Clinical signs and electroencephalographic patterns of emergence from sevoflurane anaesthesia in children: An
Laura Cornelissen1, Carolina Donado, Johanna M Lee
1From the Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital (LC, CD, JML, NEL, IM, AT, AB, CBB), Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts (LC, CD, JML, NEL, IM, AT, AB, CBB) and School of Medicine, University of California, San Francisco, San Francisco, California, USA (NEL).
Insights
Clinical signs of emergence from anesthesia in young children occur sequentially and are independent of nitrous oxide. Frontal electroencephalogram (EEG) patterns can predict behavioral recovery in children over 3 months old.
Area of Science:
- Pediatric Anesthesiology
- Neurophysiology
- Clinical Neuroscience
Background:
- Limited systematic data exists on the relationship between clinical signs, electroencephalographic (EEG) patterns, and age during pediatric anesthesia emergence.
- Understanding these relationships is crucial for optimizing anesthetic recovery in young children.
Purpose of the Study:
- To investigate the correlation between end-tidal sevoflurane (ETsevoflurane) concentration, age, and frontal EEG spectral properties in predicting the recovery of clinical-behavioral signs during sevoflurane emergence in children aged 0-3 years.
- To determine the influence of nitrous oxide exposure on emergence patterns.
Main Methods:
- An observational study was conducted in 95 children aged 0-3 years undergoing surgery.
- Data collected included ETsevoflurane concentrations, age, and time-course of clinical signs (movement, cough, grimace, eye gaze).
- Frontal EEG alpha and beta power were analyzed in relation to emergence events.
Main Results:
- Clinical emergence signs (movement, cough, grimace) occurred in a consistent sequence across all ages and were independent of age and nitrous oxide exposure.
- Dysconjugate eye gaze appeared at lower ETsevoflurane concentrations (1-0%).
- In children >3 months, frontal alpha EEG power decreased significantly as ETsevoflurane approached 0.5%, with movement occurring within 5 minutes of alpha oscillation disappearance.
Conclusions:
- Clinical emergence signs are sequential and predictable, largely unaffected by nitrous oxide.
- Eye gaze is a less reliable indicator of emergence compared to other clinical signs.
- Frontal EEG spectral analysis, particularly alpha oscillations, shows promise in predicting clinical-behavioral recovery in children over 3 months of age.
Background:
Few studies have systematically described relationships between clinical-behavioural signs, electroencephalographic (EEG) patterns and age during emergence from anaesthesia in young children.
Objective:
To identify the relationships between end-tidal sevoflurane (ETsevoflurane) concentration, age and frontal EEG spectral properties in predicting recovery of clinical-behavioural signs during emergence from sevoflurane in children 0 to 3 years of age, with and without exposure to nitrous oxide. The hypothesis was that clinical signs occur sequentially during emergence, and that for infants aged more than 3 months, changes in alpha EEG power are correlated with clinical-behavioural signs.
Design:
An observational study.
Setting:
A tertiary paediatric teaching hospital from December 2012 to August 2016.
Patients:
Ninety-five children aged 0 to 3 years who required surgery below the neck.
Outcome Measures:
Time-course of, and ETsevoflurane concentrations at first gross body movement, first cough, first grimace, dysconjugate eye gaze, frontal (F7/F8) alpha EEG power (8 to 12 Hz), frontal beta EEG power (13 to 30 Hz), surgery-end.
Results:
Clinical signs of emergence followed an orderly sequence of events across all ages. Clinical signs occurred over a narrow ETsevoflurane, independent of age [movement: 0.4% (95% confidence interval (CI), 0.3 to 0.4), cough 0.3% (95% CI, 0.3 to 0.4), grimace 0.2% (95% CI, 0 to 0.3); P > 0.5 for age vs. ETsevoflurane]. Dysconjugate eye gaze was observed between ETsevoflurane 1 to 0%. In children more than 3 months old, frontal alpha EEG oscillations were present at ETsevoflurane 2.0% and disappeared at 0.5%. Movement occurred within 5 min of alpha oscillation disappearance in 99% of patients. Nitrous oxide had no effect on the time course or ETsevoflurane at which children showed body movement, grimace or cough.
Conclusion:
Several clinical signs occur sequentially during emergence, and are independent of exposure to nitrous oxide. Eye position is poorly correlated with other clinical signs or ETsevoflurane. EEG spectral characteristics may aid prediction of clinical-behavioural signs in children more than 3 months.
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