Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2025 Apr 21;179(7):704-712.
doi: 10.1001/jamapediatrics.2025.0517. Online ahead of print.

EEG-Guided Titration of Sevoflurane and Pediatric Anesthesia Emergence Delirium: A Randomized Clinical Trial

Kiyoyuki W Miyasaka  1   2 , Yasuyuki Suzuki  2   3 , Emery N Brown  4   5   6 , Yasuko Nagasaka  2
Affiliations

EEG-Guided Titration of Sevoflurane and Pediatric Anesthesia Emergence Delirium: A Randomized Clinical Trial

Kiyoyuki W Miyasaka et al. JAMA Pediatr. .

Abstract

Importance: Pediatric anesthesia emergence delirium (PAED) is a common complication of general anesthesia and has unknown etiology. Exposure to volatile anesthetics may contribute to PAED, and excessive exposure may occur frequently during routine pediatric anesthesia.

Objective: To examine whether use of electroencephalography (EEG) monitoring can reduce PAED by minimizing exposure to sevoflurane while maintaining a state of unconsciousness under anesthesia.

Design, setting, and participants: A single-center, parallel-group, 2-arm, superiority randomized clinical trial with a 1:1 allocation ratio was conducted from October 13, 2021, to March 18, 2023, at an academic tertiary pediatric hospital in Japan. The follow-up period was 24 ± 6 hours postoperatively or uneventful discharge to home, whichever came first. The observer for the primary outcome was blinded to patient assignment. The trial included a convenience sample of children aged 1 to younger than 6 years undergoing general anesthesia for procedures for which reliable antinociception can be provided. Data analysis was performed in March 2023.

Intervention: EEG-guided titration of anesthesia to minimize sevoflurane exposure (EEG-guided group) vs standard 1.0-minimum alveolar concentration (MAC) sevoflurane anesthesia (control group).

Main outcomes and measures: Proportion of patients who developed PAED, defined by a maximum PAED score of 10 or higher.

Results: Of the 177 participants who completed follow-up, 125 (71%) were male and 52 (29%) were female. The EEG-guided group included 91 participants (mean [SD] age, 2.9 [1.5] years), and the control group included 86 participants (mean [SD] age, 2.8 [1.6] years). In the EEG-guided group, sevoflurane exposure was reduced by 1.4 MAC-hours (96.65% CI, 1.1 to 1.6 MAC-hours). A total of 30 (35%) in the control group and 19 (21%) in the EEG-guided group developed PAED (difference, 14%; 96.65% CI, -0.0019% to 28%; 95% CI, 0.92% to 27%; P = .04). Children in the EEG-guided group emerged a mean of 21.4 minutes (96.65% CI, 15.4 to 27.4 minutes) earlier from general anesthesia and spent a mean of 16.5 minutes less (96.65% CI, 10.8 to 22.3 minutes less) in the postanesthesia care unit.

Conclusions and relevance: EEG-guided management of general anesthesia reduced sevoflurane exposure and pediatric anesthesia emergence delirium in children, with faster emergence and shorter postanesthesia care unit stays. The findings suggest that high concentrations of sevoflurane for induction followed by routine use of 1.0-MAC sevoflurane for maintenance may be excessive.

Trial registration: Japan Registry of Clinical Trials Identifier: jRCTs032210248.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: Dr Miyasaka reported receiving nonfinancial support from Masimo Corp during the conduct of the study. Dr Brown reported receiving nonfinancial support from PASCALL, being a founder and board member of PASCALL, receiving personal fees from Humacyte, Simons Foundation, and Gladstone Institute, and holding US patents with Massachusetts General Hospital and Massachusetts Institute of Technology with royalties paid from Masimo Corp outside the submitted work. Dr Nagasaka reported consulting for Masimo Corp and receiving nonfinancial support from Masimo Corp during the conduct of the study. No other disclosures were reported.

Comment in

  • doi: 10.1001/jamapediatrics.2025.0514
  • doi: 10.1001/jamapediatrics.2025.0528

References

    1. Cole JW, Murray DJ, McAllister JD, Hirshberg GE. Emergence behaviour in children: defining the incidence of excitement and agitation following anaesthesia. Paediatr Anaesth. 2002;12(5):442-447. doi: 10.1046/j.1460-9592.2002.00868.x - DOI - PubMed
    1. Sikich N, Lerman J. Development and psychometric evaluation of the Pediatric Anesthesia Emergence Delirium scale. Anesthesiology. 2004;100(5):1138-1145. doi: 10.1097/00000542-200405000-00015 - DOI - PubMed
    1. Voepel-Lewis T, Malviya S, Tait AR. A prospective cohort study of emergence agitation in the pediatric postanesthesia care unit. Anesth Analg. 2003;96(6):1625-1630. doi: 10.1213/01.ANE.0000062522.21048.61 - DOI - PubMed
    1. Mason KP. Paediatric emergence delirium: a comprehensive review and interpretation of the literature. Br J Anaesth. 2017;118(3):335-343. doi: 10.1093/bja/aew477 - DOI - PubMed
    1. Lerman J. Sevoflurane in pediatric anesthesia. Anesth Analg. 1995;81(6)(suppl):S4-S10. doi: 10.1097/00000539-199512001-00002 - DOI - PubMed

LinkOut - more resources