Authors: Shen F. et al.
Anesthesiology, October 14, 2025. DOI: 10.1097/ALN.0000000000005707
This multicenter randomized clinical trial (AmPRAEC study) evaluated whether different anesthesia maintenance strategies influence postoperative respiratory adverse events (PRAEs) in children undergoing adenotonsillectomy. Conducted across 12 hospitals in China, the trial enrolled 760 pediatric patients aged 0 to 12 years who were randomly assigned to one of three groups: (1) intravenous anesthesia maintenance with propofol (IV group), (2) combined intravenous–inhalation anesthesia (IVIH group), or (3) inhalation anesthesia maintenance alone (IH group). All patients were intubated and extubated awake.
The findings revealed a clear, stepwise reduction in PRAE incidence with increasing use of propofol. The IV group had the lowest rate of PRAEs (18.8%), followed by the IVIH group (28.5%), and the highest rate occurred in the IH group (43.4%). Compared with inhalation-only anesthesia, combined maintenance (IVIH) reduced PRAE risk by more than half (adjusted odds ratio [aOR] 0.44), and propofol-only maintenance further decreased risk (aOR 0.25), with a number needed to treat of just three to prevent one adverse event.
The benefit of propofol likely stems from its bronchodilatory properties and reduced upper airway reactivity compared to volatile agents. These results demonstrate a dose–response relationship between the extent of propofol use and PRAE reduction, supporting the role of total intravenous anesthesia (TIVA) as a superior approach for pediatric airway surgery.
What You Should Know
-
Propofol-based anesthesia significantly reduces postoperative respiratory adverse events in children after adenotonsillectomy.
-
Combining propofol with inhalation agents provides intermediate benefit, while inhalation-only anesthesia carries the highest risk.
-
The protective effects of propofol likely relate to decreased airway irritability and improved control of respiratory dynamics.
-
Pediatric TIVA with propofol should be considered the preferred maintenance technique for adenotonsillectomy cases.
Editor’s Perspective
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
Thank you to Anesthesiology for publishing this pivotal multicenter trial clarifying how propofol maintenance reduces respiratory complications in pediatric airway surgery.