Comparative Assessment of Cortical Hemodynamic Activity in Children Undergoing Anesthesia With Sevoflurane and Propofol: A Functional Near Infrared Spectroscopy Based Randomized Controlled Trial

Background: Sevoflurane and propofol, the common anesthetic agents, have been under evaluation for emergence delirium in children. This pilot study examined how frontal cortex blood flow during sevoflurane and propofol anesthesia relates to emergence delirium in children aged 3–10 using functional near-infrared spectroscopy (fNIRS). Methods: Seventy-four children, undergoing urologic and orthopedic surgeries, were randomly assigned to either propofol (n = 37) or sevoflurane (n = 37) after obtaining approval from the institute ethics committee, written informed parental consent, assent, and registration in a clinical trial registry. Children with perinatal hypoxia, preterm birth, seizures, developmental disorders, psychiatric illness, or electrolyte imbalances were excluded. Anesthesia was induced and maintained per standard protocols, and pain was managed using paracetamol, ketorolac, and caudal analgesia. fNIRS readings were recorded at induction and reversal. Postoperatively, emergence delirium was assessed using the PAED and Cornell Assessment of Pediatric Delirium (CAPD) scales. Data were collected using a 20-channel fNIRS system and analyzed with NIRStar software. Results: Frontal cortex fNIRS demonstrated agent-specific cortical patterns during anesthesia induction, with distinct neural activity differences related to ED. Under propofol, children without ED demonstrated greater left frontal activation (channel 4; t = 2.30, p < 0.005), whereas those with ED showed deactivation; extubation showed no differences. Sevoflurane induction revealed that children without delirium showed greater deactivation in multiple frontal channels—channel 13 (right medial/superior frontal gyri; t = −2.252, p < 0.05), channel 2 (left middle/superior frontal gyri; t = −2.252, p < 0.05), and channel 17 (right superior/middle frontal gyri; t = −3.15, p < 0.05), while no differences were observed during extubation. ED was more frequent with sevoflurane (18.9%) compared to propofol (5.4%). Sevoflurane was linked to significantly less deactivation (more activation) in frontal brain regions in children with emergence delirium, compared to propofol during both induction, notable in channel 4 (left middle and superior frontal gyrus) (t = −5.756, p < 0.005) and extubation notable in channel 2 (left middle and superior frontal gyri) (t = −6.877, p < 0.05). Conclusion: The increased frontal cortical activation with sevoflurane may contribute to a higher incidence of emergence delirium in children compared to propofol. Trial Registration: Clinical trial registry: CTRI/2022/04/041573; https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=NjQ3NTM.