Inhalational versus Intravenous Induction of Anesthesia in Children with a High Risk of Perioperative Respiratory Adverse Events A Randomized Controlled Trial

The aim of this study was to examine the risk of adverse respiratory events with either intravenous induction (IV) with Propofol or inhalational induction with sevoflurane in children.

The trial was performed at The Princess Margaret Hospital for Children in Perth between 2010 and 2013 and involved 300 children between 0.7 to eight years of age. The children were all undergoing minor elective procedures and had at least two respiratory risk factors. These were cold symptoms within two weeks, wheezing within 12 months, exercise induced wheezing, nocturnal dry cough, history of eczema, passive smoking and family history of atopy. In all cases no premedication was given, a laryngeal mask airway was used and only the children whom the anaesthetic consultant deemed to be suitable for IV or inhalational induction were recruited.

The rates of occurrence of adverse respiratory outcomes (‘serious’ – laryngospasm, bronchospasm, and ‘non-serious’ – desaturation, airway obstruction, severe coughing and post-operative stridor) between the two groups were analysed. The frequency and timing of occurrences were also examined.

The study results show that IV induction was associated with about half the rate adverse respiratory events in comparison with the inhalational group (39/149 [26%] vs. 64/149 [43%], RR 1.7, 95% CI; 1.2 to 2.3, P = 0.002). In the IV induction group children were significantly less likely to develop an adverse respiratory event during induction (16/49 [11%] vs. 47/149 [32%], RR: 3.06, CI: 1.8 to 5.2, P<0.001). There was no significant difference in those who did or did not receive a Propofol bolus in the inhalational group. Despite the perceived unacceptability of awake IV cannulation in children, six children in the inhalation group refused the mask and requested IV induction. 15 children in the IV induction group requested inhalational induction.

Take home message

IV induction in children with two or more respiratory risk factors is safer than inhalational induction and may be more acceptable to children and their parents than we think.

Reviewed by: Dr Meredith Betts