Authors: Shen F et al.
Anesthesiology 143(6):1484–1496, December 2025
DOI: 10.1097/ALN.0000000000005707
Summary
This multicenter randomized clinical trial (AmPRAEC) evaluated whether different anesthesia maintenance strategies influence postoperative respiratory adverse events (PRAEs) in children undergoing adenotonsillectomy. A total of 760 children aged 0–12 years were enrolled across 12 hospitals in China and randomized to one of three groups: intravenous propofol maintenance (IV), combined propofol plus inhalational anesthesia (IVIH), or inhalational maintenance alone (IH). All children were intubated and extubated fully awake.
The primary outcome was the incidence of PRAEs occurring in the postanesthesia care unit. Of the 729 patients analyzed, the IV group had the lowest incidence of PRAEs (18.8%), followed by the IVIH group (28.5%), and the IH group showed the highest rate at 43.4%. Compared with inhalational-only anesthesia, the combination strategy significantly reduced PRAEs, and pure intravenous propofol maintenance reduced PRAEs even further. The adjusted odds ratios showed a graded protective effect: IVIH reduced risk by more than half compared with IH, and IV reduced risk even further compared with both IH and IVIH. The number needed to treat was low—3 for IV versus IH—demonstrating strong clinical impact.
The trial shows a clear dose–response pattern: the more propofol used for maintenance, the lower the rate of postoperative respiratory complications. These findings strongly support considering intravenous propofol maintenance, either alone or combined with volatile agents, for pediatric adenotonsillectomy, where PRAEs are a frequent concern.
What You Should Know
• 760 children randomized to IV, IV+inhalation, or inhalation-only maintenance.
• PRAE rates showed a clear gradient: IV had the lowest, IH had the highest.
• IV anesthesia cut PRAEs by roughly 75% compared to inhalational maintenance.
• Combination maintenance (IVIH) significantly reduced PRAEs versus inhalation alone.
• Number needed to treat was extremely low (3 when comparing IV vs IH).
• Propofol-based maintenance should be considered for adenotonsillectomy to minimize respiratory complications.
What We Already Know about This Topic
- Postoperative respiratory adverse events are common in children having tonsillectomy
- Numerous strategies have been suggested to reduce the incidence of these events, including varying anesthesia maintenance regimens
What This Article Tells Us That Is New
- In a large multicenter randomized controlled trial comparing three maintenance anesthesia regimens in children undergoing tonsillectomy, anesthesia maintenance with propofol infusion resulted in fewer postoperative respiratory adverse events compared to maintenance with a combination of propofol infusion and sevoflurane
- Similarly, both propofol alone and the combination of propofol and sevoflurane groups had fewer postoperative respiratory adverse events compared to sevoflurane alone
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