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Monitoring anesthesia depth with patient state index during pediatric surgery
Zaccaria Ricci1,2, Chiara Robino2, Paolo Rufini2
1Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy.
Insights
Processed electroencephalography (EEG) monitoring in children showed patient state index (PSI) values within the recommended range for anesthesia depth, but with frequent burst suppression episodes. Younger children (<2 years) exhibited higher PSI levels.
Area of Science:
- Anesthesiology
- Neuroscience
- Pediatric Medicine
Background:
- Monitoring anesthesia depth in pediatric patients is complex, often relying on indirect methods.
- Processed electroencephalography (EEG) offers a potential tool for objective anesthesia depth assessment.
- The Patient State Index (PSI) is a metric derived from processed EEG.
Purpose of the Study:
- To determine median Patient State Index (PSI) and Spectral Edge Frequency 95% (SEF 95%) values in children undergoing general anesthesia.
- To evaluate the relationship between PSI, SEF 95%, and indirect anesthesia monitoring parameters.
- To assess the influence of anesthesia type, age, and burst suppression on PSI.
Main Methods:
- A prospective observational study involving 111 children aged 1-18 years undergoing surgery >60 minutes.
- Utilized the SedLine monitor and pediatric sensors for continuous PSI and SEF 95% recording.
- Recorded PSI levels from anesthesia induction to ward discharge.
Main Results:
- Median PSI at induction was 25, maintenance 26-28, extubation 48, and discharge 69.
- Median SEF 95% values ranged from 9-12 Hz during maintenance and 17-18 Hz at extubation.
- Burst suppression occurred in 19% of patients; PSI was not significantly different between anesthesia types.
- Children under 2 years had significantly higher PSI levels compared to older children.
Conclusions:
- Non-processed EEG-guided anesthesia in children resulted in PSI values at the lower end of the recommended unconsciousness range.
- Frequent burst suppression episodes were observed, suggesting potential for deeper anesthesia than intended.
- Younger children (<2 years) consistently showed higher PSI levels, indicating age-specific considerations for interpretation.
Background:
Monitoring anesthesia depth in children is challenging. Pediatric anesthesiologists estimate general anesthesia depth using indirect methods such as pharmacokinetic models and neurovegetative reflexes. The application of processed electroencephalography may help to identify the correct anesthesia depth (i.e., patient state index between 25 and 50).
Aims:
To determine the median values of patient state index and spectral edge frequency 95% in children undergoing general anesthesia conducted according to indirect evaluation of depth. The relationships between patient state index and spectral edge frequency 95% and indirect monitoring of anesthesia depth, type of anesthesia, age subgroups, and postoperative delirium were also assessed.
Methods:
A prospective observational study on children (aged 1-18 years) undergoing surgery longer than 60 min. The SedLine monitor and the novel SedLine pediatric sensors (Masimo Inc., Irvine California) were applied. Patient state index levels were recorded for the duration of the anesthesia until the discharge to the ward at predefined time points.
Results:
In the 111 enrolled children, median patient state index level at the end of anesthesia induction was 25 (22-32) and ranged from 26 (23-34) to 28 (25-36) in the maintenance phase. Patient state index at extubation was 48 (35-60) and 69 (62-75) at discharge from the operatory room. Median right/left spectral edge frequency 95% values at the end of induction were 10 (6-14)/9 (5-14) Hz and median right/left spectral edge frequency 95% values in the maintenance phase ranged from 10 (6-14) to 12 (11-15) Hz in both hemispheres. At extubation, right/left spectral edge frequency 95% levels were 18 (15-21)/17 (15-21) Hz. We observed 39 episodes of burst suppression in 20 patients (19%). Median patient state index levels were not different between patients undergoing inhalational and intravenous anesthesia and between those undergoing general anesthesia and general anesthesia added to locoregional anesthesia. Children <2 years displayed significantly higher patient state index levels than older patients (p = .0004). The presence of a burst suppression episode was not associated with PAED levels (OR 1.58, 95% CI 0.14-16.74, p` = .18).
Conclusions:
NonpEEG-guided anesthesia in children led to median patient state index levels at the low range of recommended unconsciousness values with frequent episodes of burst suppression. Patient state index levels were generally higher in children below 2 years.
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