Effect of esmolol and lidocaine on agitation in awake phase of anesthesia among children: a double-blind, randomized clinical study

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Effect of esmolol and lidocaine on agitation in awake phase of anesthesia among children: a double-blind, randomized clinical study

If you’ve ever watched a young child wake up from surgery—confused, upset, or even thrashing—you know how distressing emergence agitation can be. For kids anesthetized with sevoflurane, a popular gas used for its fast onset and gentle effect on the airways, this agitation strikes 50% to 80% of patients. It’s even more common after strabismus (eye muscle) surgery, where bandages cover the eyes and add to fear or disorientation. But a new study from South Korea offers hope: combining two common drugs—esmolol and lidocaine—might ease this stress for young patients.

The Problem with Sevoflurane and Agitation

Sevoflurane is a go-to for pediatric anesthesia because it works quickly, doesn’t irritate the throat, and lets kids wake up fast. But that rapid wake-up comes with a catch: the brain can “wake up” faster than the body’s stress response calms down, leading to agitation. For kids with bandaged eyes after strabismus surgery, this agitation is even worse—doctors think the loss of sight adds to anxiety, even when pain is minimal.

Existing treatments for agitation (like midazolam or dexmedetomidine) have downsides: midazolam can delay wake-up, and dexmedetomidine may cause low blood pressure or slow heart rate. So researchers wanted to test two safer options:

  • Lidocaine: A numbing drug that reduces sore throats and coughs by calming airway irritation.
  • Esmolol: A beta-blocker that lowers stress hormones and helps with hemodynamic stability (like keeping heart rate steady).

What the Study Did

Led by Jae Young Ji and colleagues from the Department of Anesthesiology and Pain Medicine at Soonchunhyang University Hospital Cheonan, the study enrolled 84 children (ages 3–9) undergoing strabismus surgery between 2017 and 2018. All got sevoflurane anesthesia. They were randomly split into three groups:

  1. Control: Saline (fake drug) at the end of surgery.
  2. Lidocaine: 1.5 mg/kg of lidocaine intravenously at the end of surgery.
  3. Esmolol + Lidocaine (EL): 1.5 mg/kg lidocaine at the end of surgery plus 0.5 mg/kg esmolol when the child started moving voluntarily.

Agitation was measured using three scales:

  • Objective Pain Score (OPS): Checks blood pressure, crying, movement, and agitation.
  • Cole 5-point Score (CPS): Rates behavior from calm (score 1) to severely restless (score 5).
  • Richmond Agitation Sedation Scale (RASS): Assesses sedation (from “unarousable” to “combative”).

Researchers tracked agitation at four key times: when the child woke up, when they arrived in the recovery room, and 10 and 30 minutes later. They also looked at other factors like age, weight, surgery time, and how much pain medication (fentanyl) was used.

What They Found

The biggest takeaway? The esmolol + lidocaine combo worked best for reducing short-term agitation. Here’s the breakdown:

  • Agitation incidence: When agitation was defined as an OPS score of 4 or higher (meaning the child was restless or inconsolable), only 20% of the EL group had agitation—compared to 63% in the lidocaine group and 45% in the control group.
  • Severity of agitation: The EL group had significantly lower OPS and RASS scores when waking up (OPS = 0 vs. 4 in control/lidocaine) and when moving to the recovery room (OPS = 0 vs. 3–4 in others).
  • No other differences: There were no meaningful gaps in age, weight, surgery time, or fentanyl use between groups. Esmolol’s effects on heart rate and blood pressure were mild and short-lived.

Why This Matters

Agitation isn’t just upsetting—it’s risky. It can lead to falls, pulled tubes, or longer stays in the recovery room. For kids with bandaged eyes after strabismus surgery, even short-term calm during the transition from the operating room to recovery is a big win.

The combo works because it targets two root causes of agitation:

  1. Lidocaine reduces airway irritation from the breathing tube, which cuts down on coughing and sore throats (common triggers for agitation).
  2. Esmolol blocks beta-receptors in the brain, which lowers stress hormones and reduces “wakefulness” that can lead to confusion.

Limitations to Keep in Mind

Like all studies, this one has caveats:

  • Short-term effect: The combo only helped during wake-up and transfer to recovery—agitation levels evened out by 30 minutes.
  • No esmolol-only group: We don’t know if esmolol alone would work as well.
  • Eye coverage: Since kids had bandages, researchers couldn’t use the Pediatric Anesthesia Emergence Delirium (PAED) scale (which includes eye contact), so they relied on OPS, CPS, and RASS instead.

What This Means for Kids and Doctors

For parents, this study offers hope that a simple drug combo could make their child’s post-surgery wake-up less scary. For doctors, it adds a safe, low-risk option to manage agitation—especially for kids getting sevoflurane for strabismus surgery.

The researchers note that the effect is short-term, but even that matters: “When patients are transferred from the operating room to the recovery room, reducing agitation further lowers the risk of fall-related accidents.”

Study Details

  • Funding: Supported by the Soonchunhyang University Research Fund.
  • Conflicts of Interest: None reported.
  • Trial Registration: Clinical Research Information Service (KCT0002925).
  • Original Publication: Chinese Medical Journal (2019); doi: 10.1097/CM9.0000000000000141

For more details, you can access the full study via its DOI: doi.org/10.1097/CM9.0000000000000141

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