Discussion
Adenotonsillectomy, fasciculation, pain, agitation, hyperexcitability, fasciculations
ADVERSE EFFECTS, CORTEX
Anesthesia for day surgery in pediatric patients is more challenging than in adults due to physiological peculiarities. Adenotonsillectomy is a frequently performed pediatric day surgery procedure that often necessitates endotracheal intubation to ensure the child’s airway secured. Neuromuscular blockers (NMBs) are typically administered to facilitate intubation. To achieve this, high doses of NMBs are used for a rapid onset timePropofol is currently the most commonly used anesthetic in clinical settings. It is known for its effectiveness in including rapid awakening and is often the preferred choice for pediatric day surgery. However, one of the most common adverse effects of propofol is injection pain, which affects approximately 25–85% of childrenThe overall incidence of injection pain for ciprofol in our study was 3.5%, which was much lower than the incidence of propofol injection pain reportedPropofol causes a dose-dependent decrease in blood pressure and HR during inductionBIS is correlated with clinical indicators of anesthesia. As the depth of anesthesia increases, BIS diminishesSufentanil at a dose of 0.4 mcg/kg was administered for induction, taking into account the estimated duration of the operation (approximately 30 min). It was not planned to administer any additional doses of sufentanil during the operation. Studies have shown that it would counteract the cardiovascular responses conferred by intubation only when sufentanil amounts are ≥ 0.3 mcg/kgAlthough rocuronium 0.6 mg/kg (2 × ED95) has a rapid onset of action and provides satisfactory intubation conditionsOur results suggest that the rate of unacceptable intubation conditions in the C4 group was much higher than that of the other two groups, indicating that the induction dose of 0.4 mg/kg ciprofol was too low for pediatric patients. Notably, the recommended starting dose for adult induction is 0.4 mg/kg. This difference may be attributed to a larger extracellular fluid volume in children. When we increased the induction dose to 0.6 mg/kg, the rate of intubation conditions that were clinically acceptable significantly increased. Increasing the ciprofol dose to 0.8 mg/kg did not further improve intubation conditions, suggesting that the anesthetic effect of ciprofol may have reached a plateau. As observed in the specific parameters for assessing intubation conditions, the primary difference among the three groups was predominantly in limb movement. This difference was most pronounced at the low dose, possibly due to fasciculation. There is a possibility that fasciculations, which are caused by the inhibition of gamma-aminobutyric acid and result in increased sensitizes of the cortex, can lead to hyperexcitability in response to even small amounts of stimulation. This condition is mostly associated with low doses of anesthetic drugs, as most fasciculations occur at low drug concentrations during the induction and awakening periodsBased on these findings, we conclude that a combination of 0.6 mg/kg ciprofol and low-dose rocuronium can provide satisfactory intubation conditions in children undergoing daytime adenotonsillectomy. This combination also helps maintain circulatory stability and ensures prompt awakening.Our study had some weaknesses. Aspects of vital signs were only observed during the induction phase. It was not whether ciprofol can affect circulatory function during surgery. In addition, we only observed the overall incidence of injection pain and did not investigate whether it was correlated with the dosage of ciprofol. Last, we did not record whether the children experienced agitation upon awakening after extubation, which is an important factor in evaluating the effectiveness of the medication.