Processed electroencephalogram-guided anesthesia and its impact on postoperative delirium and perioperative efficiency: A systematic review and meta-analysis

Processed electroencephalography (pEEG) provides quantitative indices for monitoring anesthetic depth and is recommended in international guidelines. Prior meta-analyses have assessed EEG-guided anesthesia but none have evaluated available evidence stratified by pEEG technology.

We performed a systematic literature review and meta-analysis of randomized controlled trials in adults undergoing surgical, endoscopic, or dental procedures comparing pEEG-guided with non-pEEG-guided anesthesia. Primary outcomes were anesthetic drug use (TIVA and volatile agents) and postoperative delirium (POD ≤10 days). Secondary outcomes were extubation time, wake-up time, time to orientation, and post-anesthesia care unit (PACU) length of stay. Searches (PubMed Central, MEDLINE) were conducted on 11 April 2025; the protocol was registered in PROSPERO (CRD420251067170). Random-effects models produced standardized mean differences (SMD), mean differences (MD), and risk ratios (RR) with 95% confidence interval (CI).

Eighty-seven RCTs (30,611 patients; 13,586 pEEG; 17,025 non-pEEG) were included. pEEG significantly reduced propofol use (SMD -0.42, 95% CI -0.74 to -0.10; p = 0.01) and volatile anesthetic use (SMD -1.27, 95% CI -1.88 to -0.66; p < 0.01). The risk of POD decreased by 27% (RR 0.73, 95% CI 0.63 to 0.84; p < 0.01). Efficiency outcomes favored pEEG: extubation time (MD -2.90 min, 95% CI -3.64 to -2.16; p < 0.01), wake-up time (MD -1.83 min, 95% CI -2.42 to -1.25; p < 0.01), time to orientation (MD -4.11 min, 95% CI -6.99 to -1.23; p < 0.01), and PACU length of stay (MD -2.81 min, 95% CI -4.66 to -0.96; p < 0.01). Subgroup analyses suggested benefits were most consistently observed for BIS; estimates for Entropy and SEDLine were less precise due to fewer studies. Heterogeneity was substantial for several outcomes.

Across 87 RCTs, pEEG-guided monitoring utilizing multiple device types improved perioperative efficiency and reduced POD compared with not using pEEG. Evidence is strongest for BIS; further well-reported trials are needed to delineate device-specific effects.