EEG-guided Titration of Sevoflurane in Pediatric Patients Undergoing Elective Non- cardiac Surgery: A meta-analysis of randomized controlled trials

Background: Pediatric anesthesia emergence delirium (PAED) is a common complication after general anesthesia, but its specific mechanism of occurrence is not yet clear. Sevoflurane is the most commonly used inhalation anesthetic drug for general anesthesia in children and its use may increase the risk of PAED. The utilization of electroencephalography (EEG) monitoring can permits anesthesiologists to titrate and achieve desired depth of anesthesia. Thus, the aim of this meta-analysis is to examine whether EEG-guided monitoring can reduce emergence delirium by reducing exposure to sevoflurane in pediatric patients undergoing elective non-cardiac surgery. Methods: A literature search for meta-analysis was performed using the PubMed, EMbase, Ovid Medline, Cochrane Library, WanFang Data and China National Knowledge Infrastructure (CNKI) databases for randomized controlled trial (RCT) until May 1, 2025 by two investigators who independently screened and reviewed studies for inclusion and performed data extraction. Our primary outcome was the average end-tidal sevoflurane concentration. The secondary outcomes were (1) incidence of emergence delirium; (2) incidence of burst suppression detected; (3) PAED total score; (4) time to extubation; (5) length of PACU stay. Heterogeneity was assessed by the I2 and chi-square tests. The odds ratio (OR) of the dichotomous data, mean difference (MD) of continuous data, and 95% confidence intervals (CI) were calculated to assess the pooled data. The risk of bias was assessed using the Cochrane methodology. Meta-analysis was carried out by using RevMan 5.3 software. Results: Of 233 articles retrieved, 7 RCTs (involving 902 pediatric patients undergoing elective non-cardiac surgery) were included in the final analysis. Compare with standard anesthesia administration, the utilization of EEG-guided sevoflurane administration reduced the average end tidal sevoflurane concentration (MD= -0.90, 95% CI: -1.24~-0.57, P ＜ 0.00001) and incidence of emergence delirium (OR=2.73, 95% CI:1.80~4.14, P ＜0.00001) in pediatric patients. However, no diference was found in PAED total score (MD= 1.36, 95% CI: -1.34~4.15, P=0.34), incidence of burst suppression detected (OR=0.64, 95% CI:0.38~1.09, P=0.1), time to extubation (MD= -1.65, 95% CI: -4.65~1.25, P=0.26) and length of PACU stay (MD= -5.90, 95% CI: -12.27~0.47, P=0.07 ) between EEG-guided group and control group. Conclusions: In pediatric participants, EEG-guided monitoring of anesthesia depth and titrating the use of sevoflurane accordingly may reduce exposure of inhalation anesthetics and incidence of PAED. However, there is no evidence suggesting that sevoflurane titration guided by EEG has advantages in other outcome indicators in pediatric patients undergoing elective non-cardiac surgery. In the future, larger sample sizes and rigorously designed RCTs are still needed for further discussion. PROSPERO registration number: CRD420251046992