Effect of Intravenous, Inhalational, or Combined Anesthesia Maintenance on Postoperative Respiratory Adverse Events in Children Undergoing Adenotonsillectomy (AmPRAEC)

Authors: Shen, Fangming et al.

Anesthesiology 2025 Oct 14 | DOI: 10.1097/ALN.0000000000005707

This multicenter randomized clinical trial (the AmPRAEC study) evaluated how different anesthesia-maintenance strategies affect postoperative respiratory adverse events (PRAEs) in children undergoing adenotonsillectomy. The investigators enrolled 760 children aged 0–12 years at 12 hospitals in China and randomly allocated them to one of three groups: (1) intravenous maintenance with propofol (IV), (2) combined intravenous-inhalational maintenance (IV + IH), or (3) inhalational maintenance alone (IH) using sevoflurane. All children were tracheally intubated and extubated awake. The primary outcome was the incidence of PRAEs in the post-anesthesia care unit. PubMed+1

Results showed a progressive reduction in the incidence of PRAEs across the groups: 43.4% (106/244) in the IH group, 28.5% (70/246) in the IV + IH group, and 18.8% (45/239) in the IV group (modified intention-to-treat n = 729). Compared to the IH group, the IV + IH group had an adjusted odds ratio (aOR) of 0.44 (95% CI 0.29–0.65; number needed to treat [NNT] ≈ 7). The IV group had an aOR of 0.25 (95% CI 0.16–0.39; NNT ≈ 3) compared to the IH group, and an aOR of 0.57 (95% CI 0.36–0.90; NNT ≈ 6) compared to the IV + IH group. PubMed

The authors conclude that propofol‐based intravenous anesthesia maintenance—either alone or in combination with inhalational agents—significantly reduces the risk of postoperative respiratory adverse events in children undergoing adenotonsillectomy. They recommend considering intravenous propofol maintenance for this high-risk airway surgery population. PubMed

What You Should Know

• In children undergoing adenotonsillectomy, anesthesia maintenance strategy influences the rate of postoperative respiratory adverse events, with intravenous propofol being the most protective.

• Using propofol solely provided the greatest benefit, with the lowest incidence of PRAEs and the smallest number needed to treat.

• Even combining propofol with inhalational agents provided a meaningful risk reduction compared to inhalation alone.

• This finding may influence anesthetic planning in pediatric airway surgery, particularly in populations at high risk for respiratory complications.

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