Paediatric anaesthesia: Overview

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.

Abstract
Background: Anesthetic exposure in young children raises concerns about neurodevelopmental safety, with preclinical evidence suggesting potential neurotoxicity of volatile anesthetics. This study aimed to assess whether the combination of dexmedetomidine and remifentanil, by reducing sevoflurane exposure, has any differential effect on neurodevelopmental outcomes in young children compared with sevoflurane alone.

Methods: This study was a prospective, double-blind, randomized clinical trial including children younger than 2 yr undergoing nonstaged, nonrepetitive surgeries. Participants received dexmedetomidine and remifentanil as adjuncts to sevoflurane (DEX-R group) or sevoflurane alone (control group). The study assessed their neurodevelopmental status at 28 to 30 months using the Korean Leiter International Performance Scale and the Child Behavior Checklist, as predefined secondary outcomes. The primary endpoint-full-scale IQ at 5 yr of age-will be reported after completion of long-term follow-up.

Results: Among 400 enrolled participants, 343 completed assessments (169 control, 176 DEX-R). There was no difference in the mean anesthesia duration between the control and DEX-R groups (77.1 min vs. 72.8 min; mean difference [95% CI], 4.4 [-3.8 to 12.6]; P = 0.293). The mean end-tidal sevoflurane concentration was significantly lower in the DEX-R group than in the control group (1.8 vol% vs. 2.6 vol%; mean difference [95% CI], -0.9 [-1.0 to -0.7] vol%; P < 0.001). The mean full-scale IQ score was 102.5 ± 11.5 in the DEX-R group and 103.6 ± 11.5 in the control group (mean difference, -1.1; 95% CI, -3.9 to 1.7; P = 0.442). No significant difference was observed in the Child Behavior Checklist total score between groups.

Conclusions: The addition of dexmedetomidine and remifentanil to sevoflurane anesthesia was not associated with significant differences in neurodevelopmental outcomes at 28 to 30 months compared to sevoflurane alone.

Trial registration: ClinicalTrials.gov NCT04364945.