Effect of Electroencephalography Guided General Anesthesia on Postoperative Delirium in Children

Postoperative delirium (POD) is an acute postoperative behavioral change defined as an impairment in the child's awareness or attention to the environment, accompanied by disorientation and perceptual changes, including hypersensitivity to stimuli and hyperactive motor behavior, usually in the immediate post-anesthesia period. The incidence of POD may depend largely on age, anesthesia technique, surgical procedure, and adjunctive medication administration. Its incidence in preschool children receiving sevoflurane anesthesia varies between 10-80%. Although POD is mostly self-limiting and occurs within the first minutes of the postoperative period, physical injuries cannot be ignored as children can move their limbs uncontrollably, get rid of their catheters, and even lose important equipment.

Prevention of POD includes pharmacological treatment and non-pharmacological treatment. Pharmacological treatment, including the administration of midazolam, ketamine, dexmedetomidine, and melatonin in the preoperative or intraoperative period, is effective, but these measures can prolong the stay in the postoperative anesthesia care unit (PACU) and cause many adverse reactions, such as postoperative nausea and vomiting, respiratory depression. Non-pharmacological treatments, such as parental companionship, preoperative education, or playing music upon entering the room, offer therapeutic effects at lower cost and greater convenience. Therefore, finding ways to prevent POD using non-pharmacological treatments is valuable.

Nowadays, more and more anesthesiologists titrate the anesthesia dose by monitoring the depth of anesthesia. In 2020, electroencephalography (EEG) monitoring was recommended by the American Society of Anesthesiologists (ASA) as one of the important organ monitoring methods to guide general anesthesia management. In the adult population, the potential benefits of monitoring intraoperative depth of anesthesia have been confirmed, including a lower incidence of hypotension under anesthesia and intraoperative awareness, faster awakening and recovery time, and reduced drug dosage use. Many meta-analyses have shown that anesthesia management through EEG monitoring can reduce the occurrence of POD in adult patients undergoing general anesthesia. EEG and depth of anesthesia monitoring have been used in pediatric anesthesia management since 2000; It is especially recommended for use in children who have undergone major or long-term surgery. EEG monitoring in pediatric anesthesia has been proven to be beneficial for children by reducing anesthetic consumption. Pediatric routine anesthesia management largely depends on the experience of the anesthesiologist.

Xu et al. reported that in pediatric surgery, EEG parameters [SEF (spectral edge frequency), PSI (patient state index), DSA (density spectral array) and raw EEG waves] may be more effective than special indices in reflecting the depth of anesthesia. Recent studies have also reported that SEF may be more effective in representing the depth of anesthesia, and that DSA can be used as a measure of the depth of anesthesia in young children undergoing sevoflurane anesthesia. In addition, in the studies of Koch et al., raw EEG features were analyzed in children undergoing general anesthesia and some relationships were found between POD and EEG epileptiform discharges. However, it is still unclear whether the use of these EEG parameters (SEF, DSA, raw EEG wave) can reduce the incidence of POD.

In this study, the investigators used SEF, PSI, DSA and EEG waves to monitor the depth of anesthesia in children. SEF, PSI, DSA and raw EEG waves can reflect the depth of anesthesia more precisely. The aim is to investigate whether the use of SEF, DSA and EEG wave measurement to guide and manage pediatric anesthesia can reduce the incidence of POD and anesthesia consumption.