Paediatric anaesthesia: Overview

Abstract
Background: Sevoflurane anesthesia is employed as the standard protocol for pediatric patients undergoing fundus examination. This study investigates the incidence of emergence delirium (ED) and its risk factors in this population, and explores the relationship between ED and negative postoperative behavioral changes (NPOBC).

Methods: A prospective observational study was conducted from May to September 2024, involving 155 children aged 0-3 years undergoing fundus examination under general anesthesia. Patient and surgery-related data were recorded. ED was assessed using the Pediatric Anesthesia Emergence Delirium (PAED) scale, with logistic regression identifying associated factors. Postoperative behaviors were evaluated one week later using the Post-Hospital Behavior Questionnaire for Ambulatory Surgery (PHBQ-AS), with linear regression analyzing the relationship between ED and NPOBC.

Results: In 155 patients, ED incidence was 51%. In the 96 followed-up, NPOBC one week postoperatively was seen in 30.2%. Risk factors for ED included prenatal medical history (OR = 3.70, 95% CI 1.31-10.40, P = 0.013), anesthesia exposure (OR = 1.73, 95% CI 1.36-2.20, P < 0.001), preoperative anxiety (OR = 2.35, 95% CI 1.40-3.94, P = 0.001), and postoperative pain (OR = 1.69, 95% CI 1.31-2.19, P < 0.001). Increased negative behavioral scale scores were associated with anesthesia exposure (B = 0.260, 95% CI 0.123-0.396, P < 0.001) and ED occurrence (B = 1.420, 95% CI 0.598-2.234, P < 0.001).

Conclusion: Our study shows a high incidence of negative emotions and behaviors. Future research should focus on optimizing postoperative analgesia and preoperative anti-anxiety interventions for this high-risk group, and further exploring the connections among anesthesia exposure, ED and NPOBC.

Impact: Our study showed a high incidence of negative emotions and behaviors (emergence delirium and postoperative behavioral changes) in minimally invasive fundus examinations under total inhalation anesthesia. Risk factors for emergence delirium are prenatal medical history, anesthesia exposure, preoperative anxiety and postoperative pain. Higher negative behavior scores were associated with anesthesia exposure and emergence delirium. This is the first study to explore the incidence and risk factors of behavioral abnormalities in infants and preterm children after general anesthesia, making it easier to spot high-risk kids having fundus exams and to fine-tune anesthesia and perioperative care for short, minimally invasive procedures.

Abstract
Emergence delirium (ED) is a frequent postoperative complication in children, marked by confusion, disorientation, and agitation following general anesthesia. Electroencephalogram (EEG)-guided anesthesia offers a promising approach to optimize anesthetic dosing, reduces sevoflurane exposure, and potentially lowers the incidence of ED. This systematic review and meta-analysis evaluates the impact of EEG-guided anesthesia on key outcomes in pediatric patients, including ED incidence, PACU stay duration, and PAED scores. This systematic review and meta-analysis followed PRISMA guidelines and was registered on PROSPERO (CRD420251121848). A comprehensive search of PubMed, Embase, Scopus, and Cochrane Library was conducted up to July 2025. Only randomized controlled trials comparing EEG-guided anesthesia with standard care in pediatric patients undergoing sevoflurane-based general anesthesia were included. Primary outcomes were PAED scores and incidence of emergence delirium; secondary outcomes included sevoflurane exposure, PACU stay duration, extubation time, FLACC scores, and burst suppression. Risk of bias was assessed using the Cochrane RoB 2.0 tool, and certainty of evidence was evaluated using GRADE. Statistical analysis was performed using a random effects model. Our analysis demonstrated that EEG-guided anesthesia significantly reduced PAED scores at 10 min post-extubation (MD: - 0.94; 95% CI - 1.59 to - 0.29; p = 0.004) and lowered the incidence of emergence delirium (PAED score > 10) by 60% (OR: 0.40; 95% CI 0.27-0.59; p < 0.00001), with no heterogeneity for the latter outcome. EEG guidance also shortened extubation time by over 3 min (MD: - 3.09; 95% CI - 3.87 to - 2.32; p < 0.00001, I2 = 0%) and reduced maintenance end-tidal sevoflurane concentration (MD: - 0.46%; 95% CI - 0.84 to - 0.08; p = 0.02). While reductions in PACU stay (MD: - 7.01 min), induction EtSevo (MD: - 0.32%), burst suppression (OR: 0.54), and postoperative pain scores (MD: - 0.62) favored EEG-guided management, these did not reach statistical significance, often with substantial heterogeneity. EEG-guided anesthesia significantly reduces emergence delirium and PAED scores in children. It also lowers sevoflurane consumption and shortens recovery time. These findings support its routine use in pediatric anesthesia for improved outcomes.

Abstract
The anaesthesia of a young child under 3 years of age is a challenge for every anaesthetist. The peculiarities of this group of patients, particularly neonates and infants, resulting primarily from differences in both physiology, anatomy and the immaturity of individual organs which translate into different pharmacokinetics and pharmacodynamics of the drugs used in anaesthesiology, underlie the significantly more frequently recorded critical events during anaesthesia compared with the adult patient population. Concerned about the safety of children undergoing anaesthesia and aiming to ensure the highest possible quality and uniform standard of anaesthetic services, the Expert Panel of the Section of Paediatric Anaesthesiology and Intensive Care has prepared a Section position paper on anaesthesia in children under 3 years of age.