Making brain monitoring routine: why processed EEG monitoring should be standard practice.

Despite major technological advances and a growing evidence base, perioperative electroencephalographic (EEG) monitoring remains underused, even though general anaesthesia is fundamentally a brain-targeted intervention. Processed EEG (pEEG) captures clinically relevant brain physiology and provides actionable information to guide anaesthetic dosing, yet its adoption has been hindered by expectations of outcome certainty that exceed those applied to other standard monitors. Much of the controversy reflects misaligned endpoints-such as movement or binary awareness detection-rather than the domains in which EEG plausibly adds value, including avoidance of excessively deep anaesthesia and optimisation of drug titration. While large trials have produced heterogeneous results and have not demonstrated uniform benefit across broad surgical populations, some analyses have explored the possibility that EEG-guided anaesthesia may be more relevant in selected high-risk groups, particularly older adults vulnerable to postoperative neurocognitive disorders. Continued failure to integrate routine brain monitoring into standard anaesthetic practice may therefore pose a greater patient safety risk than adopting it in the setting of imperfect yet biologically coherent evidence.