Brain Monitors to Reduce Child Confusion After Anesthesia

Emergence delirium (ED) represents a significant neurobehavioral complication that frequently occurs during the immediate postoperative period in pediatric populations, particularly following otorhinolaryngological procedures such as adenoidectomy and tonsillectomy. Characterized by severe agitation, altered awareness, disturbed psychomotor behavior, and inconsolability, ED poses safety risks to the recovering patient and increases the burden on healthcare providers and caregivers. While the etiology of ED is multifactorial, the intraoperative depth of anesthesia and the cumulative exposure to specific volatile anesthetics, such as sevoflurane, are known modifiable risk factors. Both excessively deep and inadequately light anesthesia can contribute to poor recovery profiles. The Bispectral Index (BIS) is an electroencephalogram (EEG)-based monitor that provides an objective measurement of a patient's level of consciousness, allowing anesthesiologists to precisely titrate anesthetic agents to an optimal depth.

This prospective, randomized controlled study was designed to investigate the role of BIS-guided anesthetic titration in mitigating the risk of ED. Upon enrollment, pediatric patients undergoing adenoidectomy and/or tonsillectomy were randomized into one of two clinical care pathways: a BIS-guided anesthesia group or a standard-care group.

To ensure baseline consistency across the study, all participants followed a standardized anesthetic induction protocol. Following routine premedication, general anesthesia was induced using inhaled sevoflurane combined with intravenous lidocaine, rocuronium (for muscle relaxation), and fentanyl (for analgesia). For the maintenance phase of anesthesia, patients in both arms received a combination of inhaled sevoflurane and continuous remifentanil infusions.

The critical divergence in the study protocol occurred during the intraoperative maintenance phase:

BIS-Guided Pathway: Anesthesiologists continuously monitored the patient's EEG activity using the BIS monitor. The concentration of the sevoflurane gas was deliberately titrated to maintain a BIS value between 40 and 60, which represents an optimal and safe depth for surgical anesthesia. By keeping patients within this precise target range, the protocol systematically avoided periods of excessively deep (BIS < 40) or overly light (BIS > 60) anesthesia.

Standard-Care Pathway: Anesthesiologists adjusted the sevoflurane concentrations based entirely on traditional clinical signs and autonomic responses, specifically monitoring hemodynamic fluctuations such as heart rate and blood pressure, without the use of EEG-guided depth parameters.

Following the completion of the surgical procedure, patients were transferred to the post-anesthesia care unit (PACU) for close observation. The clinical team systematically evaluated the patients' transition from unconsciousness to wakefulness. To ensure a robust, multi-faceted assessment of neurobehavioral status, the clinical staff utilized three validated behavioral assessment tools: the Pediatric Anesthesia Emergence Delirium (PAED) scale, the Watcha scale, and the Cravero scale. Simultaneously, postoperative physical pain was managed and tracked using the Face, Legs, Activity, Cry, Consolability (FLACC) behavioral scale.

If a patient exhibited signs meeting predetermined thresholds for severe emergence delirium (specifically, a PAED score of 10 or higher, a Watcha score of 3 to 4, or a Cravero score of 4 or higher), the clinical protocol dictated the administration of intravenous fentanyl as a rescue pharmacological intervention to safely manage the agitation.

Through this methodology, the study sought to define the relationship between strict, brain-monitored anesthetic titration and postoperative behavior. It comprehensively evaluated how preventing fluctuations in anesthetic depth impacts overall volatile anesthetic consumption, the necessity for rescue opioids in the recovery room, and the overall quality and speed of pediatric recovery following airway surgery.

Inclusion criteria

• Children between the ages of 2 and 12 years
• Scheduled for a planned surgery to remove adenoids, tonsils, or both
• Generally healthy or having only mild medical conditions (American Society of Anesthesiologists class I or II)
• Expected to have a surgery that lasts less than 4 hours
• Having the procedure as an outpatient and expected to go home the same day

Exclusion criteria

• Having severe medical conditions (American Society of Anesthesiologists class III or IV)
• Having a known history of neurological or psychiatric diseases
• Diagnosed with a developmental delay
• Having severe heart, lung, or metabolic conditions
• Having a known allergy to any of the medications used in the study
• Parents or legal guardians refuse to provide written consent to participate