Background: Adenotonsillectomy is one of the most common pediatric surgeries and is often complicated by postoperative emergence agitation (POEA), a short-lived but distressing state of confusion and restlessness after anesthesia. POEA may decrease comfort and increase the risk of perioperative complications.

Objective: To compare four commonly used anesthetic strategies-propofol bolus, ketamine bolus, lidocaine infusion, and magnesium sulfate infusion-with respect to POEA and early recovery quality in children undergoing adenotonsillectomy.

Methods: In this single-center, prospective randomized trial, 100 children aged 3-10 years with American Society of Anesthesiologists (ASA) physical status I-II scheduled for adenotonsillectomy were assigned to one of four anesthetic groups. 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 signs, Face, Legs, Activity, Cry, Consolability (FLACC) pain score , Pediatric Anesthesia Emergence Delirium (PAED) score, Modified Aldrete Score (MAS) were recorded and compared.

Adenotonsillectomy operations are the most common childhood surgeries. Although they are so common, still adenotonsillectomy procedures remain challenging with increased risks of morbidity and mortality for both the surgeon and the anesthesiologist .

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%, 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).

Various pharmacological strategies have been investigated to reduce POEA, including propofol, ketamine, magnesium sulfate, lidocaine, opioids, benzodiazepines, clonidine, and α2-agonists, with conflicting results . However, the optimal anesthetic strategy to minimize POEA while preserving efficient recovery remains unclear. The investigators 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 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. The investigators 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.

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.

Hemodynamic variables were recorded intraoperatively. After emergence, the investigators 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 . 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.

Inclusion Criteria

• pediatric patients aged 3-10 years
• American Society of Anesthesiologists (ASA) physical status I-II
• scheduled for elective adenotonsillectomy

Exclusion Criteria:

• ASA III or higher
• emergency surgery
• communication barriers
• history of allergy to any study medication
• known cognitive or developmental delay.

Study medications (propofol, ketamine, lidocaine, and magnesium sulfate) are prepared by an anesthesiologist who is involved in intraoperative management . Postop assessment is done by another anesthesiologist. Postoperative outcome assessors remain blinded to group allocation until completion of data collection and database lock.