Rescue propofol at emergence is associated with reduced severe emergence agitation in children undergoing dental general anesthesia: a retrospective cohort study
TL;DR
Receipt of clinician-initiated rescue propofol was associated with a lower observed risk of severe emergence agitation, but the observational design, marked baseline imbalance, single unblinded assessor, residual sedation, and limited propensity-score overlap preclude causal interpretation.
Abstract
Emergence agitation occurs in up to 80% of children following sevoflurane anesthesia; universal prophylaxis exposes non-susceptible patients to unnecessary sedation. A selective rescue approach—delivering intervention only when dysregulation signs first manifest—may offer an alternative. In this single-center retrospective cohort study (May 2024–February 2026), children aged 4–12 years (ASA I–II) with a Watcha Agitation Scale score of 3 or 4 at PACU arrival received rescue propofol (1 mg/kg IV; n = 122) or no immediate pharmacological intervention ( n = 123) at clinician discretion; children with scores of 0–2 ( n = 205) formed a reference cohort. Because treatment was not randomized and the groups differed substantially at baseline, confounding by indication was expected. The primary outcome was severe emergence agitation (peak PAED ≥ 12 at 5, 15, or 25 min). Modified Poisson regression with robust variance provided the primary adjusted estimate, with complementary propensity-score sensitivity analyses including matching, inverse-probability weighting, and restriction to empirical common support. Severe emergence agitation occurred in 30% of the propofol group versus 77% in controls (RR 0.39, 95% CI 0.30–0.52; risk difference − 46.9% points; p < 0.001). The primary adjusted estimate, from propensity score–adjusted modified Poisson regression, was RR 0.33 (95% CI 0.24–0.45; p < 0.001); the propensity score–adjusted odds ratio (OR 0.07, 95% CI 0.03–0.18; p < 0.001) is retained as a sensitivity comparison. PAED scores were significantly lower at all time points (all p < 0.001). The Watcha Agitation Scale demonstrated sensitivity 84.8% (95% CI 78.2–91.5%) and specificity 87.0% (82.6–91.5%). No serious adverse events occurred. Receipt of clinician-initiated rescue propofol was associated with a lower observed risk of severe emergence agitation, but the observational design, marked baseline imbalance, single unblinded assessor, residual sedation, and limited propensity-score overlap preclude causal interpretation. The time-dependent PAED domain pattern was compatible with an early sedative contribution. The Watcha Agitation Scale findings are exploratory internal classification characteristics and require prospective external validation. Not applicable. This was a retrospective observational study and was not a clinical trial.