We mostly use propofol/remifent for maintenance of anaesthesia, and there is (some) reasonable evidence that this leads to less emergence delirium than sevoflurane. We use EEG-like monitors in all paralysed patients over a few months old.

Annoyingly I can’t access the full study, but would be interested to know why the kids in the low sevoflurane use group weren’t moving or coughing with surgical stimulation. The commonly used doses of sevoflurane are used because they are supposed to inhibit movement in response to noxious stimulus. So presumably these patients are all being paralysed or given a lot of opioid to stop them moving?

Using sevoflurane instead of propofol for maintenance if you are trying to reduce PAED is not really standard of care and makes me suspicious they are trying to overstate the effectiveness of their device.

Do we already measure EEG for adults? Or not? If we do, why has it taken so long to do with kids? If not, is this a first step? Why start with kids rather than adults?

This article provides shockingly little context.

There are a lot of not backed by science beliefs in the medical field that won't die until the doctors that believe them do.

https://pubmed.ncbi.nlm.nih.gov/23548489/

PS: this has been debunked, still docs keep saying it.

But has that statement been debunked for sedentary people or people with kidney disease?

Had a great overview.

> As long as you have don’t have pre-existing kidney issues, you don’t need to worry about high-protein intakes killing your kidneys, and it’s time to put this myth to bed.

The one study of overweight individuals mentioned found no adverse side effects but only lasted six months, which may not be long enough for clinical effects to become obvious.

Also, the author overlooked gout entirely.

Based on all that, I'm not convinced it is safe for sedentary individuals.

I think the author should have written:

> As long as you are highly active and have don’t have pre-existing kidney issues...

So with this kind of practice, you create any patient's worst nightmare: being cut open, feeling everything, knowing everything, but unable to stop it. And you are unknowing, uncaring or too cheap to prevent that e.g. via EEG monitoring.

Edit: Parent removed his comment. Roughly, from memory, there was some claim by him about being a professional anesthetist, having very rarely encountered EEG and only bi-spectral index monitoring (an EEG-derived computed measurement) in some IV cases, some claims about the unreliability of both and about the preference for MAC (minimum alveolar concentration) to monitor depth of anesthesia.

The nightmare scenario you describe is when a patient has neuromuscular blockade, is not being given sufficient gas/propofol to depress consciousness, and has inadequate pain control that isn't being picked up in the blood pressure either because the anesthesia provider isn't paying attention or is controlling blood pressure through drugs to the point they can't see anything.

https://www.nejm.org/doi/full/10.1056/NEJMoa0707361

........................................

>Awareness during anesthesia: how sure can we be that the patient is sleeping indeed? (2009)

https://pmc.ncbi.nlm.nih.gov/articles/PMC2683150/

........................................

>Awake Under Anesthesia (2018)

https://www.newyorker.com/books/page-turner/are-we-all-awake...

https://archive.ph/t9T7o

........................................ >Single-trial classification of awareness state during anesthesia by measuring critical dynamics of global brain activity (2019)

https://www.nature.com/articles/s41598-019-41345-4

........................................

>Intraoperative and Anesthesia Awareness (2023)

https://www.ncbi.nlm.nih.gov/books/NBK582138/

> The minimum alveolar concentration (MAC) is the minimum concentration of an inhaled anesthetic at 1 atm of pressure that prevents skeletal muscle movement in response to a surgical incision in 50% of patients.

So first, you do not measure the depth of anesthesia, you measure the concentration of the anesthetic. Second, you judge this concentration by the prevention of muscle movement. Called paralysis.

Please tell me you are not really a doctor.

[0] https://www.sciencedirect.com/topics/medicine-and-dentistry/...

Edit: In case you are wondering why this response doesn't really fit the parent comment, the parent saw fit to completely replace his comment without an indication that he did so. Originally there was a claim in the parent comment about "MAC being the primary indication of anesthetic depth being the textbook definition" or something to that effect. To which I responded. I guess I must have hit a nerve there ;)

I am an attending anesthesiologist and this is true. MAC cannot be interpreted at face value, though. You've got other drugs on board (not accounted for in MAC), the patient might be frail or very old, etc. etc. All things changing MAC interpretation, which is why there are still anesthesia providers instead of robots ;-) We currently have no way of faithfully measuring the depth of anesthesia, and our understanding of consciousness/awareness is incomplete. Anesthesiologists have to rely mostly on know-how, even in 2025.

https://journals.lww.com/anesthesia-analgesia/fulltext/2024/...

How so?

> 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

In general, a very simple mental model for general anesthesia is that it's an unnatural state for your body and your body will do its best to get rid of it, similar to say alcohol or drugs. This means systemic inflammation, stress on your cardiovascular system, liver and kidneys, brain, and so forth. Most all of these issues scale with how much anesthetic you receive, similar to a hangover being worse the more you drink.

In other words, general anesthesia is rough on you just like getting black out drunk is, it's just more controlled and we do our best to try and limit the downsides because it's invaluable for surgery where applicable.

Can confirm having watched our kids recover from general anesthesia multiple times.

Full disclosure: have three kids, eldest child at lifetime total of 4x general anesthesia so far (1x for endoscopy, 3x for surgery), youngest child lifetime total of two (1x endoscopy, 1x dental work). Middle child seems to have escaped so far... he asked recently what it was like, siblings answered unanimously - "terrible".

I had a general anesthesia at 21 for dental surgery. The come back was a nightmare: nausea, shaking, cold and hot alternating, terrible headache, cramps, exhausted and mentally depressed during ~2 days. I couldn't eat, I couldn't drink (but brute force myself to do it), I couldn't think or concentrate on anything but the pain. The only close experience I can remember is the wake up after a blackout hangover but it really wasn't that bad compare to the anesthesia.

6 years later a car crash required artificial coma during 3 days. They drug me along the week following my come back. The dreams during the last day of coma and that week took me through fascinating and terrifying experiences half real (intubation, interactions with family and medics...) and imaginary (ever-repeting-same-day, interns having a fireplace in the ICU floor with guitars, mind-controlled bed to move around the room...). They finally gradually stop the drug and I was only a bit angry and physically suffering from my injuries but not that bad.

Big up to the amazing Royal Perth Hospital team for that amazing care. They saved my life and made the process a confortable trip.

I always wonder what was that drug that produce so weird half-wake dreams with not much side effects. And why they don't always use that for dental surgery and everything else. I heard hypnosis can work instead of a classical general anesthesia and am keen to try if the funny Australian drug isn't an option. Everything but not the general anesthesia.

edit: wonder if both experiences could have been the same sedative drug but the second had a hypnotic wake-up parachute drug during the comeback.

I’ve had one for an operation on a broken jaw, just didn’t think it was particularly rough. Of course it takes time to come round and be clear headed, but the OP kinda implied serious physical problems with “dangerous and very rough on you”. Maybe I just misunderstood what they were saying, but I thought they meant rough as in long lasting damage (which I didn’t think was the case), not temporary discomfort.

Your situation obviously isn’t ideal, but doesn’t have the same implication.

> I always wonder what was that drug that produce so weird half-wake dreams

The sibling comment here mentions Ketamine, which is possible, but if they’re giving that to you intravenously then all perception of time and space will be warped. It’s extreme. So wild dreams is one thing, questioning what is even real is more like ketamine.

It is after effect free though and doesn’t last long, so once stopped you can be over it within the hour. It also has antidepressant effects afterwards.

I’m sure everyone’s experience is different, but it made me feel groggy in a way that was difficult to bounce back from.

The key thing is that when people are given muscle relaxants, you need an independent method to measure consciousness directly.

I haven't followed this in decades so it's a total surprise to me if it isn't mainstream yet.

You could buy a module for your anesthesia monitor for this, no need to use a separate device.

Do they think the nervous system is "turned off" in kids and "turns on" later? Likewise with the formation of memories. A human consciousness that is dealt searing pain under paralysis for an eon of thought-time, might trigger a life long psychosis that impairs living and learning.

Or a thirst for revenge.

This was state of the art in medicine for quite some time. I fear the general trend of "medication bad" will get us back to those dark times.

Btw, those dark times ended only as recently as 1987! https://www.newsweek.com/when-doctors-start-using-anesthesia...

Modern technology and medicine in particular have made our lives better and longer in ways our near ancestors could not have dreamed of or hoped for.

It's not hard to find counterexamples of course: opioid addiction, climate change, etc. But on balance we're a hellava lot better off now than 50 or 500 years ago.

Nice to use a bit less anesthesia for faster/better recovery and money savings. But for goodness sake - let's not go TOO far down that path.

I think the rest of what you're saying is fairly accurate, though.

Note that this does not mean that general anaesthesia was not given at all to kids before 1987, but that there was a belief in the USA (and elsewhere) that newborns did not need pain relief during anaesthesia. Your use of 'kids' versus 'newborns' is a bit misleading in that respect.

> textbooks at the time taught that [open heart] surgery [...] ‘‘could be safely accomplished with only oxygen and a paralytic’’ 69(p.580) when performed on infants.

Textbooks isn't "some doctors errorneously believed", it is what most doctors believed, taught and practiced.

> infant surgery routinely conducted with no or minimal anesthesia well into the 1980s

"Routinely" isn't a few isolated cases, that's the word for "this is the usual thing to do".

https://pubmed.ncbi.nlm.nih.gov/20608214/

> The study by McGraw (1941), although badly designed, convinced the vast majority of clinicians that infants do not feel pain and do not require analgesia. This theory, reinforced by the fear of using opioids in young children, dominated medical thinking for more than 30 years.

"Vast majority" and "dominated" also doesn't sound like just "some cases".

https://www.nytimes.com/1987/12/17/opinion/l-why-infant-surg...

> surveys of medical professionals indicate that as recently as 1986 infants as old as 15 months were receiving no anesthesia during surgery at most American hospitals.

We can discuss the definition of "kid" and "newborn", but I would no longer call them "newborn" when they start walking. Also "most American hospitals" means the practice was very widespread even in 1986.

I think the whole situation is one of the medical community failing to recognize and admit their own mistakes. Instead, the obvious barbarism of the whole situation is played down, diminished and belittled. Thereby protecting their own feelings and standing at the cost of the victims' right to the truth. And thereby paving the way for a repetition of such gruesome mistakes. At which point I would argue, it might even be a little callousness or even intent...

The exact same reaction kills non-adults. The proof took longer, but it is there now. That doctors even needed proof instead of, without further experimental knowledge, assuming the null hypothesis of children being small adults in this case already is proof of a kind of chauvinistic barbarism. Infants were some kind of lesser human to them, thus couldn't react in the same way as adults.

Remember, the norm was _no_ analgesia, _no_ pain relief. For the majority of infants. Its not that they decided on a case by case basis on the right balance of analgesia vs. risk. They decided as a matter of course that analgesia was superfluous for infants.

And the exact definition of the anesthesia given to most infants before 1987: A paralytic. Nothing else.

If you feel adventurous, have your family doctor give you a paralytic and then push a sterile needle under your fingernail. Then tell me the exact definition of sufficient anesthesia in that case ;)

To my knowledge, this was only true for newborns. Infants and up usually got some sort of hypnotic.

I think this won't ever happen. Modern docs would absolutely not accept working under such conditions. Anesthesia is not only comfort for the patient, but also for care providers. As you can often see when surgeons advise patients on refusing local anesthesia or nurses demanding benzos for the screaming demented patient at 2 a.m.

They did major surgery. Like opening the cranium or abdomen. Like removing limbs. Like removing burnt skin by brushing it off and applying skin grafts. And no, they didn't even apply Lidocain, because children don't feel pain. At best, they gave muscle relaxants as chemical restraints and to make the tissue easier to cut.

Jesus, I tried as hard as I knew how not to start a fight, knowing this place plays host to a few foreskin mourners. Better just to avoid entirely, it appears, and duly noted.

What a shame the eyeroll emoji is filtered here. That, apparently, is the level people are on. A paragraph is too much! Or is everyone still rationing since Cerebral, or whatever that telemedicine pill mill was called, shut down a few years back? Is that why no one is reading today?

I never thought I'd say this, but for God's sake and as a favor to us both, pipe my shit through ChatGPT and ask for a reframing on a sixth-grade reading level. You pay for access to the damned robot, let it wipe your nose through the remedial work. I've got embroidery to do and movies to watch.

For example there is stuff like Ketamine, which in some cases can live up to its other use as a recreational drug and give the patient very colorful dreams. There are sedatives that just take away the capacity to form memories, but leave you awake and aware, just calmer. In cases like some knee surgeries, it is possible to leave the patient fully awake, just paralyze and numb the legs.

Apparently I had a small anesthetic overdose in the hospital as a kid and woke up a day or two later than expected, but from my perspective, nothing happened and I just went to sleep then woke up.

Did it once for a back injury as an adult, also only remember the countdown.

But my system was flushed with opiates when I woke up, so I was in a pretty good mood at least.

It combines a sedative from the benzodiazepine family with a synthetic opioid painkiller. This is the most common sedation for colonoscopies. I had a colonoscopy using this, with fentanyl as the opioid and probably midazolam for the benzodiazepine (if not that probably diazepam).

I was aware of the doctor starting the procedure and felt something cold. I could feel pushing sometimes. But nothing hurt or was even annoying (except that cold right at the start). I remember being asked how I was doing and answering. I remember the doctor talking about the quality of my prep--the laxatives had not been as effective as they could have been--and noting that it was still good enough to allow them to continue.

There are some gaps so I think at some points I was more out of it.

I had an earlier colonoscopy with deep sedation using propofol. Here's the experience with that: (1) they start it and I have maybe 10 seconds of memories after that point. At this point I wasn't even in the procedure room. I was in a bed in a waiting area. (2) My next memory is waking up, in the same waiting area, with a nurse telling me they are done, putting the basket with my pants and glasses and phone on the bed, and telling me I could put my pants on.

I've got no memory of being wheeled into the procedure area, or of anything that happened there, or being wheeled back.

That doesn't necessarily mean I didn't feel anything during the procedure. When we were going over the sedation options when arranging for that colonoscopy I asked if deep sedation means you don't feel anything at all, and all the doctor would say is that I would not have any memories of anything.

That isn't exactly reassuring.

If someone offered to pay me a large amount of money to undergo a couple of hours or horrible torture with a guarantee that they would give me a drug to prevent forming long term memories of that torture I would not accept. I would be too worried that there could be other negative persistent effects of such mental trauma than just the formation of long term recallable memories and that the memory preventing drug would not stop those other effect.