Pre‐Extubation Low‐Dose Propofol in Pediatric Ear, Nose, and Throat Procedures: A Meta‐Analysis With Trial Sequential Analysis

BACKGROUND: Post-extubation emergence agitation (EA) is common in pediatric ear, nose, and throat (ENT) procedures and may lead to serious complications. AIMS: To assess the efficacy of low-dose propofol administered before extubation, compared with placebo, for preventing EA, using meta-analysis with trial sequential analysis (TSA). METHODS: We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs) comparing low-dose propofol versus placebo administered before extubation in pediatric ENT procedures. The primary outcomes were laryngospasm, severity of EA, assessed by the Pediatric Anesthesia Emergence Delirium (PAED) scale score, and incidence of EA. Secondary outcomes included post-anesthesia care unit (PACU) length of stay, time to recovery, and time to extubation. Random-effects models were used to pool effect estimates with 95% confidence intervals (CIs). TSA was performed for all outcomes to assess the robustness of the evidence. RESULTS: Ten RCTs were included in the review, of which six (414 pediatric patients) contributed to the meta-analysis. Compared with control, propofol significantly reduced the incidence of EA (risk ratio [RR] = 0.57; 95% CI, 0.42-0.78) and lowered agitation severity (mean difference [MD] = -3.94; 95% CI, -5.74 to -2.13). Time to extubation was slightly longer (MD = 1.8 min; 95% CI, 1.4-2.3), whereas time to recovery (MD = 0.9 min; 95% CI, -1.9 to 3.6) and PACU length of stay (MD = -0.63 min; 95% CI, -3.2 to 1.9) did not differ. TSA confirmed the robustness of the findings for incidence of EA, severity of EA, and time to extubation. However, the certainty of evidence was very low for severity of EA and moderate for EA incidence and time to extubation. Laryngospasm outcomes were not pooled due to substantial heterogeneity. CONCLUSIONS: Our findings suggest that pre-extubation propofol probably reduces the incidence of EA in pediatric ENT surgery, supported by moderate-certainty evidence, and may lower EA severity measured by PAED scale scores, for which the certainty of evidence was very low. Propofol was also associated with a slightly longer time to extubation, with no difference in overall recovery time or PACU length of stay.