Different anesthetic approaches on postoperative emergence agitation in pediatric patients undergoing adenotonsillectomy: a prospective randomized study

Background Adenotonsillectomy is among the most frequently performed pediatric surgeries worldwide. Despite its routine nature, the perioperative period is often complicated by postoperative emergence agitation (POEA), a transient state of dissociated consciousness characterized by irritability, uncooperativeness, restlessness, and crying, with reported incidence ranging from 10% to 80%. POEA reduces patient comfort and may increase the risk of perioperative complications. We aimed to compare four anesthetic approaches with respect to POEA and recovery quality in children undergoing adenotonsillectomy. Methods In this prospective randomized study, 100 children aged 3–10 years with American Society of Anesthesiologists (ASA) physical status I–II scheduled for adenotonsillectomy were allocated to one of four anesthetic groups: propofol bolus, ketamine bolus, lidocaine infusion, or magnesium sulfate infusion. All patients received standardized premedication, intraoperative management, and multimodal analgesia. Postoperative complications, analgesic requirements, postoperative nausea and vomiting (PONV), time to eye opening, duration of stay in the post-anesthesia care unit (PACU), vital parameters, and pain–delirium scores (Face, Legs, Activity, Cry, Consolability [FLACC] pain score; Pediatric Anesthesia Emergence Delirium [PAED] score; Modified Aldrete Score [MAS]) were recorded. Data were analyzed using Kruskal–Wallis tests with Bonferroni-adjusted post hoc comparisons and Pearson chi-square tests. Results Groups were comparable in age and surgical duration. Significant differences were observed in complication rates (p = 0.046), eye-opening times (p = 0.001), and PACU stay durations (p < 0.001). Magnesium sulfate was associated with the shortest eye-opening times and PACU stay, along with the lowest agitation scores. Propofol prolonged emergence and PACU stay, whereas ketamine and lidocaine were associated with higher complication rates. By 2 hours postoperatively, FLACC, PAED, and MAS scores were similar across all groups. Conclusions Among the four anesthetic strategies evaluated, magnesium sulfate infusion provided the most favorable balance of reduced POEA, shorter recovery times, and fewer complications in pediatric adenotonsillectomy. These findings support the use of magnesium sulfate as an effective adjunct in pediatric anesthetic protocols for adenotonsillectomy. Trial registration: Magnesium Sulfate Versus Other Anesthesia Drugs to Reduce Agitation After Adenotonsillectomy in Pediatric Patients (POEA) NCT07433231 * 02/21/2026-last release