EEG-guided sevoflurane anesthesia vs. standard care in pediatric emergence delirium: a grade-assessed systematic review and meta-analysis with trial sequential analysis.

Emergence delirium (ED) is a frequent postoperative complication in children, marked by confusion, disorientation, and agitation following general anesthesia. Electroencephalogram (EEG)-guided anesthesia offers a promising approach to optimize anesthetic dosing, reduces sevoflurane exposure, and potentially lowers the incidence of ED. This systematic review and meta-analysis evaluates the impact of EEG-guided anesthesia on key outcomes in pediatric patients, including ED incidence, PACU stay duration, and PAED scores. This systematic review and meta-analysis followed PRISMA guidelines and was registered on PROSPERO (CRD420251121848). A comprehensive search of PubMed, Embase, Scopus, and Cochrane Library was conducted up to July 2025. Only randomized controlled trials comparing EEG-guided anesthesia with standard care in pediatric patients undergoing sevoflurane-based general anesthesia were included. Primary outcomes were PAED scores and incidence of emergence delirium; secondary outcomes included sevoflurane exposure, PACU stay duration, extubation time, FLACC scores, and burst suppression. Risk of bias was assessed using the Cochrane RoB 2.0 tool, and certainty of evidence was evaluated using GRADE. Statistical analysis was performed using a random effects model. Our analysis demonstrated that EEG-guided anesthesia significantly reduced PAED scores at 10 min post-extubation (MD: - 0.94; 95% CI - 1.59 to - 0.29; p = 0.004) and lowered the incidence of emergence delirium (PAED score > 10) by 60% (OR: 0.40; 95% CI 0.27-0.59; p < 0.00001), with no heterogeneity for the latter outcome. EEG guidance also shortened extubation time by over 3 min (MD: - 3.09; 95% CI - 3.87 to - 2.32; p < 0.00001, I2 = 0%) and reduced maintenance end-tidal sevoflurane concentration (MD: - 0.46%; 95% CI - 0.84 to - 0.08; p = 0.02). While reductions in PACU stay (MD: - 7.01 min), induction EtSevo (MD: - 0.32%), burst suppression (OR: 0.54), and postoperative pain scores (MD: - 0.62) favored EEG-guided management, these did not reach statistical significance, often with substantial heterogeneity. EEG-guided anesthesia significantly reduces emergence delirium and PAED scores in children. It also lowers sevoflurane consumption and shortens recovery time. These findings support its routine use in pediatric anesthesia for improved outcomes.