - 18.2%) at 5-years. There was no statistically significant difference in the re-intervention rate between office and day-case groups (HR = 0.7, 95% CI: 0.68 - 3.1, p = .3). The satisfaction rate, measured by Visual Analogue Scale, was not statistically different (p = .5) between office (109; 80.7%) and day-case (96; 82.8%) groups. This study showed lower surgical re-intervention rate than previously reported in observational studies, and high rates of long-term women satisfaction. The outcomes were similar in office and day-case settings.Impact statementWhat is already known on this subject? Previous studies have shown the safety and effectiveness of radiofrequency endometrial ablation for treating heavy periods. However, studies investigating it, outside clinical trials, either included a small sample size, a short-term follow-up, poor reporting so that it is impossible to judge whether some women underwent re-intervention in another centre, failed to discriminate in analysis between second-generation techniques, or assessed only short-term satisfaction.What do the results of this study add? This is the largest series reported from a single centre and the first study reporting long-term satisfaction in women, outside clinical trials. Surgical re-intervention was used as the primary outcome measure which is an objective measure rather than the change in the monthly flow which is rather subjective. More importantly, the study records the similarity, in the outcome and women's satisfaction rate, between office and day-case procedures under general anaesthetics.What are the implications of these findings for clinical practice and/or further research? Endometrial ablation service is widely implemented in office-setting in the UK. We hope the result of this study encourages implementation on a larger scale in office across centres in the world with its multiple advantages both to women and service alike.

Prevalence of postoperative delirium with different combinations of intraoperative general anesthetic agents in patients undergoing cardiac surgery: A retrospective propensity-score-matched study.

ABSTRACT: Postoperative delirium (PD) remains an issue in cardiac surgery despite the constant efforts to reduce its incidence. In this retrospective study, the incidence of PD was evaluated in patients who underwent cardiac surgery with cardiopulmonary bypass (CPB) according to different primary anesthetic agents: sevoflurane and dexmedetomidine- versus propofol-based anesthesia.A total of 534 patients who underwent heart-valve surgery or coronary artery bypass graft surgery with CPB between January 2012 and August 2017 were divided into 2 groups according to the main anesthetic agent: sevoflurane with dexmedetomidine (sevo-dex group, n = 340) and propofol (propofol group, n = 194). The incidence of PD was evaluated as the primary outcome. Patient-, surgery-, and anesthesia-related factors and postoperative complications were investigated as secondary outcomes. To reduce the risk of confounding effects between the 2 groups, 194 patients were selected from the sevo-dex group after propensity-score matching.After propensity-score matching, the incidence of PD was not significantly different between the sevo-dex (6.2%) and propofol (10.8%) groups (P = .136). In comparisons of the incidence of each type of PD, only hyperactive PD occurred significantly less frequently in the sevo-dex group (P = .021). Older age, lower preoperative albumin levels, and emergency surgery were significant risk factors for PD.The overall incidence of PD after cardiac surgery with CPB did not differ between patients receiving sevoflurane and dexmedetomidine-based versus propofol-based anesthesia. Only hyperactive PD occurred less frequently in patients receiving sevoflurane and dexmedetomidine-based anesthesia.

Comparison of Sevoflurane and Propofol on the Incidence of Postoperative Pain and Quality of Life in Patients Undergoing Total Knee Arthroplasty With Chronic Pain Before Surgery.

BACKGROUND: Propofol and sevoflurane as frequently used general anesthetics can affect postoperative pain. Our study explored whether the incidence of postoperative pain differed among patients with chronic pain undergoing total knee arthroplasty (TKA) anesthetized with sevoflurane or propofol. METHODS: Patients were randomly assigned to groups receiving either sevoflurane (Group S, n = 50) or propofol (Group P, n = 47) for anesthesia maintenance during TKA. The incidences of postoperative pain and quality of life (QoL) were measured using the EuroQol 5-Dimension (EQ-5D) scale at 1, 3, and 7 days post-operation (DPO), and 1 and 3 months post-operation (MPO). RESULTS: At 3 DPO, fewer patients reported moderate pain (P = 0.001) and more patients reported no pain (P = 0.003) in Group S than that in Group P. At 3 MPO, more patients reported no pain (P = 0.04) and fewer patients reported moderate pain (P = 0.04) in Group S than in Group P. No significant differences were found in the incidence of postoperative pain between the 2 groups of patients at the other time points. The EQ-5D scores were higher in Group S than in Group P (P = 0.022), and the difference was 0.15 at most, which was not optimal. The EQ-5D clinical results might be not very significant. CONCLUSIONS: Sevoflurane anesthesia may have potential advantages in reducing postoperative pain in patients undergoing TKA with a preoperative VAS score > 4.

Efficacy Of Intravenous Lignocain Vs Sevoflurane In Prevention Of Coughing And Desaturation At Extubation In Children.

BACKGROUND: Inadvertent coughing and desaturation are the most commonly faced and feared respiratory complications in post-anaesthesia period. The study was done to compare the efficacy of intravenous lignocaine versus sevoflurane in prevention of coughing and desaturation at extubation in children less than 6 years of age. METHODS: This Randomized Control Trial was carried out from May 2013 to May 2016, at Combined Military Hospital Nowshera after obtaining approval from the hospital ethics committee (IREC-0003/5/13/Aneas). Children aged three months to six years undergoing surgical procedures requiring the placement of definitive airway were randomly assigned into two groups. Patients were anaesthetized by standardized balanced anaesthesia technique. In Group A (n=355), three minutes prior to extubation lignocaine 2% was used intravenously. In Group B (n=355), isoflurane was switched off, breathing circuit changed and sevoflurane started at minimum alveolar concentration (MAC 3-4%) for 3 minutes prior to extubation. Assessment for extubation was clinical. Oxygen saturation and severity of coughing were noted for 5 consecutive minutes, after extubation. RESULTS: In group-A, 156 patients were less than 2 years of age while in group-B, 135 patients were less than 2 years old. In group-A, 199 and in group-B, 220 children were 2-6 years of age respectively. Post stratification the p-value for weight was 0.17 (p-value >0.05) and t-statistic was 1.36. Post stratification p-value for gender was 0.12 (p-value>0.05) and chi square statistic was 2.49. Group A had more eventful extubation with 270 cases of cough (76%) as compared to group-B where it was noted in 199 cases (56%). Similarly, desaturation was observed in 85 cases in group-A (24%) as compared to 28 cases (8%) in group-B. The difference between the groups was statistically significant. CONCLUSIONS: Sevoflurane based anaesthetic vapours mixture causes statistical significant prevention from events like coughing episodes and desaturation in post-extubation in children less than six years of age undergoing elective surgery.

Regulatory Effect of General Anesthetics on Activity of Potassium Channels.

General anesthesia is an unconscious state induced by anesthetics for surgery. The molecular targets and cellular mechanisms of general anesthetics in the mammalian nervous system have been investigated during past decades. In recent years, K+ channels have been identified as important targets of both volatile and intravenous anesthetics. This review covers achievements that have been made both on the regulatory effect of general anesthetics on the activity of K+ channels and their underlying mechanisms. Advances in research on the modulation of K+ channels by general anesthetics are summarized and categorized according to four large K+ channel families based on their amino-acid sequence homology. In addition, research achievements on the roles of K+ channels in general anesthesia in vivo, especially with regard to studies using mice with K+ channel knockout, are particularly emphasized.

Neurotoxicity versus Neuroprotection of Anesthetics: Young Children on the Ropes?

Normal brain development in young children depends on a balance between excitation and inhibition of neurons, and alterations to this balance may cause apoptosis. During the perioperative period, both surgical stimuli and anesthetics can induce neurotoxicity. This article attempts to expand the perspective of a topical issue-anesthetic-induced neurotoxicity-by also considering the protective effect of general anesthetics against surgery-induced neurotoxicity, all of which may generate some controversy in the current literature. The "new" major factor influencing neurotoxicity-nociceptive stimulus-is discussed together with other factors to develop clinical and research strategies to obtain a balance between neurotoxicity and neuroprotection.

Implication of general anaesthetic and sedation techniques in temporomandibular joint disorders - a systematic review.

The purpose of this study was to conduct a systematic review of the literature on temporomandibular joint damage directly related to general anaesthesia and sedation. We searched MEDLINE, SCOPUS and the COCHRANE Library for titles and abstracts containing terms related to the subject. The search delimiters were analytical and descriptive studies with abstracts in Spanish, German, English or French, with no time limit. The search was updated in January 2015. Of the 398 articles found, 89 were duplicates and only 28 were of interest. Of these, 23 (82.14%) were case and case series reports, 4 (14.28%) were longitudinal studies and 1 (3.57%) was a cross-sectional study. General anaesthesia and sedation are risk factors for temporomandibular joint damage because of the drop in muscle tone caused by the drugs employed and because of airway management manoeuvres involving the joint. Joint complications have been described with spontaneous ventilation as well as with ventilation assisted by a face or laryngeal mask and with intubation. They are more frequent in women and/or patients with previous temporomandibular problems. Proper assessment is required both before and after anaesthesia or sedation in order to foresee and avoid or minimize temporomandibular complications. The data should be treated with caution, as the evidence of case and case series reports is not of a high standard and the small number of analytical studies is not entirely comparable. General anaesthesia and sedation techniques can influence the onset of temporomandibular joint disorders. More studies are needed to provide better clinical evidence.

Use of Posterior Root-Muscle Reflexes in Peripheral Nerve Surgery: A Case Report.

It is well established that a mixed-agent general anesthetic regimen of volatile gas and intravenous anesthetic or total intravenous anesthetic (TIVA) is required to obtain adequate transcranial motor-evoked potentials (TcMEPs) to detect and hopefully prevent injury during brain, spinal cord, and peripheral nerve surgery. But even under ideal general anesthetic conditions, TcMEPs are not always detectable in every muscle monitored, and are prone to anesthetic fade, especially when neuropathic or injured tissue is monitored. TcMEP sensitivity to general anesthesia can be especially problematic during peripheral nerve surgery where there is often only one or a few essential muscles required to provide adequate monitoring; thus, maximum fidelity is essential. However, there is an anesthetic-resistant high-fidelity modality available to successfully monitor the motor component of distant peripheral nerves originating from the cauda equina. Percutaneus transabdominal electrical stimulation elicits a relatively anesthetic-resistant, robust motor response in muscles innervated by cauda equina nerve roots. We report the successful use of posterior root-muscle (PRM) reflex to monitor the decompression of the sciatic nerve at its bifurcation in a 22-year-old female with a history of severe sciatic nerve neuropathic pain and muscle weakness following benign thigh tumor resection.

[PHARMACOLOGICAL NEUROPROTECTION IN CARDIOSURGERY (Part 1): DRUGS FOR GENERAL ANESTHESIA].

This literature review is devoted to modern condition of pharmacological neuroprotection. Aeuroprotection as a complex method of brain protection and reduction of neurological complications is a relevant trend in practical anesthesia and intensive care. The following data represents frequency of neurological complications in different types of surgery and its main classifications. In the first part of the review potential neuroprotectional abilities of modern anesthesia medications are discussed Mechanisms of neuronal destruction and possible ways of impact on the pathophysiological processes via pharmacological agents are observed. The most promising drugs with neuroprotectional effects are selected. In the second part of the review we are going to examine neuroprotection effects of non-anesthetic drugs.

Analgesic, anxiolytic and anaesthetic effects of melatonin: new potential uses in pediatrics.

Exogenous melatonin is used in a number of situations, first and foremost in the treatment of sleep disorders and jet leg. However, the hypnotic, antinociceptive, and anticonvulsant properties of melatonin endow this neurohormone with the profile of a drug that modulates effects of anesthetic agents, supporting its potential use at different stages during anesthetic procedures, in both adults and children. In light of these properties, melatonin has been administered to children undergoing diagnostic procedures requiring sedation or general anesthesia, such as magnetic resonance imaging, auditory brainstem response tests and electroencephalogram. Controversial data support the use of melatonin as anxiolytic and antinociceptive agents in pediatric patients undergoing surgery. The aim of this review was to evaluate available evidence relating to efficacy and safety of melatonin as an analgesic and as a sedative agent in children. Melatonin and its analogs may have a role in antinociceptive therapies and as an alternative to midazolam in premedication of adults and children, although its effectiveness is still controversial and available data are clearly incomplete.

Propofol as a panacea for acute kidney injury?

Yoo and colleagues report a small but provocative randomized clinical trial to prevent acute kidney injury in the setting of cardiopulmonary bypass surgery. Their article describes a trial of 112 patients undergoing valvular surgery with cardiopulmonary bypass who were randomized to receive sevoflurane (an inhaled anesthetic) or propofol for general anesthesia. The use of propofol was associated with a significant decrease in the rate of postoperative acute kidney injury.

Considerations for the use of short-acting opioids in general anesthesia.

Anesthesiologists play a critical role in facilitating a positive perioperative experience and early recovery for patients. Depending on the kind of procedure or surgery, a wide variety of agents and techniques are currently available to anesthesiologists to administer safe and efficacious anesthesia. Notably, the fast-track or ambulatory surgery environment requires the use of agents that enable rapid induction, maintenance, and emergence combined with minimal adverse effects. Short-acting opioids demonstrate a safe and rapid onset/offset of effect; that short effect is both predictable and precise. It also ensures easier titration and reduced or rapidly reversed side effects. Due to their distinct pharmacokinetic and pharmacodynamic properties, and, in one case, rapid extra-hepatic clearance of remifentanil, these agents have several applications in general anesthesia.

Evaluation of risk factors, including fluconazole administration, for prolonged anesthetic recovery times in horses undergoing general anesthesia for ocular surgery: 81 cases (2006-2013).

OBJECTIVE--To determine risk factors for prolonged anesthetic recovery time in horses that underwent general anesthesia for ocular surgery. DESIGN--Retrospective cohort study. ANIMALS--81 horses that underwent general anesthesia for ocular surgery between 2006 and 2013. PROCEDURES--Descriptive information recorded included the ocular procedure performed, concurrent fluconazole treatments, analgesic and anesthetic agents administered, procedure duration, use of sedation for recovery, and recovery time. Data were analyzed for associations between recovery time and other variables. RESULTS--81 horses met inclusion criteria. In 72 horses, anesthesia was induced with ketamine and midazolam; 16 horses treated concurrently with fluconazole had significantly longer mean recovery time (109 minutes [95% confidence interval {CI}, 94 to 124 minutes]) than did 56 horses that were not treated with fluconazole (50 minutes [95% CI, 44 to 55 minutes]). In 9 horses anesthetized with a protocol that included ketamine but did not include midazolam, there was no difference between mean recovery time in horses that either received (59 minutes [95% CI, 36 to 81 minutes]; n = 5) or did not receive (42 minutes [95% CI, 16 to 68 minutes]; 4) fluconazole. Other variables identified as risk factors for prolonged recovery included duration of anesthesia and use of acepromazine for premedication. CONCLUSIONS AND CLINICAL RELEVANCE--Fluconazole administration was associated with prolonged anesthetic recovery time in horses when ketamine and midazolam were used to induce anesthesia for ocular surgery. Duration of anesthesia and premedication with acepromazine were also identified as risk factors for prolonged recovery time.

Anesthetics influence the incidence of acute kidney injury following valvular heart surgery.

Propofol has been shown to provide protection against renal ischemia/reperfusion injury experimentally, but clinical evidence is lacking. Here we studied the effect of propofol anesthesia on the occurrence of acute kidney injury following heart surgery with cardiopulmonary bypass. One hundred and twelve patients who underwent valvular heart surgery were randomized to receive either propofol or sevoflurane anesthesia, both with sufentanil. Using Acute Kidney Injury Network criteria, significantly fewer patients developed acute kidney injury postoperatively in the propofol group compared with the sevoflurane group (6 compared with 21 patients). The incidence of severe renal dysfunction was significantly higher in the sevoflurane group compared with the propofol group (5 compared with none). The postoperative cystatin C was significantly lower in the propofol group at 24 and 48 h. Serum interleukin-6 at 6 h after aorta cross-clamp removal, C-reactive protein at postoperative day 1, and segmented neutrophil counts at postoperative day 3 were also significantly lower in the propofol group. Thus, propofol anesthesia significantly reduced the incidence and severity of acute kidney injury in patients undergoing valvular heart surgery with cardiopulmonary bypass compared with sevoflurane. This beneficial effect of propofol may be related to its ability to attenuate the perioperative increase in proinflammatory mediators.

Postoperative analgesia in children after propofol versus sevoflurane anesthesia.

OBJECTIVE: Postoperative analgesia remains a problem, especially in pediatric patients. We hypothesize that patients anesthetized with sevoflurane have more postoperative pain than with propofol. DESIGN: Randomized, prospective, double-blind study. SETTING: University teaching hospital. SUBJECTS: The subjects were 88 premedicated children, aged 3-6 years, and American Society of Anesthesiologists (ASA) Physical Status I or II. INTERVENTIONS: Subjectsunderwent hernia repair surgery. METHODS: Anesthesia was maintained with propofol (group P, N = 46) or sevoflurane (group S, N = 42) and fentanyl was administered during surgery. All children before surgical incision received 40 mg/kg paracetamol, rectally. Prior to wound closure, the margins were infiltrated with 0.5% bupivacaine. OUTCOME MEASURES: The primary outcome was pain score assessed by Faces Pain Scale (FPS) 2 hours postoperatively. The secondary outcomes included recovery time and adverse events within the first 2 hours. RESULTS: Group S had a significantly higher proportion of patients who exhibited postoperative pain than group P (24.3% vs 4.5%, respectively; P < 0.05). FPS score in group P was 1.2 ± 0.6, compared with 3.4 ± 1.5 in group S (P < 0.001). Mean recovery time in group S was significantly shorter than the corresponding mean for group P (10.1 ± 1.3 vs 16.5 ± 5.4 minutes, respectively; P < 0.001). CONCLUSION: In children, anesthesia maintenance with propofol was associated with a significantly lower incidence of postoperative pain than with sevoflurane.

Robotic assistance and general anaesthesia improve catheter stability and increase signal attenuation during atrial fibrillation ablation.

AIMS: Recurrent arrhythmias after ablation procedures are often caused by recovery of ablated tissue. Robotic catheter manipulation systems increase catheter tip stability which improves energy delivery and could produce more transmural lesions. We tested this assertion using bipolar voltage attenuation as a marker of lesion quality comparing robotic and manual circumferential pulmonary vein ablation for atrial fibrillation (AF). METHODS AND RESULTS: Twenty patients were randomly assigned to robotic or manual AF ablation at standard radiofrequency (RF) settings for our institution (30 W 60 s manual, 25 W 30 s robotic, R30). A separate group of 10 consecutive patients underwent robotic ablation at increased RF duration, 25 W for 60 s (R60). Lesions were marked on an electroanatomic map before and after ablation to measure distance moved and change in bipolar electrogram amplitude during RF. A total of 1108 lesions were studied (761 robotic, 347 manual). A correlation was identified between voltage attenuation and catheter movement during RF (Spearman's rho -0.929, P < 0.001). The ablation catheter was more stable during robotic RF; 2.9 ± 2.3 mm (R30) and 2.6 ± 2.2 mm (R60), both significantly less than the manual group (4.3 ± 3.0 mm, P < 0.001). Despite improved stability, there was no difference in signal attenuation between the manual and R30 group. However, there was increased signal attenuation in the R60 group (52.4 ± 19.4%) compared with manual (47.7 ± 25.4%, P = 0.01). When procedures under general anaesthesia (GA) and conscious sedation were analysed separately, the improvement in signal attenuation in the R60 group was only significant in the procedures under GA. CONCLUSIONS: Robotically assisted ablation has the capability to deliver greater bipolar voltage attenuation compared with manual ablation with appropriate selection of RF parameters. General anaesthesia confers additional benefits of catheter stability and greater signal attenuation. These findings may have a significant impact on outcomes from AF ablation procedures.

General anesthetics in pediatric anesthesia: influences on the developing brain.

Millions of newborn and infants receive anesthetic, sedative and analgesic drugs for surgery and painful procedures on a daily basis. However, recent laboratory reports clearly demonstrate that anesthetic and sedative drugs induced both neuroapoptosis and neurocognitive deficits in laboratory models. This issue is of paramount interest to pediatric anesthesiologists and intensivists because it questions the safety of anesthetics used for fetal and neonatal anesthesia. Most clinically utilized anesthetic drugs have been found to induce neuronal cell death in the developing brain and to potentially cause long-term neurological impairment. Conversely, painful stimuli without analgesia and anesthesia have been implicated in triggering neuro-apoptosis in juvenile mammalian models. Published retrospective reviews demonstrate temporary neurological sequelae after prolonged anesthetic exposure in young children and larger studies identify long-term neurodevelopmental impairment after neonatal surgery and anesthesia. This paper examines the evidence for the effects of commonly used anesthetics on neuronal structure and neurocognitive function in laboratory models and reviews the relevant clinical human epidemiologic data.