Reader response
Myron Yaster MD
From Lynn Martin MD MBA retired Seattle Children’s Hospital
I read with interest the editorial by Drs. Yaster, Veyckermans, and von Ungern-Sternberg, the original article by Shen F, et al.1, and the accompanyi ng editorial by Matava, Pryton, and Davidson2 that are highlighted in the PAAD on December 9, 2025 here. Shen et al. completed a large, multicenter RCT comparing intravenous (propofol), inhalational (sevoflurane), or combined (both) maintenance of anesthesia for patient undergoing an adenotonsillectomy. The primary endpoint was the incidence of perioperative respiratory adverse events (PRAE). As stated in the PAAD review, the results were robust and clinically compelling. Propofol alone or with sevoflurane during maintenance significantly reduces the incidence of PRAEs. So now are we all expected to start doing TIVA for adenotonsillectomy to reduce PRAEs? Matava et al.2 appropriately called out many of the potential challenges associated with this approach.
I commend Yaster et al. for highlighting some important methodologic details. Why allow premedication with midazolam when these same investigators have previously shown that midazolam premedication had significantly more PRAEs than dexmedetomidine or saline. They also discussed the challenges of awake extubation in the PACU.
My biggest problem with this RCT is how far afield from routine clinical practice at least for us here in the Seattle it is.3 Let me list the similarities and difference from our practice.
1. Anxiolysis: Similar - Parental presence and premedication when needed (typically dexmedetomidine).
2. Induction: Different - We generally use inhalational induction BUT give propofol and dexmedetomidine with IV placement. They had 95% intravenous induction.
3. Opioids: Different - All of their cases got opioids (90% sufentanil or 10% fentanyl in induction and 100% remifentanil during maintenance) while we are 99.7% opioid-free with 100% receiving non-opioid analgesic agents (acetaminophen, dexmedetomidine, ketamine, and ketorolac).
4. Neuromuscular blockade: Different – All received NMBA (60% mivacurium, 20% rocuronium, or 20% cisatracurium) while we use none. I literally can’t remember the last time I gave a T&A patient a planned dose of NMBAs.
5. Airway: Similar – Both perform oral intubation for adenotonsillectomy patients.
6. Maintenance: Different – This was the experimental variable (IV, IH, or combine). Our standard is either combined or TIVA. Patients common get some propofol during maintenance with or without sevoflurane. The logistics of infusions techniques for 15-minute procedures are significant and costly.
7. Extubation: Different – They transport to the PACU and do an awake extubation in the PACU. We generally perform a deep extubation in the operating suite.
8. Neuromuscular blockade reversal: Different – They reverse blockade with neostigmine while this is not necessary in our practice.
9. PACU analgesia: Different – Although our processes are different, outcomes are similar. Their PACU opioid (fentanyl) use rate of 6%-8% is comparable to our (morphine) rate is 4.5% over the last 6 months
10. PONV: Different – The PONV prophylaxis processes differ. They give dexamethasone (5 mg???) while we give both dexamethasone and ondansetron 0.15 mg.kg. Their incidence of PONV was 2.9% while our has been 0% (last case treated was October 2024).
In summary, they have demonstrated something I like to highlight whenever possible. The conduct of this well controlled, randomized clinical trial is representative of artificial world of research and is not easily translatable to the real-world of our clinical practices. Only 2 of the ten elements I highlighted are similar. However, I suspect the sub-group of anesthesia providers here in Seattle that advocate for TIVA will likely use it as evidence that we should change. I would argue that with our standardized clinical practices, we could easily conduct a small QI ‘test of change’ to learn if they are right or not. Bottomline, always use translatable evidence and data to drive your practice changes.
References
1. Shen F, Zhang L, Wang W, et al. Effect of Intravenous, Inhalational, or Combined Anesthesia Maintenance on Postoperative Respiratory Adverse Events in Children Undergoing Adenotonsillectomy (AmPRAEC): A Multicenter Randomized Clinical Trial. Anesthesiology 2025;143(6): 1484-96. PMID: 40768554.
2. Matava C, Peyton J, Davidson A. Choice of Anesthetic Maintenance in Not Merely a Matter of Preference, but One of Safety: Insights from the AmPRAEC Study. Anesthesiology 2025;143(6): 1440-2. doi: 10.1097/ALN.0000000000005736.
3. Chiem JL, Fanz AM, Hansen EE, et al. Optimizing pediatric tonsillectomy outcomes with an opioid sparing anesthesia protocol: Learning and continuously improving with real-world data. Pediatr Anesth 2024;34:1087-94. PMID: 39212292.
From Yvonne Wagner MD, FANZCA, Consultant in Anaesthesia, Auckland City Hospital on Emergency Front of the Neck Access here
Dr Gauger comments on a scenario that we all fear. ANZCA has a set of emergency response skills that all are required to do for CME/CPD. One of these is CICO/FONA practice which is a minimum of every 3 years but most of us practice this skill more often. In Australasia as airway experts the ability to rescue an airway with FONA is now considered an essential anesthesia skill. The teaching & practice, which includes human factors review, means we are faster than most any surgeon, so can save the patient's brain. Several of my colleagues have used this skill. Indeed, when we do the workshop with Paul Baker (recent SAM president) he uses a stopwatch & if you can’t do it in 2 min you have to practice until you can. I think it’s 3 min for v large BMI.
PS from Myron: This PAAD generated an enormous amount of interest…we will be reviewing another article on this topic and some comments from Dr. Charlie Cote in the next couple of weeks.
From Neural Foundry on tumor lysis syndrome here
Solid overview of a tricky clinical scenario. The fluid management piece really underscores how TLS sits at this uncomfortable intersection where the textbook answer (aggressive hydration) can actually backfire if you've got compressive airway stuff going on. I remember rotating through peds onc and seeing that exact tension play out in real time between the teams. One thing that stuck with me is how rasburicase basically changed the game compared to the old alkalinization protocols, but the risk calculus around fluid still feels pretty case-dependent. Would be curious if there's emerging data on using biomarkers to titrate fluid more precisely rather than relying on fixed multipliers of maintenance.