Effect of Intravenous, Inhalational, or Combined Anesthesia Maintenance on Postoperative Respiratory Adverse Events in Children Undergoing Adenotonsillectomy (AmPRAEC): A Multicenter Randomized Clinical Trial.

Summary

In 729 children analyzed by modified intention-to-treat, intravenous propofol maintenance yielded the lowest PACU respiratory adverse events (18.8%) versus combined (28.5%) and inhalational maintenance (43.4%). Adjusted odds ratios favored IV over IH (0.25) and over IVIH (0.57), with small numbers-needed-to-treat (3–7). Findings support choosing propofol infusion for maintenance in pediatric adenotonsillectomy.

Key Findings

• PRAE incidence: IV 18.8% (45/239), IVIH 28.5% (70/246), IH 43.4% (106/244).
• Adjusted odds ratios: IV vs IH aOR 0.25 (95% CI 0.16–0.39); IV vs IVIH aOR 0.57 (0.36–0.90); IVIH vs IH aOR 0.44 (0.29–0.65).
• Numbers-needed-to-treat: IV vs IH = 3; IV vs IVIH = 6; IVIH vs IH = 7.
• Airway managed with tracheal tubes and awake extubation across groups; primary endpoint assessed in PACU.

Clinical Implications

Prefer intravenous propofol maintenance over inhalational maintenance for pediatric adenotonsillectomy to reduce PRAEs; institutions should review protocols and training to support IV maintenance and PACU monitoring pathways.

Limitations

• Likely lack of provider blinding due to maintenance strategy differences.
• Outcomes focused on PACU events; no long-term respiratory or readmission data; single procedure type and country may limit generalizability.

Future Directions

Test IV maintenance across other pediatric procedures and risk strata, evaluate cost-effectiveness, and assess long-term respiratory outcomes and implementation strategies.