• Wolfgang F Puchner, Martin W Dünser, Patrick Paulus, Markus P Neuner, Charlotte L Mayer, Irmgard M Pomberger, Ruth Hackl, and Jens M Meier.
• Department of Anesthesiology and Intensive Care, Kepler University Hospital and Johannes Kepler University, Krankenhausstraße 9, 4021, Linz, Austria. wolfgang.puchner@kepleruniklinikum.at.
• Can J Anaesth. 2020 Jun 1; 67 (6): 664-673.

PurposeTo compare the clinical judgement of electroencephalogram (EEG)-naïve anesthesiologists with an EEG-based measurement of anesthetic depth (AD) using the Narcotrend® monitor.MethodsIn this prospective cohort study including 600 patients, AD during stable anesthesia was assessed by clinical judgement of the attending, EEG-blinded anesthesiologist (using a scale staging the AD as mid-adequate, adequate but fairly deep, or adequate but fairly light) and by simultaneously recorded Narcotrend measurements.ResultsIn 42% of patients (n = 250), the anesthesiologist's clinical judgement was in agreement with anesthetic levels as measured by the Narcotrend monitor. In 46% of patients (n = 274), the anesthesiologist's judgement and the Narcotrend monitor differed by one AD level (minor discordance). Major discordance was observed in 76 (13%) measurements (judged deeper than measured, n = 29 [5%]; judged lighter than measured, n = 47 [8%]). In 7% of patients (n = 44), the Narcotrend index was outside the limits of adequate AD (too deep, n = 28 [5%]; too superficial, n = 16 [3%]). The overall level of agreement between the anesthesiologist's judgement and the Narcotrend monitor was not statistically significant (Cohen's kappa, -0.039; P = 0.17). Using a random forests algorithm, age, mean blood pressure, the American Society of Anesthesiologists classification, body mass index, and frailty were the variables with the highest relative feature importance to predict the level of agreement.ConclusionThese results suggest that clinical judgement of AD during stable anesthesia was not in agreement with EEG-based assessment of anesthetic depth in 58% of cases. Nevertheless, this finding could be influenced by the lack of validated scales to clinically judge AD.Trial Registrationwww.clinicaltrials.gov (NCT02766894); registered 10 May, 2016.

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