Intraoperative burst suppression and emergence delirium in pediatric
A prospective observational study.
Journal of Clinical Anesthesia
Submitted April 2026 by Dr Megan Wellbeloved
Summary
Following the premise that intraoperative burst suppression has been associated with postoperative delirium in adults these authors aimed to investigate whether intraoperative burst (IBS) suppression may show an association with emergence delirium (ED) in children.
Other secondary aims of the study included comparison of ED in propofol based and sevoflurane based anaesthetics and comparison of ED in two age groups (less than 2 years old and 2-5 years old).
A single centre prospective cohort study design was followed with appropriate ethics committee approval.
The study population included ASA 1 and 2 children from the age of 6 months to 9 years. The sample size calculated was 246 children. 246 children were recruited but after exclusion the sample group comprised 207 children.
The choice of a propofol or sevoflurane based technique was decided by the attending anaesthetist, and standard ASA monitoring was used. Patients in both propofol and sevoflurane groups received atropine fentanyl and rocuronium at induction and remifentanil was used during maintenance.
Sedline processed EEG monitoring was used from the start of induction to emergence and removal of the airway device. Attending anaesthetists were blinded to the EEG monitoring and alarms and anaesthetic doses were changed according to vital signs and experience.
Postoperatively ED was assessed using the PAED scale and pain assessed using the FLACC score.
Findings
Overall BS: 47.8% and overall ED: 24.6%
The BS group demonstrated patients with a lower age (27.68 +/-20.41 months) compared to the non BS group (41.85 +/-27.87 months). While a higher average BMI was noted in the BS group compared to the non BS group, no other demographic differences were shown between the two groups.
The authors also demonstrated a lower likelihood of BS in the propofol based anaesthetic patients. They also reported that a propofol technique reduced the risk of ED compared to sevoflurane by 57 %.
IBS increased the risk of ED with an OR of 8.262 (95% CI 3.478-19.626)
Limitations
The authors acknowledged limitations in using a wide range of age groups with a small sample size. They also discussed limitations when using a 4 lead EEG in assessing BS. The subjective nature of the PAED score when assessing ED was acknowledged.
Commentary
Emergence delirium (ED) does provide a challenge for anaesthesia and can have implications for patients and their carers. Techniques that help to reduce the risk of ED can be beneficial in the postoperative period.
Adult data does suggest an association between BS and postoperative delirium in adults although the evidence quality is low (Anesthesiology 2025; 142:107–20) and so it seems fair to establish whether there may be an association within the paediatric population.
This study did highlight a high number of BS in the sample group and an increased risk of ED in patients who had BS during the anaesthetic.
Limitations should be noted however. This was a single centre study with a small sample group resulting in poor quality data (with wide CI). The sample group included a wide range in age. It may be more appropriate to use a narrower age group and more specifically age 3-5 years where we would expect higher incidence of ED.
Assessment of ED using the PAED score can be subjective and may not be accurate.
The authors did not present other possible confounders such as the use of other agents ( α 2 agonists for example), alternative analgesic techniques (caudal or regional blocks). That said, findings from this study support the use of a TIVA based technique to reduce the incidence of ED.
It was also interesting in that anaesthetists were blinded to the EEG. Maintenance doses of anaesthesia may have been different with different incidences of BS if practitioners were not blinded to the EEG.
Future trials with larger groups may provide more clarification.
