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

Different anesthetic approaches on postoperative emergence agitation in pediatric patients undergoing adenotonsillectomy: a prospective randomized study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Different anesthetic approaches on postoperative emergence agitation in pediatric patients undergoing adenotonsillectomy: a prospective randomized study Ayfer Kaya Gök, Zuhal Çavuş, Döndü Genc Moralar, Talal Çakmak This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8980486/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract 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 Adenotonsillectomy Postoperative emergence agitation Pediatric anesthesia Propofol Ketamine Lidocaine Magnesium sulfate Figures Figure 1 Figure 2 Background Adenotonsillectomy operations are the most common childhood surgeries. In the United States alone, tonsillectomy is performed more than 530,000 times annually in children younger than 15 years ( 3 ) . Although they are so common, still adenotonsillectomy procedures remain challenging with increased risks of morbidity and mortality for both the surgeon and the anesthesiologist ( 1 ) . Postanesthetic emergence agitation (POEA) is a temporary state of dissociated consciousness during recovery from general anesthesia, in which the child is irritable, uncooperative, restless, and often crying. Reported incidence ranges from 10% to 80% (2) , and POEA is particularly common after ear, nose, and throat (ENT) procedures, including adenotonsillectomy. POEA is usually self-limited, children suffer anxiety, fasting, they are afraid of uncertainty, pain and seperation from parents .POEA needs special consideration because it may lead to self-injury, disruption of surgical sites, removal of catheters or tubes, and delayed discharge from the post-anesthesia care unit (PACU). Multiple risk factors contribute to POEA and can be broadly categorized as patient-related (younger age, high baseline anxiety of patient and parents, previous negative anesthetic experience), surgery-related (site of surgery, postoperative pain, airway manipulation), and anesthesia-related (type of anesthetic agent, premedication, rapid emergence, duration of anesthesia, perioperative environment) ( 4 ) . A planned, multimodal approach that considers these factors is essential for preventing POEA and improving recovery quality ( 5 ) . Various pharmacological strategies have been investigated to reduce POEA, including propofol, ketamine, magnesium sulfate, lidocaine, opioids, benzodiazepines, clonidine, and α2-agonists, with conflicting results ( 6 ) . Magnesium sulfate and ketamine, both non-competitive N-methyl-D-aspartate (NMDA) receptor antagonists, have shown to reduce POEA ( 7 , 8 ) . Conversely, propofol, known for its sedative effects, has been associated with prolonged recovery times ( 9 ) . Ketamine and lidocaine, despite their analgesic properties, have mixed efficacy reports necessitating careful consideration ( 10 , 11 , 12 ) . However, the optimal anesthetic strategy to minimize POEA while preserving efficient recovery remains unclear. We therefore designed a prospective randomized study to compare four anesthetic approaches—propofol, ketamine, lidocaine, and magnesium sulfate—on POEA incidence, recovery characteristics, and perioperative complications in children undergoing adenotonsillectomy. Methods Study design and ethics This prospective randomized study was conducted at Gaziosmanpaşa Research and Training Hospital. The study protocol was approved by the institutional Ethics Committee, and written informed consent was obtained from the parents or legal guardians of all participants. Patients We enrolled 100 pediatric patients aged 3–10 years with American Society of Anesthesiologists (ASA) physical status I–II who were scheduled for elective adenotonsillectomy. Exclusion criteria included ASA III or higher, emergency surgery, communication barriers, history of allergy to any study medication, and known cognitive or developmental delay. All children were fasted according to standard guidelines. This study was designed, conducted, and reported in accordance with the Consolidated Standards of Reporting Trials (CONSORT) guidelines. A completed CONSORT checklist has been submitted as a supplementary file. Randomization and anesthetic management Patients were randomized into four groups using a computer-generated sequence: Magnesium sulfate (MgSO4) group: MgSO4 infusion (loading dose 30 mg/kg over 10 minutes after intubation, followed by 10 mg/kg/h infusion). Propofol group: propofol 1 mg/kg bolus administered before the end of surgery. Ketamine group: ketamine 2 mg/kg bolus administered after induction. Lidocaine group: lidocaine 1.5 mg/kg infusion over 15 minutes after induction. All patients received the same premedication (intravenous midazolam 0.1 mg/kg) and standardized induction with fentanyl 1 µg/kg, propofol 2 mg/kg, and rocuronium 0.5 mg/kg. After tracheal intubation, anesthesia was maintained with sevoflurane in an oxygen/air mixture. At the end of surgery, all patients received dexamethasone 0.2 mg/kg and acetaminophen 20 mg/kg intravenously as part of a multimodal analgesic regimen. Postoperative evaluation Hemodynamic variables were recorded intraoperatively. After emergence, we documented time to eye opening, surgery duration, postoperative complications, need for rescue analgesia, and nausea and vomiting (PONV). Duration of stay in the post-anesthesia care unit ( PACU) was recorded from arrival until the discharge. Vital signs and pain–delirium scales were assessed at 5 and 15 minutes in the PACU and at 2 hours postoperatively in the ward (Score Fig. 1 , 2 , 3). The following scales were used: Face, Legs, Activity, Cry, Consolability (FLACC) pain score, Pediatric Anesthesia Emergence Delirium (PAED) score, Modified Aldrete Score (MAS). Anesthesiologists responsible for intraoperative management did not participate in postoperative assessments. Statistical analysis Statistical analyses were performed using IBM SPSS Statistics version 27 (IBM Corp., Armonk, NY, USA). Normality of continuous variables was examined using the Kolmogorov–Smirnov and Shapiro–Wilk tests. Descriptive statistics are presented as median (minimum–maximum) and interquartile range (IQR) for continuous variables and as frequency (percentage) for categorical variables. Group comparisons for categorical variables were made using Pearson chi-square or Fisher’s exact tests. Continuous variables were compared among the four groups using the Kruskal–Wallis test with Bonferroni-corrected post hoc analyses where appropriate. A p-value < 0.05 was considered statistically significant. Results The final analysis included 100 participants who completed the study protocol, with a complete participant flow detailed in Figure A. The four groups were similar with respect to age and surgical duration. There were no significant differences in gender distribution, incidence of PONV, or requirement for rescue analgesia among the groups (Table 1 ). Table 1 Comparison of categorical variables among anesthetic groups Variable Subgroup Ketamine (n = 25) Lidocaine (n = 25) Magnesium sulfate (n = 26) Propofol (n = 24) p value Gender Male 11 (23.9) 10 (21.7) 11 (23.9) 14 (30.4) 0.569 Female 14 (25.9) 15 (27.8) 15 (24.8) 10 (18.5) Complication No 17 (21.0) 18 (22.2) 24 (29.6) 22 (27.2) 0.046 Yes 8 (42.1)* 7 (36.8)* 2 (10.5) 2 (10.5) PONV No 23 (24.0) 24 (25.0) 26 (27.1) 23 (24.0) 0.547 Yes 2 (50.0) 1 (25.0) 0 (0) 1 (25.0) Additional analgesia No 20 (23.5) 22 (25.9) 24 (28.2) 19 (22.4) 0.494 Yes 5 (33.3) 3 (20.0) 2 (13.3) 5 (33.3) Data are presented as n (%). Pearson’s chi-square test; p < 0.05 considered significant. *Groups contributing to the overall p < 0.05. The results of the comparison of age, surgical time, eye opening and PACU time parameters between the anesthesia groups are shown in Table 2 . No significant difference was found between the groups in terms of age and surgical time parameters (Table 2 ; p > 0.05). Complication rates differed significantly between groups (p = 0.046), with higher rates observed in the ketamine and lidocaine groups compared with magnesium sulfate and propofol. Eye-opening times showed a significant difference among groups (p = 0.001). Post hoc analysis demonstrated prolonged eye-opening times in the propofol group compared with the magnesium sulfate group. Similarly, PACU stay duration differed significantly (p < 0.001), with the propofol group having significantly longer PACU times than the ketamine, lidocaine, and magnesium sulfate groups (Fig. 1 ) . Table 2 Perioperative times (Comparison of age, surgical time, eye opening time and PACU time) by anesthetic group Data are median (min–max) [interquartile range]. Kruskal–Wallis tests with Bonferroni-adjusted post hoc comparisons; p < 0.05 considered significant. Variable Ketamine (n = 25) Lidocaine (n = 25) Magnesium sulfate (n = 26) Propofol (n = 24) p value Age (years) 6 (3–10) [3] 6 (3–10) [1] 6 (4–10) [3] 6.5 (3–10) [3.3] 0.998 Surgery time (min) 62 (30–130) [34] 75 (35–175) [35] 81 (45–147) [30] 67.5 (35–140) [26.3] 0.148 Eye-opening time (min) 17 (7–43) [6] 15 (8–25) [10] 11 (3–30) [7.8] 20 (10–35) [6] 0.001 PACU stay (min) 20 (15–30) [4] 15 (15–30) [5] 18 (15–30) [5] 20 (15–46) [7.8] < 0.001 Hemodynamic and clinical variables, including mean arterial pressure (MAP), heart rate (HR), SpO2, FLACC, PAED, and MAS scores at different time points, varied across groups (Table 3 ). Significant differences were observed in pre-extubation HR, PACU 5-minute SpO2 and FLACC scores, and PACU 15-minute MAP and HR. Despite these early differences, by 2 hours postoperatively FLACC, PAED, and MAS scores were comparable among all groups, and all children met discharge criteria (Fig. 2 ) . Table 3 Comparison of MAP, HR, SPO2, FLACC, PAED, MAS and PACU time among anesthesia agents Variables Ketamine (n = 25) Lidocaine (n = 25) MgSO4 (n = 26) Propofol (n = 24) p Median (min-max) IQR PREOP MAP 82(62–95)12 82(65–92)6 83.5(64–104)11.3 85(65–99)19.3 0.703 PREOP HR 118(80–146)20 110(82–140)22 115.5(81–150)24.8 105(84–140)20.3 0.282 PREOP SPO2 100(97–100)0 100(96–140)1 100(97–100)1 99(98–100)1 0.077 5. min. MAP 70(53–105)9 73(60–112)6 69.5(58–99)9.8 70(55–99)8.5 0.222 5. min.HR 106(82–135)24 108(73–139)24 111.5(72–140)25 107(10–130)16.8 0.665 5. min. SPO2 100(97–100)1 100(98–100)0 100(99–100)0 100(99–100)1 0.201 PRE Extubation MAP 75(48–100)17 68(62–90)6 68(56–95)9.5 70(60–85)6.8 0.337 PRE Extubation HR 100(77–120)16 98(54–140)13 90.5(62–130)17.8 104(80–120)16.8 0.026 PRE Extubation SPO2 100(98–100)1 100(98–100)0 100(99–100)0 100(98–100)1 0.308 PACU 5. min. MAP 80(68–105)10 75(68–98)10 80(66–104)7.3 75(65–85)10 0.155 PACU 5. min. HR 116(88–140)23 110(72–139)26 106(11–135)32.5 110(85–140)21 0.226 PACU 5. min. SPO2 100(97–100)0 99(97–100)2 100(94–100)1 99(98–100)1 0.012 PACU 5. min. FLACC 0(0–7)2 4(0–10)5 5(0–10)6 4(0–8)7 0.018 PACU 5. min. PAED 11(2–15)3 12(2–20)4 12(0–20)5 11(0–17)6 0.122 PACU 5. min. MAS 8(6–10)1 8(6–10)1 8(6–10)1 9(5–10)1 0.598 PACU 15. min. MAP 80(70–110)13 78(68–100)8 85(72–106)11 79(65–90)9.3 0.003 PACU 15. min.HR 120(98–147)20 111(77–137)15 117(90–168)21 108(79–132)11 0.006 PACU 15. min. SPO2 100(98–100)0 100(94–100)2 100(96–100)1 100(98–100)1 0.070 PACU 15. min. FLACC 2(0–8)3 4(0–9)2 4(0–10)5 4(0–9)5 0.175 PACU 15. min.PAED 7(0–15)5 5(2–15)6 6(0–13)8 8(0–12)8 0.833 PACU 15. min.MAS 10(5–10)1 10(8–10)1 10(2–10)1 10(6–10)1 0.905 POSTOP 2. Hour FLACC 0(0–9)0 0(0–0)0 0(0–0)0 0(0–6)0 0.092 POSTOP 2. Hour PAED 0(0–7)0 0(0–0)0 0(0–0)0 0(0–4)0 0.092 POASTOP 2. Hour MAS 10(10–10)0 10(10–10)0 10(10–10)0 10(10–10)0 1.000 Kruskal Wallis test used and post hoc Bonferroni's correction used p < 0.05 considered significant. IQR; Interquartile range Discussion In this prospective randomized study of children undergoing adenotonsillectomy, we compared four anesthetic strategies—propofol, ketamine, lidocaine, and magnesium sulfate—with respect to POEA, recovery characteristics, and perioperative complications. Our principal finding was that magnesium sulfate infusion was associated with shorter emergence and PACU stay, lower agitation scores, and fewer complications relative to the other regimens. Adenotonsillectomy is a most common pediatric procedure and POEA is a frequent postoperative complication in this operation ( 1 , 2 , 3 ) , optimizing anesthetic management has important implications for patient safety, comfort, and resource use. POEA should be dealt with ultimate care because it’s associated with life threating complications, delaying discharge and functional recovery. POEA and delirium should be considered as a vital sign, which should be followed and documented on every child in PACU ( 4 ) . Consequently, strategies that reduce POEA while preserving efficient recovery are of particular value. Multiple risk factors contribute to POEA and can be broadly categorized as patient-related (younger age, high baseline anxiety of patient and parents, previous negative anesthetic experience), surgery-related (site of surgery, postoperative pain, airway manipulation), and anesthesia-related (type of anesthetic agent, premedication, rapid emergence, duration of anesthesia, perioperative environment) ( 4 ) . Anesthesiologist should consider a planned multimodal approach knowing all the possible risk factors, identifying and reducing the triggers. This plan must begin preoperatively and continue into the postoperative period, in order to minimize the pain, anxiety and stay safe- comfortable in PACU ( 5 ) . A lot of environmental, supportive (parent-present induction, and preoperative education for surgery) and pharmacological interventions (several anesthetic agents and pharmacological methods such as total intravenous anesthesia, propofol, µ-opioid agonists, N-methyl-Daspartate receptor antagonists, nefopam, α2-adrenoreceptor agonists, regional analgesia, multimodal analgesia) have been suggested for POEA ( 5 , 6 ) . However, the optimal anesthetic strategy to minimize POEA while preserving efficient recovery remains unclear. We therefore designed a prospective randomized study to compare four anesthetic approaches—propofol, ketamine, lidocaine, and magnesium sulfate—on POEA incidence, recovery characteristics, and perioperative complications in children undergoing adenotonsillectomy. Total intravenous anaesthesia (TIVA) techniques have become popular in recent years, a review has shown TIVA may help to reduce the incidence of POEA ( 13 , 14 ) . Propofol is commonly used to prevent or treat POEA ( 15 ) , but can prolong recovery time ( 9 ) , as reflected in our longer eye-opening and PACU stay times in the propofol group so it’s not practical in hardworking operative rooms. Magnesium sulfate and ketamine, both non-competitive N-methyl-D-aspartate (NMDA) receptor antagonists, have shown to reduce POEA ( 5 , 7 , 8 ) . Ketamine has sedative, amnestic, and analgesic properties ( 5 ) . In a study, low-dose ketamine during induction of anesthesia reduces POEA and postoperative pain following adenotonsillectomy in children ( 16 ) . Also in a meta-analysis of 13 randomized controlled trials, high degree of heterogeneity and low certainty of evidence limit the recommendations of ketamine for the prevention of emergence agitation in children undergoing surgery or imaging procedures. However, the use of ketamine is well-tolerated without any notable adverse effects across all the included trials ( 10 , 11 ) . In our study, ketamine, although analgesic, was associated with higher complication rates such as increased secretions and POEA . Magnesium sulfate is a non-competitive NMDA receptor antagonist like ketamine, which has central sedative, neuroprotective, and analgesic-sparing effects so it can reduce the incidence of POEA ( 8 , 17 ) . Elsersy et al. proposed that magnesium’s potential to decrease agitation might be associated with its protective role against the adverse effects of prolonged hypotension and other contributing factors on the brain ( 18 ) . Magnesium sulfate has shown to effectively control agitation without significant sedation, respiratory depression, or delayed recovery, making it particularly suitable for pediatric anesthesia ( 7 ) . But a review showed, unlike the studies in adults, there is no statistically significant effect of perioperative use of magnesium in the postoperative pain control in children undergoing tonsillectomies, but it had benefits in reducing rescue analgesia, emergence agitation incidence, and laryngospasm ( 19 ) . Our results align with previous studies suggesting that intraoperative magnesium sulfate can reduce POEA and improve postoperative comfort. The absence of clinically important adverse events and the ease of administration further support its incorporation into pediatric adenotonsillectomy anesthetic protocols. Intravenous infusion of lidocaine relieves postoperative sore throat and reduces POEA and coughing although it may delay recovery ( 20 , 21 , 22 ) . Lidocaine reduces secretion of neuropeptides in the brainstem and airway by inhibiting stimulation of sensory C fibers in the airway and reducing stimulation of the mucosa in the airway by the tracheal tube ( 12 , 23 ) . The pathophysiologic changes leading to this ED are not completely understood. In adults, endothelial dysfunction due to the release of inflammatory cytokines is a common perioperative event influencing the incidence of delirium ( 24 ) . Amide-local anesthetics have been demonstrated to be able to preserve endothelial barrier function upon an inflammatory stimulus and might therefore also potentially be able to influence pathophysiologic events leading to neurologic disturbances after surgery ( 25 , 26 ) . Lidocaine administered intravenously, may reduce postoperative pain and POEA but reported to extend recovery times and may cause hemodynamic fluctuations, which may explain the higher complication rates observed in our lidocaine group. The study has limitations, including its single-center design and modest sample size, which may limit the generalizability of our findings. Additionally, while we used validated scales (FLACC, PAED, MAS), the assessment of agitation and pain in young children always carries some subjectivity. Future multicenter trials with larger sample sizes and standardized multimodal protocols would help confirm the advantages of magnesium sulfate and refine dose–response relationships. Conclusions Among four anesthetic strategies evaluated in pediatric adenotonsillectomy, magnesium sulfate infusion provided the most favorable profile, combining reduced postoperative emergence agitation with shorter recovery times and fewer complications. These findings support the inclusion of magnesium sulfate as a valuable adjunct in pediatric anesthesia protocols for adenotonsillectomy. Abbreviations ASA American Society of Anesthesiologists ENT Ear, nose, and throat FLACC Face, Legs, Activity, Cry, Consolability HR Heart rate IQR Interquartile range MAP Mean arterial pressure MAS Modified Aldrete Score MgSO4 Magnesium sulfate PACU Post-anesthesia care unit PAED Pediatric Anesthesia Emergence Delirium POEA Postoperative emergence agitation PONV Postoperative nausea and vomiting SpO2 Peripheral oxygen saturation TIVA Total intravenous anesthesia Declarations Ethics approval and consent to participate The study protocol was approved by the Ethics Committee of Gaziosmanpaşa Research and Training Hospital (Approval No. 2023-65). Clinical Trial Registry: NCT07433231 Magnesium Sulfate Versus Other Anesthesia Drugs to Reduce Agitation After Adenotonsillectomy in Pediatric Patients It adheres to the principles outlined in the Declaration of Helsinki and the CONSORT 2010 guidelines. Written informed consent was obtained from the parents or legal guardians of all participants. We confirm our study complies with the Declaration of Helsinki. Consent for publication Not applicable. The manuscript does not contain any individual person’s identifiable data. Availability of data and materials The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding The authors received no specific funding for this work. Authors’ contributions AKG conceived and designed the study, collected data, and drafted the manuscript. ZÇ contributed to data acquisition and interpretation and critically revised the manuscript for important intellectual content. DGM contributed to statistical analysis, interpretation of data, and critical revision of the manuscript. All authors read and approved the final manuscript. 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Ropivacaine attenuates endotoxin plus hyperinflation-mediated acute lung injury via inhibition of early-onset Src-dependent signaling. BMC Anesthesiol. 2014;14:57. Additional Declarations No competing interests reported. Supplementary Files scoringsystems.docx consortdiagram.docx CompletedCONSORT2010Checklist1.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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Gök","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBUlEQVRIiWNgGAWjYFACxgcMDAfALGaGD0CSjZ2gFmYDuBbGGSAtzKRoYeaBWIYf8M9IZnxcccYusb9/8WFjm1/b5PmYGRg/fMzBrUXiRjKz4ZkbyYkzbjxLTs7tu23YxszALDlzGx5rbuQfk2z4wJzYcOOM8eHcntuMQC1szLx4tMjfSGb/2fChPnE+SItlz217gloMbiSzMTbcOJy44XyPcTLDj9uJBLUYnnnMLNlw5rjxxhtsyYa9DbeT25gZm/H6Re54MuPHhmPVsvPOHz4s8ePPbdv57c0HP3zE532BBDDl2CABZDC2gdiMDXjUAwH/ATBlD2H8wa94FIyCUTAKRiYAAIs2WoamyFilAAAAAElFTkSuQmCC","orcid":"","institution":"Gaziosmanpaşa Eğitim Ve Araştırma Hastanesi","correspondingAuthor":true,"prefix":"","firstName":"Ayfer","middleName":"Kaya","lastName":"Gök","suffix":""},{"id":604073899,"identity":"78e38e2e-ad6f-48b8-8286-a370126ec7b2","order_by":1,"name":"Zuhal Çavuş","email":"","orcid":"","institution":"medifema hospital","correspondingAuthor":false,"prefix":"","firstName":"Zuhal","middleName":"","lastName":"Çavuş","suffix":""},{"id":604073900,"identity":"4adb826e-d3fe-42ac-93db-fde835c5bdaa","order_by":2,"name":"Döndü Genc Moralar","email":"","orcid":"","institution":"Gaziosmanpaşa Eğitim Ve Araştırma Hastanesi","correspondingAuthor":false,"prefix":"","firstName":"Döndü","middleName":"Genc","lastName":"Moralar","suffix":""},{"id":604073901,"identity":"cd99e65f-95d9-4aa2-8abb-0f67e8ab65c9","order_by":3,"name":"Talal Çakmak","email":"","orcid":"","institution":"Gaziosmanpaşa Eğitim Ve Araştırma Hastanesi","correspondingAuthor":false,"prefix":"","firstName":"Talal","middleName":"","lastName":"Çakmak","suffix":""}],"badges":[],"createdAt":"2026-02-26 17:39:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8980486/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8980486/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104780923,"identity":"636b1fd4-e834-425c-b9c8-77e7e4f1db34","added_by":"auto","created_at":"2026-03-17 07:54:17","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":34458,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of age, surgical time, eye opening time and PACU time among anesthesia agents\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8980486/v1/0739418938c8882f63f48349.jpg"},{"id":104557554,"identity":"1d1734bc-dc92-4105-b0d7-f9be688e14d4","added_by":"auto","created_at":"2026-03-13 09:28:00","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":34477,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of a MAP, FLACC, SPO\u003c/strong\u003e\u003csub\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/sub\u003e\u003cstrong\u003e, heart rate in different time periods among anesthesia agents\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8980486/v1/8c6ac85b8e546ff81b3bfa7a.jpg"},{"id":108803644,"identity":"a4a2190b-835b-4032-810d-99b09486c866","added_by":"auto","created_at":"2026-05-08 15:02:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":450487,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8980486/v1/9741a0a0-3b46-4ef7-b157-ee74e7f7d6e9.pdf"},{"id":104557538,"identity":"648a955f-82cf-48ab-a075-fc5e51f45008","added_by":"auto","created_at":"2026-03-13 09:27:56","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":13080,"visible":true,"origin":"","legend":"","description":"","filename":"scoringsystems.docx","url":"https://assets-eu.researchsquare.com/files/rs-8980486/v1/0cb4b5f2e94f2b60543370f8.docx"},{"id":104557640,"identity":"ecd8f018-a64f-4eb8-bfe1-7955688eec84","added_by":"auto","created_at":"2026-03-13 09:28:31","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":44052,"visible":true,"origin":"","legend":"","description":"","filename":"consortdiagram.docx","url":"https://assets-eu.researchsquare.com/files/rs-8980486/v1/aef496f2efe6332ff7cf2a7a.docx"},{"id":104557566,"identity":"caf0fbaa-2dd7-49c3-b00d-3c65f2ec8aab","added_by":"auto","created_at":"2026-03-13 09:28:03","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":47839,"visible":true,"origin":"","legend":"","description":"","filename":"CompletedCONSORT2010Checklist1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8980486/v1/67379808693abb8d0e76da72.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Different anesthetic approaches on postoperative emergence agitation in pediatric patients undergoing adenotonsillectomy: a prospective randomized study","fulltext":[{"header":"Background","content":"\u003cp\u003eAdenotonsillectomy operations are the most common childhood surgeries. In the United States alone, tonsillectomy is performed more than 530,000 times annually in children younger than 15 years\u003csup\u003e(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/sup\u003e. Although they are so common, still adenotonsillectomy procedures remain challenging with increased risks of morbidity and mortality for both the surgeon and the anesthesiologist \u003csup\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/sup\u003e .\u003c/p\u003e \u003cp\u003ePostanesthetic emergence agitation (POEA) is a temporary state of dissociated consciousness during recovery from general anesthesia, in which the child is irritable, uncooperative, restless, and often crying. Reported incidence ranges from 10% to 80% \u003csup\u003e(2)\u003c/sup\u003e, and POEA is particularly common after ear, nose, and throat (ENT) procedures, including adenotonsillectomy. POEA is usually self-limited, children suffer anxiety, fasting, they are afraid of uncertainty, pain and seperation from parents .POEA needs special consideration because it may lead to self-injury, disruption of surgical sites, removal of catheters or tubes, and delayed discharge from the post-anesthesia care unit (PACU).\u003c/p\u003e \u003cp\u003eMultiple risk factors contribute to POEA and can be broadly categorized as patient-related (younger age, high baseline anxiety of patient and parents, previous negative anesthetic experience), surgery-related (site of surgery, postoperative pain, airway manipulation), and anesthesia-related (type of anesthetic agent, premedication, rapid emergence, duration of anesthesia, perioperative environment) \u003csup\u003e(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/sup\u003e. A planned, multimodal approach that considers these factors is essential for preventing POEA and improving recovery quality \u003csup\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/sup\u003e .\u003c/p\u003e \u003cp\u003eVarious pharmacological strategies have been investigated to reduce POEA, including propofol, ketamine, magnesium sulfate, lidocaine, opioids, benzodiazepines, clonidine, and α2-agonists, with conflicting results \u003csup\u003e(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/sup\u003e. Magnesium sulfate and ketamine, both non-competitive N-methyl-D-aspartate (NMDA) receptor antagonists, have shown to reduce POEA \u003csup\u003e(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/sup\u003e. Conversely, propofol, known for its sedative effects, has been associated with prolonged recovery times \u003csup\u003e(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/sup\u003e. Ketamine and lidocaine, despite their analgesic properties, have mixed efficacy reports necessitating careful consideration \u003csup\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/sup\u003e. However, the optimal anesthetic strategy to minimize POEA while preserving efficient recovery remains unclear. We therefore designed a prospective randomized study to compare four anesthetic approaches\u0026mdash;propofol, ketamine, lidocaine, and magnesium sulfate\u0026mdash;on POEA incidence, recovery characteristics, and perioperative complications in children undergoing adenotonsillectomy.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design and ethics\u003c/p\u003e \u003cp\u003eThis prospective randomized study was conducted at Gaziosmanpaşa Research and Training Hospital. The study protocol was approved by the institutional Ethics Committee, and written informed consent was obtained from the parents or legal guardians of all participants.\u003c/p\u003e \u003cp\u003ePatients\u003c/p\u003e \u003cp\u003eWe enrolled 100 pediatric patients aged 3\u0026ndash;10 years with American Society of Anesthesiologists (ASA) physical status I\u0026ndash;II who were scheduled for elective adenotonsillectomy. Exclusion criteria included ASA III or higher, emergency surgery, communication barriers, history of allergy to any study medication, and known cognitive or developmental delay. All children were fasted according to standard guidelines.\u003c/p\u003e \u003cp\u003e This study was designed, conducted, and reported in accordance with the Consolidated Standards of Reporting Trials (CONSORT) guidelines. A completed CONSORT checklist has been submitted as a supplementary file.\u003c/p\u003e \u003cp\u003eRandomization and anesthetic management\u003c/p\u003e \u003cp\u003ePatients were randomized into four groups using a computer-generated sequence:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e Magnesium sulfate (MgSO4) group: MgSO4 infusion (loading dose 30 mg/kg over 10 minutes after intubation, followed by 10 mg/kg/h infusion).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e Propofol group: propofol 1 mg/kg bolus administered before the end of surgery.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eKetamine group: ketamine 2 mg/kg bolus administered after induction.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eLidocaine group: lidocaine 1.5 mg/kg infusion over 15 minutes after induction.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eAll patients received the same premedication (intravenous midazolam 0.1 mg/kg) and standardized induction with fentanyl 1 \u0026micro;g/kg, propofol 2 mg/kg, and rocuronium 0.5 mg/kg. After tracheal intubation, anesthesia was maintained with sevoflurane in an oxygen/air mixture. At the end of surgery, all patients received dexamethasone 0.2 mg/kg and acetaminophen 20 mg/kg intravenously as part of a multimodal analgesic regimen.\u003c/p\u003e \u003cp\u003ePostoperative evaluation\u003c/p\u003e \u003cp\u003eHemodynamic variables were recorded intraoperatively. After emergence, we documented time to eye opening, surgery duration, postoperative complications, need for rescue analgesia, and nausea and vomiting (PONV). Duration of stay in the post-anesthesia care unit ( PACU) was recorded from arrival until the discharge. Vital signs and pain\u0026ndash;delirium scales were assessed at 5 and 15 minutes in the PACU and at 2 hours postoperatively in the ward (Score Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, 3). The following scales were used: Face, Legs, Activity, Cry, Consolability (FLACC) pain score, Pediatric Anesthesia Emergence Delirium (PAED) score, Modified Aldrete Score (MAS). Anesthesiologists responsible for intraoperative management did not participate in postoperative assessments.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using IBM SPSS Statistics version 27 (IBM Corp., Armonk, NY, USA). Normality of continuous variables was examined using the Kolmogorov\u0026ndash;Smirnov and Shapiro\u0026ndash;Wilk tests. Descriptive statistics are presented as median (minimum\u0026ndash;maximum) and interquartile range (IQR) for continuous variables and as frequency (percentage) for categorical variables. Group comparisons for categorical variables were made using Pearson chi-square or Fisher\u0026rsquo;s exact tests. Continuous variables were compared among the four groups using the Kruskal\u0026ndash;Wallis test with Bonferroni-corrected post hoc analyses where appropriate. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe final analysis included 100 participants who completed the study protocol, with a complete participant flow detailed in Figure A. The four groups were similar with respect to age and surgical duration. There were no significant differences in gender distribution, incidence of PONV, or requirement for rescue analgesia among the groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of categorical variables among anesthetic groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubgroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKetamine (n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLidocaine (n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMagnesium sulfate (n\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePropofol (n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (23.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10 (21.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (23.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14 (30.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.569\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (25.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15 (27.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 (24.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10 (18.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (21.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24 (29.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e22 (27.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (42.1)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7 (36.8)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2 (10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePONV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23 (24.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26 (27.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e23 (24.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.547\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdditional analgesia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (23.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22 (25.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24 (28.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e19 (22.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.494\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eData are presented as n (%). Pearson\u0026rsquo;s chi-square test; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered significant. *Groups contributing to the overall p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe results of the comparison of age, surgical time, eye opening and PACU time parameters between the anesthesia groups are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. No significant difference was found between the groups in terms of age and surgical time parameters (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e; p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Complication rates differed significantly between groups (p\u0026thinsp;=\u0026thinsp;0.046), with higher rates observed in the ketamine and lidocaine groups compared with magnesium sulfate and propofol. Eye-opening times showed a significant difference among groups (p\u0026thinsp;=\u0026thinsp;0.001). Post hoc analysis demonstrated prolonged eye-opening times in the propofol group compared with the magnesium sulfate group. Similarly, PACU stay duration differed significantly (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with the propofol group having significantly longer PACU times than the ketamine, lidocaine, and magnesium sulfate groups (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) .\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003ePerioperative times (Comparison of age, surgical time, eye opening time and PACU time) by anesthetic group\u003c/b\u003e Data are median (min\u0026ndash;max) [interquartile range]. Kruskal\u0026ndash;Wallis tests with Bonferroni-adjusted post hoc comparisons; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered significant.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKetamine (n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLidocaine (n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMagnesium sulfate (n\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePropofol (n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (3\u0026ndash;10) [3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (3\u0026ndash;10) [1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (4\u0026ndash;10) [3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.5 (3\u0026ndash;10) [3.3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.998\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (30\u0026ndash;130) [34]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75 (35\u0026ndash;175) [35]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81 (45\u0026ndash;147) [30]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67.5 (35\u0026ndash;140) [26.3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.148\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEye-opening time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (7\u0026ndash;43) [6]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (8\u0026ndash;25) [10]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (3\u0026ndash;30) [7.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20 (10\u0026ndash;35) [6]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePACU stay (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (15\u0026ndash;30) [4]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (15\u0026ndash;30) [5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (15\u0026ndash;30) [5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20 (15\u0026ndash;46) [7.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eHemodynamic and clinical variables, including mean arterial pressure (MAP), heart rate (HR), SpO2, FLACC, PAED, and MAS scores at different time points, varied across groups (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Significant differences were observed in pre-extubation HR, PACU 5-minute SpO2 and FLACC scores, and PACU 15-minute MAP and HR. Despite these early differences, by 2 hours postoperatively FLACC, PAED, and MAS scores were comparable among all groups, and all children met discharge criteria (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) .\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of MAP, HR, SPO2, FLACC, PAED, MAS and PACU time among anesthesia agents\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKetamine (n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLidocaine (n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMgSO4\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePropofol\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eMedian (min-max) IQR\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePREOP MAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82(62\u0026ndash;95)12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82(65\u0026ndash;92)6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e83.5(64\u0026ndash;104)11.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e85(65\u0026ndash;99)19.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.703\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePREOP HR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e118(80\u0026ndash;146)20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e110(82\u0026ndash;140)22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e115.5(81\u0026ndash;150)24.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e105(84\u0026ndash;140)20.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.282\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePREOP SPO2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100(97\u0026ndash;100)0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100(96\u0026ndash;140)1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100(97\u0026ndash;100)1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e99(98\u0026ndash;100)1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.077\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. min. MAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70(53\u0026ndash;105)9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73(60\u0026ndash;112)6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e69.5(58\u0026ndash;99)9.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70(55\u0026ndash;99)8.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.222\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. min.HR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e106(82\u0026ndash;135)24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e108(73\u0026ndash;139)24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e111.5(72\u0026ndash;140)25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e107(10\u0026ndash;130)16.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.665\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. min. SPO2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100(97\u0026ndash;100)1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100(98\u0026ndash;100)0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100(99\u0026ndash;100)0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100(99\u0026ndash;100)1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.201\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePRE Extubation MAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75(48\u0026ndash;100)17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68(62\u0026ndash;90)6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68(56\u0026ndash;95)9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70(60\u0026ndash;85)6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.337\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePRE Extubation HR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100(77\u0026ndash;120)16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98(54\u0026ndash;140)13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90.5(62\u0026ndash;130)17.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e104(80\u0026ndash;120)16.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.026\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePRE Extubation SPO2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100(98\u0026ndash;100)1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100(98\u0026ndash;100)0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100(99\u0026ndash;100)0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100(98\u0026ndash;100)1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.308\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePACU 5. min. MAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80(68\u0026ndash;105)10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75(68\u0026ndash;98)10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80(66\u0026ndash;104)7.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e75(65\u0026ndash;85)10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.155\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePACU 5. min. HR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e116(88\u0026ndash;140)23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e110(72\u0026ndash;139)26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e106(11\u0026ndash;135)32.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e110(85\u0026ndash;140)21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.226\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePACU 5. min. SPO2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100(97\u0026ndash;100)0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99(97\u0026ndash;100)2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100(94\u0026ndash;100)1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e99(98\u0026ndash;100)1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.012\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePACU 5. min. FLACC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0\u0026ndash;7)2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(0\u0026ndash;10)5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5(0\u0026ndash;10)6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4(0\u0026ndash;8)7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.018\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePACU 5. min. PAED\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11(2\u0026ndash;15)3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12(2\u0026ndash;20)4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12(0\u0026ndash;20)5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11(0\u0026ndash;17)6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.122\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePACU 5. min. MAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8(6\u0026ndash;10)1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8(6\u0026ndash;10)1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8(6\u0026ndash;10)1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9(5\u0026ndash;10)1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.598\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePACU 15. min. MAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80(70\u0026ndash;110)13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78(68\u0026ndash;100)8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85(72\u0026ndash;106)11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e79(65\u0026ndash;90)9.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePACU 15. min.HR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120(98\u0026ndash;147)20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e111(77\u0026ndash;137)15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e117(90\u0026ndash;168)21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e108(79\u0026ndash;132)11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePACU 15. min. SPO2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100(98\u0026ndash;100)0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100(94\u0026ndash;100)2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100(96\u0026ndash;100)1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100(98\u0026ndash;100)1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.070\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePACU 15. min. FLACC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(0\u0026ndash;8)3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(0\u0026ndash;9)2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4(0\u0026ndash;10)5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4(0\u0026ndash;9)5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.175\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePACU 15. min.PAED\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(0\u0026ndash;15)5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(2\u0026ndash;15)6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6(0\u0026ndash;13)8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8(0\u0026ndash;12)8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.833\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePACU 15. min.MAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10(5\u0026ndash;10)1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10(8\u0026ndash;10)1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10(2\u0026ndash;10)1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10(6\u0026ndash;10)1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.905\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePOSTOP 2. Hour FLACC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0\u0026ndash;9)0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0\u0026ndash;0)0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0\u0026ndash;0)0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0\u0026ndash;6)0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.092\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePOSTOP 2. Hour PAED\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0\u0026ndash;7)0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0\u0026ndash;0)0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0\u0026ndash;0)0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0\u0026ndash;4)0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.092\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePOASTOP 2. Hour MAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10(10\u0026ndash;10)0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10(10\u0026ndash;10)0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10(10\u0026ndash;10)0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10(10\u0026ndash;10)0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eKruskal Wallis test used and post hoc Bonferroni's correction used p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered significant.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eIQR; Interquartile range\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this prospective randomized study of children undergoing adenotonsillectomy, we compared four anesthetic strategies\u0026mdash;propofol, ketamine, lidocaine, and magnesium sulfate\u0026mdash;with respect to POEA, recovery characteristics, and perioperative complications. Our principal finding was that magnesium sulfate infusion was associated with shorter emergence and PACU stay, lower agitation scores, and fewer complications relative to the other regimens.\u003c/p\u003e \u003cp\u003eAdenotonsillectomy is a most common pediatric procedure and POEA is a frequent postoperative complication in this operation \u003csup\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/sup\u003e, optimizing anesthetic management has important implications for patient safety, comfort, and resource use. POEA should be dealt with ultimate care because it\u0026rsquo;s associated with life threating complications, delaying discharge and functional recovery. POEA and delirium should be considered as a vital sign, which should be followed and documented on every child in PACU\u003csup\u003e(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/sup\u003e. Consequently, strategies that reduce POEA while preserving efficient recovery are of particular value.\u003c/p\u003e \u003cp\u003eMultiple risk factors contribute to POEA and can be broadly categorized as patient-related (younger age, high baseline anxiety of patient and parents, previous negative anesthetic experience), surgery-related (site of surgery, postoperative pain, airway manipulation), and anesthesia-related (type of anesthetic agent, premedication, rapid emergence, duration of anesthesia, perioperative environment) \u003csup\u003e(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/sup\u003e. Anesthesiologist should consider a planned multimodal approach knowing all the possible risk factors, identifying and reducing the triggers. This plan must begin preoperatively and continue into the postoperative period, in order to minimize the pain, anxiety and stay safe- comfortable in PACU \u003csup\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/sup\u003e .\u003c/p\u003e \u003cp\u003eA lot of environmental, supportive (parent-present induction, and preoperative education for surgery) and pharmacological interventions (several anesthetic agents and pharmacological methods such as total intravenous anesthesia, propofol, \u0026micro;-opioid agonists, N-methyl-Daspartate receptor antagonists, nefopam, α2-adrenoreceptor agonists, regional analgesia, multimodal analgesia) have been suggested for POEA \u003csup\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/sup\u003e. However, the optimal anesthetic strategy to minimize POEA while preserving efficient recovery remains unclear. We therefore designed a prospective randomized study to compare four anesthetic approaches\u0026mdash;propofol, ketamine, lidocaine, and magnesium sulfate\u0026mdash;on POEA incidence, recovery characteristics, and perioperative complications in children undergoing adenotonsillectomy.\u003c/p\u003e \u003cp\u003eTotal intravenous anaesthesia (TIVA) techniques have become popular in recent years, a review has shown TIVA may help to reduce the incidence of POEA\u003csup\u003e(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/sup\u003e. Propofol is commonly used to prevent or treat POEA \u003csup\u003e(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/sup\u003e, but can prolong recovery time \u003csup\u003e(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/sup\u003e, as reflected in our longer eye-opening and PACU stay times in the propofol group so it\u0026rsquo;s not practical in hardworking operative rooms.\u003c/p\u003e \u003cp\u003eMagnesium sulfate and ketamine, both non-competitive N-methyl-D-aspartate (NMDA) receptor antagonists, have shown to reduce POEA \u003csup\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eKetamine has sedative, amnestic, and analgesic properties\u003csup\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/sup\u003e. In a study, low-dose ketamine during induction of anesthesia reduces POEA and postoperative pain following adenotonsillectomy in children\u003csup\u003e(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/sup\u003e. Also in a meta-analysis of 13 randomized controlled trials, high degree of heterogeneity and low certainty of evidence limit the recommendations of ketamine for the prevention of emergence agitation in children undergoing surgery or imaging procedures. However, the use of ketamine is well-tolerated without any notable adverse effects across all the included trials \u003csup\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/sup\u003e. In our study, ketamine, although analgesic, was associated with higher complication rates such as increased secretions and POEA .\u003c/p\u003e \u003cp\u003eMagnesium sulfate is a non-competitive NMDA receptor antagonist like ketamine, which has central sedative, neuroprotective, and analgesic-sparing effects so it can reduce the incidence of POEA\u003csup\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/sup\u003e. Elsersy et al. proposed that magnesium\u0026rsquo;s potential to decrease agitation might be associated with its protective role against the adverse effects of prolonged hypotension and other contributing factors on the brain \u003csup\u003e(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/sup\u003e. Magnesium sulfate has shown to effectively control agitation without significant sedation, respiratory depression, or delayed recovery, making it particularly suitable for pediatric anesthesia \u003csup\u003e(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/sup\u003e. But a review showed, unlike the studies in adults, there is no statistically significant effect of perioperative use of magnesium in the postoperative pain control in children undergoing tonsillectomies, but it had benefits in reducing rescue analgesia, emergence agitation incidence, and laryngospasm \u003csup\u003e(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/sup\u003e. Our results align with previous studies suggesting that intraoperative magnesium sulfate can reduce POEA and improve postoperative comfort. The absence of clinically important adverse events and the ease of administration further support its incorporation into pediatric adenotonsillectomy anesthetic protocols.\u003c/p\u003e \u003cp\u003eIntravenous infusion of lidocaine relieves postoperative sore throat and reduces POEA and coughing although it may delay recovery \u003csup\u003e(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/sup\u003e. Lidocaine reduces secretion of neuropeptides in the brainstem and airway by inhibiting stimulation of sensory C fibers in the airway and reducing stimulation of the mucosa in the airway by the tracheal tube \u003csup\u003e(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/sup\u003e. The pathophysiologic changes leading to this ED are not completely understood. In adults, endothelial dysfunction due to the release of inflammatory cytokines is a common perioperative event influencing the incidence of delirium \u003csup\u003e(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/sup\u003e. Amide-local anesthetics have been demonstrated to be able to preserve endothelial barrier function upon an inflammatory stimulus and might therefore also potentially be able to influence pathophysiologic events leading to neurologic disturbances after surgery \u003csup\u003e(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/sup\u003e. Lidocaine administered intravenously, may reduce postoperative pain and POEA but reported to extend recovery times and may cause hemodynamic fluctuations, which may explain the higher complication rates observed in our lidocaine group.\u003c/p\u003e \u003cp\u003eThe study has limitations, including its single-center design and modest sample size, which may limit the generalizability of our findings. Additionally, while we used validated scales (FLACC, PAED, MAS), the assessment of agitation and pain in young children always carries some subjectivity. Future multicenter trials with larger sample sizes and standardized multimodal protocols would help confirm the advantages of magnesium sulfate and refine dose\u0026ndash;response relationships.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eAmong four anesthetic strategies evaluated in pediatric adenotonsillectomy, magnesium sulfate infusion provided the most favorable profile, combining reduced postoperative emergence agitation with shorter recovery times and fewer complications. These findings support the inclusion of magnesium sulfate as a valuable adjunct in pediatric anesthesia protocols for adenotonsillectomy.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican Society of Anesthesiologists\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eENT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEar, nose, and throat\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFLACC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFace, Legs, Activity, Cry, Consolability\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHeart rate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIQR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInterquartile range\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMAP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMean arterial pressure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eModified Aldrete Score\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMgSO4\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnesium sulfate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePACU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePost-anesthesia care unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePAED\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePediatric Anesthesia Emergence Delirium\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePOEA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePostoperative emergence agitation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePONV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePostoperative nausea and vomiting\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSpO2\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePeripheral oxygen saturation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTIVA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTotal intravenous anesthesia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Ethics Committee of Gaziosmanpaşa Research and Training Hospital (Approval No. 2023-65).\u003c/p\u003e\n\u003cp\u003eClinical Trial Registry: \u0026nbsp;NCT07433231 Magnesium Sulfate Versus Other Anesthesia Drugs to Reduce Agitation After Adenotonsillectomy in Pediatric Patients\u003cbr\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt adheres to the principles outlined in the Declaration of Helsinki and the CONSORT 2010 guidelines. Written informed consent was obtained from the parents or legal guardians of all participants. We confirm our study complies with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable. The manuscript does not contain any individual person’s identifiable data.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThe authors received no specific funding for this work.\u003c/p\u003e\n\u003cp\u003eAuthors’ contributions\u003c/p\u003e\n\u003cp\u003eAKG conceived and designed the study, collected data, and drafted the manuscript. ZÇ contributed to data acquisition and interpretation and critically revised the manuscript for important intellectual content. DGM contributed to statistical analysis, interpretation of data, and critical revision of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eThe authors thank the operating room and PACU nursing staff for their assistance with patient care and data collection.\u003c/p\u003e\n\u003cp\u003eAuthors' information\u003c/p\u003e\n\u003cp\u003eGaziosmanpaşa Training and Research Hospital, Department of Anesthesiology and Reanimation, İstanbul, Türkiye\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBecke K. Anesthesia for ORL surgery in children. 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BMC Anesthesiol. 2014;14:57.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Adenotonsillectomy, Postoperative emergence agitation, Pediatric anesthesia, Propofol, Ketamine, Lidocaine, Magnesium sulfate","lastPublishedDoi":"10.21203/rs.3.rs-8980486/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8980486/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAdenotonsillectomy 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.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIn this prospective randomized study, 100 children aged 3\u0026ndash;10 years with American Society of Anesthesiologists (ASA) physical status I\u0026ndash;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\u0026ndash;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\u0026ndash;Wallis tests with Bonferroni-adjusted post hoc comparisons and Pearson chi-square tests.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eGroups were comparable in age and surgical duration. Significant differences were observed in complication rates (p\u0026thinsp;=\u0026thinsp;0.046), eye-opening times (p\u0026thinsp;=\u0026thinsp;0.001), and PACU stay durations (p\u0026thinsp;\u0026lt;\u0026thinsp;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.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAmong 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.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTrial registration:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMagnesium Sulfate Versus Other Anesthesia Drugs to Reduce Agitation After Adenotonsillectomy in Pediatric Patients (POEA) NCT07433231 * 02/21/2026-last release\u003c/p\u003e","manuscriptTitle":"Different anesthetic approaches on postoperative emergence agitation in pediatric patients undergoing adenotonsillectomy: a prospective randomized study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-13 09:23:55","doi":"10.21203/rs.3.rs-8980486/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d20ff2b5-edeb-46d4-82b9-a86256bd10b9","owner":[],"postedDate":"March 13th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-04T07:42:48+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-30T13:09:03+00:00","index":36,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T07:56:14+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-13 09:23:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8980486","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8980486","identity":"rs-8980486","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}