Newly published results of a randomized, controlled clinical trial in Japan among more than 170 children aged 1 to 6 who underwent surgery show that by using electroencephalogram (EEG) readings of brain waves to monitor unconsciousness, an anesthesiologist can significantly reduce the amount of the anesthesia administered to safely induce and sustain each patient’s anesthetized state. On average, the little patients experienced significant improvements in several post-operative outcomes, including quicker recovery and reduced incidence of delirium.

“I think the main takeaway is that in kids, using the EEG, we can reduce the amount of anesthesia we give them and maintain the same level of unconsciousness,” says study co-author Emery N. Brown, the Edward Hood Taplin Professor of Medical Engineering and Computational Neuroscience at MIT, an anesthesiologist at Massachusetts General Hospital, and a professor at Harvard Medical School. The study appeared April 21 in JAMA Pediatrics.

Yasuko Nagasaka, chair of anesthesiology at Tokyo Women’s Medical University and a former colleague of Brown’s in the United States, designed the study. She asked Brown to train and advise lead author Kiyoyuki Miyasaka of St. Luke’s International Hospital in Tokyo on how to use EEG to monitor unconsciousness and adjust anesthesia dosing in children. Miyasaka then served as the anesthesiologist for all patients in the trial. Attending anesthesiologists not involved in the study were always on hand to supervise.

Brown’s research in The Picower Institute for Learning and Memory, the Institute for Medical Engineering and Science, and the Department of Brain and Cognitive Sciences at MIT has shown that a person’s level of consciousness under any particular anesthetic drug is discernible from patterns of their brain waves. Each child’s brain waves were measured with EEG, but in the control group Miyasaka adhered to standard anesthesia dosing protocols while in the experimental group he used the EEG measures as a guide for dosing. The results show that when he used EEG, he was able to induce the desired level of unconsciousness with a concentration of 2 percent sevoflurane gas, rather than the standard 5 percent. Maintenance of unconsciousness, meanwhile, only turned out to require 0.9 percent concentration, rather than the standard 2.5 percent.

Meanwhile, a separate researcher, blinded to whether EEG or standard protocols were used, assessed the kids for “pediatric anesthesia emergence delirium” (PAED), in which children sometimes wake up from anesthesia with a set of side effects including lack of eye contact, inconsolability, unawareness of surroundings, restlessness, and non-purposeful movements. Children who received standard anesthesia dosing met the threshold for PAED in 35 percent of cases (30 out of 86), while children who received EEG-guided dosing met the threshold in 21 percent of cases (19 out of 91). The difference of 14 percentage points was statistically significant.

Meanwhile, the authors reported that, on average, EEG-guided patients had breathing tubes removed 3.3 minutes earlier, emerged from anesthesia 21.4 minutes earlier, and were discharged from post-acute care 16.5 minutes earlier than patients who received anesthesia according to the standard protocol. All of these differences were statistically significant. Also, no child in the study ever became aware during surgery.

The authors noted that the quicker recovery among patients who received EEG-guided anesthesia was not only better medically, but also reduced health-care costs. Time in post-acute care in the United States costs about $46 a minute, so the average reduced time of 16.5 minutes would save about $750 per case. Sevoflurane is also a potent greenhouse gas, Brown notes, so reducing its use is better for the environment.

In the study, the authors also present comparisons of the EEG recordings from children in the control and experimental groups. There are notable differences in the “spectrograms” that charted the power of individual brain wave frequencies both as children were undergoing surgery and while they were approaching emergence from anesthesia, Brown says.

For instance, among children who received EEG-guided dosing, there are well-defined bands of high power at about 1-3 Hertz and 10-12 Hz. In children who received standard protocol dosing, the entire range of frequencies up to about 15 Hz are at high power. In another example, children who experienced PAED showed higher power at several frequencies up to 30Hz than children who did not experience PAED.

The findings further validate the idea that monitoring brain waves during surgery can provide anesthesiologists with actionable guidance to improve patient care, Brown says. Training in reading EEGs and guiding dosing can readily be integrated in the continuing medical education practices of hospitals, he adds.

In addition to Miyasuka, Brown, and Nagasaka, Yasuyuki Suzuki is a study co-author.

Funding sources for the study include the MIT-Massachusetts General Brigham Brain Arousal State Control Innovation Center, the Freedom Together Foundation, and the Picower Institute.