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Comparative Assessment of Cortical Hemodynamic Activity in Children Undergoing Anesthesia With Sevoflurane and
Kavya V Nair1, Soumya Sarkar2, Puneet Khanna1
1Department of Anaesthesia, Pain Medicine & Critical Care, AIIMS, New Delhi, India.
Insights
Emergence delirium (ED) in children is linked to frontal cortex blood flow differences during anesthesia. Sevoflurane anesthesia showed increased frontal activation, correlating with higher ED rates compared to propofol.
Area of Science:
- Neuroscience
- Anesthesiology
- Pediatric Medicine
Background:
- Emergence delirium (ED) is a common postoperative complication in children.
- Sevoflurane and propofol are frequently used anesthetic agents with differing ED profiles.
- Understanding the neurophysiological basis of ED is crucial for prevention and management.
Purpose of the Study:
- To investigate the relationship between frontal cortex blood flow and emergence delirium in pediatric patients.
- To compare the effects of sevoflurane and propofol anesthesia on frontal brain activity during induction and emergence.
- To identify potential neuroimaging biomarkers for predicting ED in children.
Main Methods:
- A pilot study involving 74 children (aged 3-10) undergoing surgery, randomized to sevoflurane or propofol anesthesia.
- Functional near-infrared spectroscopy (fNIRS) was used to measure frontal cortex blood flow changes during anesthesia induction and reversal.
- Postoperative emergence delirium was assessed using the Pediatric Anesthesia Emergence Delirium (PAED) and Cornell Assessment of Pediatric Delirium (CAPD) scales.
Main Results:
- Children receiving sevoflurane exhibited a higher incidence of emergence delirium (18.9%) compared to those receiving propofol (5.4%).
- fNIRS revealed distinct frontal cortex activation patterns: propofol anesthesia was associated with left frontal activation in children without ED, while sevoflurane showed greater deactivation in multiple frontal regions in children without ED.
- Sevoflurane-induced anesthesia was linked to significantly less deactivation (i.e., more activation) in frontal brain regions in children with ED compared to propofol.
Conclusions:
- Increased frontal cortical activation during sevoflurane anesthesia may contribute to the higher incidence of emergence delirium in pediatric patients.
- fNIRS can differentiate neural activity patterns associated with emergence delirium under different anesthetic agents.
- These findings suggest potential neurophysiological mechanisms underlying sevoflurane-associated emergence delirium.
Background:
Sevoflurane and propofol, the common anesthetic agents, have been under evaluation for emergence delirium in children. This pilot study examined how frontal cortex blood flow during sevoflurane and propofol anesthesia relates to emergence delirium in children aged 3-10 using functional near-infrared spectroscopy (fNIRS).
Methods:
Seventy-four children, undergoing urologic and orthopedic surgeries, were randomly assigned to either propofol (n = 37) or sevoflurane (n = 37) after obtaining approval from the institute ethics committee, written informed parental consent, assent, and registration in a clinical trial registry. Children with perinatal hypoxia, preterm birth, seizures, developmental disorders, psychiatric illness, or electrolyte imbalances were excluded. Anesthesia was induced and maintained per standard protocols, and pain was managed using paracetamol, ketorolac, and caudal analgesia. fNIRS readings were recorded at induction and reversal. Postoperatively, emergence delirium was assessed using the PAED and Cornell Assessment of Pediatric Delirium (CAPD) scales. Data were collected using a 20-channel fNIRS system and analyzed with NIRStar software.
Results:
Frontal cortex fNIRS demonstrated agent-specific cortical patterns during anesthesia induction, with distinct neural activity differences related to ED. Under propofol, children without ED demonstrated greater left frontal activation (channel 4; t = 2.30, p < 0.005), whereas those with ED showed deactivation; extubation showed no differences. Sevoflurane induction revealed that children without delirium showed greater deactivation in multiple frontal channels-channel 13 (right medial/superior frontal gyri; t = -2.252, p < 0.05), channel 2 (left middle/superior frontal gyri; t = -2.252, p < 0.05), and channel 17 (right superior/middle frontal gyri; t = -3.15, p < 0.05), while no differences were observed during extubation. ED was more frequent with sevoflurane (18.9%) compared to propofol (5.4%). Sevoflurane was linked to significantly less deactivation (more activation) in frontal brain regions in children with emergence delirium, compared to propofol during both induction, notable in channel 4 (left middle and superior frontal gyrus) (t = -5.756, p < 0.005) and extubation notable in channel 2 (left middle and superior frontal gyri) (t = -6.877, p < 0.05).
Conclusion:
The increased frontal cortical activation with sevoflurane may contribute to a higher incidence of emergence delirium in children compared to propofol.
Trial Registration:
Clinical trial registry: CTRI/2022/04/041573; https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=NjQ3NTM.
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