Indian expert consensus on intra-operative consciousness monitoring using processed electroencephalogram-based indices: A Delphi-based approach.

Background and Aims: In India, depth of anaesthesia monitoring with processed electroencephalogram (pEEG) is not routinely implemented. During volatile-based anaesthesia, end-tidal anaesthetic gas concentrations and age-adjusted minimum alveolar concentration values are widely accepted surrogates of anaesthetic depth. However, these measures do not directly reflect cortical activity, and no equivalent objective surrogate exists during total intravenous anaesthesia (TIVA). pEEG monitoring provides a direct assessment of cerebral activity and may support optimised anaesthetic titration, particularly in TIVA and other high-risk scenarios. The primary objective of this Delphi consensus was to develop expert-based, India-specific recommendations for the use of pEEG-based indices in intra-operative anaesthesia practice. Methods: A modified Delphi approach was employed with 15 anaesthesiology experts (13 Indian and 2 international). A Preferred Reporting Items for Systematic Reviews and Meta-analyses-based literature review, covering studies from 2016 to 2025, was conducted to develop 27 draft statements across 10 themes, including indications, target ranges, interpretation, and integration of pEEG with existing monitoring. Through structured iterative rounds involving a steering committee meeting (March 2025), and two rounds of advisory board (May 2025), the statements were revised, eliminated, or accepted based on high (≥80%), moderate (60-80%), or low (<60%) consensus. Results: Of the 27 initial statements, 19 achieved consensus and were included in the final statements. The statements spanned key clinical domains, including the need for depth of anaesthesia monitoring, role of pEEG-based indices, clinical benefits, indications based on anaesthetic techniques (TIVA and inhalational anaesthesia), patient characteristics, surgical context, and practical usage guidance, including target ranges and interpretation. Overall, the consensus supports the use of pEEG monitoring as an adjunct to optimise anaesthetic delivery, reduce drug consumption, and improve recovery profiles, particularly in high-risk and TIVA settings. Conclusion: This Delphi-based consensus provides a clinically relevant framework for integrating pEEG monitoring into anaesthesia practice in India. These recommendations aim to support personalised anaesthetic titration, enhance patient safety, and align peri-operative care with evolving global standards while accounting for local practice variability.