Authors: Shen, Fangming et al.
Anesthesiology, August 6, 2025. DOI: 10.1097/ALN.0000000000005707
This large multicenter randomized clinical trial (AmPRAEC study) evaluated how different anesthesia maintenance strategies affect postoperative respiratory adverse events (PRAEs) in children undergoing adenotonsillectomy. Although PRAEs are among the most common and potentially serious complications in pediatric anesthesia, the influence of maintenance techniques—specifically propofol-based versus inhalational approaches—had not been clearly established in this population.
A total of 760 children aged 0 to 12 years were randomized across 12 hospitals in China into three groups: intravenous propofol maintenance (IV), combined intravenous-inhalation maintenance (IVIH), or inhalation-only maintenance (IH). All children were managed with tracheal intubation and underwent awake extubation. The primary endpoint was the incidence of PRAEs in the post-anesthesia care unit (PACU).
Of the 729 participants analyzed, the incidence of PRAEs decreased progressively from the IH group to the IVIH group and was lowest in the IV group. Specifically, PRAEs occurred in 43.4% of the IH group, 28.5% of the IVIH group, and 18.8% of the IV group. Compared with inhalation anesthesia alone, combined and intravenous maintenance reduced PRAE risk significantly: adjusted odds ratio (aOR) 0.44 for IVIH and 0.25 for IV, corresponding to numbers needed to treat (NNT) of 7 and 3, respectively. The difference between IV and IVIH groups was also significant (aOR 0.57, NNT 6).
These results demonstrate a clear dose–response relationship between the extent of propofol use and reduced respiratory complications. Propofol’s airway-stabilizing and anti-inflammatory properties may explain its protective effect against laryngospasm, coughing, and hypoxemia following extubation.
What You Should Know:
In children undergoing adenotonsillectomy, propofol-based anesthesia—whether combined with or replacing inhalational agents—substantially reduces postoperative respiratory adverse events compared to inhalation anesthesia alone. The findings support considering intravenous propofol maintenance as a safer alternative for pediatric airway surgeries.
Thank you to Anesthesiology for publishing this pivotal trial guiding safer anesthesia maintenance strategies in pediatric surgery.