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.
