Aims/Background Perioperative respiratory adverse events (PRAEs) are common in pediatric anesthesia, especially in otolaryngology procedures. In this randomized controlled trial, we investigated the impact of administering propofol before extubation on PRAEs in pediatric patients undergoing tonsillectomy and adenoidectomy. Methods We enrolled children aged 3 to 8 years old, of American Society of Anesthesiologists (ASA) classes I to III, scheduled for tonsillectomy, and randomly divided them into propofol and control groups. The subjects in the propofol group received multiple small doses of propofol (0.5 mg/kg per dose, total 1–2 mg/kg) until the patient resumed regular spontaneous breathing and exhibited no bodily movements. The subjects in the control group received 0.15 mL/kg of saline. The primary outcome was the rate of PRAEs, such as laryngospasm, bronchospasm, breath-holding spell, severe coughing, desaturation, and airway obstruction, post-extubation. The secondary outcomes were the extubation time, pre-extubation Richmond Agitation-Sedation Scale (RASS) score, end-tidal sevoflurane concentration at extubation, incidence of postoperative agitation, time to consciousness, and Face, Legs, Activity, Cry, and Consolability (FLACC) pain score in the recovery room. Results were reported with risk ratios (RR) and their 95% confidence intervals (CI), as well as the p-values indicating statistical significance. Results A total of 239 patients were included, including 119 in the propofol group and 120 in the control group. Our findings indicated no significant difference in the rate of PRAEs between the two groups (5.9% vs 10.8%, RR: 0.54, 95% CI: 0.23 to 1.31, p = 0.17). However, the propofol group showed a notable decrease in moderate to severe coughs (13.4% vs 60.0%, RR: 0.22, 95% CI: 0.14 to 0.36, p < 0.001) and postoperative agitation (4.2% vs 60.8%, RR: 0.07, 95% CI: 0.03 to 0.17, p < 0.001). Conclusion This trial demonstrated that while administering repeated small doses of propofol before extubation does not significantly reduce respiratory adverse events in children undergoing tonsillectomy and adenoidectomy, it does significantly reduce the incidence of severe coughing, improving postoperative recovery and clinical outcomes. Moreover, propofol helps reduce postoperative agitation, enhancing the safety and effectiveness of postoperative care, and maintaining its valuable clinical role in postoperative management. Clinical Trial Registration ClinicalTrials.gov ( NCT05769842 ).
