The physiological effects of patient positioning may impact the occurrence of perioperative respiratory adverse events (PRAE), the leading cause of critical incidents in children undergoing surgery. This randomized controlled trial aimed to determine whether a 30-degree head-elevated position (HE30), compared to no head elevation (NHE), in the pre- and postoperative period, impacts the incidence of PRAE in children.

We conducted a prospective cluster-randomized trial comprising two phases: Phase One: all children managed in-hours were allocated to either HE30 or NHE positioning, with allocated positions alternating weekly for 8 weeks. Phase Two: A four-week period of routine practice, wherein patient positioning was at the treating clinician’s discretion.

There were 1935 patients in Phase One (959 HE30 and 976 NHE), with no difference in the primary outcome of overall incidence of PRAE (14% and 15% respectively, p  = 0.42). Patients managed with a tracheal tube (TT) had a higher incidence of PRAE when positioned NHE compared to HE30 (28% versus 18%, respectively, p  = 0.017) (multivariable: OR 1.75 (95% CI 1.01–3.02 p  = 0.04)). We collected data for 905 children in Phase Two. Managing patients in NHE and 15-degree head-elevated positions was preferred by staff. There was no difference in the incidence of PRAE between Phase One and Phase Two, both 14% (OR 0.93 95%CI 0.74–1.17 p  = 0.53).

Overall, standardized perioperative HE30 did not influence the occurrence of PRAE in children undergoing general anaesthesia. Patients requiring a TT did, however, show a reduction in PRAE, including severe PRAE, when positioned HE30 compared to NHE.