Esketamine or Sevoflurane for Calmer Wake Ups in Young Children?
Anyone who has worked in a pediatric recovery room knows emergence agitation. A child wakes up from a quick procedure crying, thrashing, and unable to be consoled, and the parents are understandably upset. After eye surgery it matters even more, because rubbing and straining can stress a healing wound. A randomized trial published November 6, 2026 in Drug Design, Development and Therapy compared an esketamine based anesthetic with a sevoflurane based anesthetic in young children, and the difference in agitation was large. So was the tradeoff in blood pressure.
The study
Yi and colleagues at the Eye and ENT Hospital of Fudan University in Shanghai enrolled 116 children, ages 3 months to 5 years, who needed corneal suture removal under the microscope. All of them received a small dose of propofol for parental separation, atropine, and dexmedetomidine 1 µg/kg. Then half got esketamine 0.25 mg/kg at induction with a second 0.25 mg/kg dose before the eye speculum went in, plus small propofol boluses if the case ran longer. The other half got sevoflurane by mask and then through a nasopharyngeal airway. Children breathed on their own throughout. A blinded observer scored agitation in recovery.
Emergence agitation occurred in 6.9% of the esketamine group and 27.6% of the sevoflurane group (relative risk 0.25). Respiratory depression, which the authors defined broadly, was also much less common with esketamine (3.4% vs 43.1%), and recovery room discharge was statistically, though not meaningfully, faster. On the other side, 22.4% of the esketamine children developed hypertension while none in the sevoflurane group did, and intraocular pressure was higher with esketamine (median 16 vs 13 mmHg), although both stayed in the normal range.
How I read it
The agitation result is interesting partly because ketamine has a reputation for causing rough wake ups, not preventing them. The dose here was modest and every child also had dexmedetomidine, which probably smoothed things out. Sevoflurane, for its part, is well known for agitation in small children, so this was a fair comparison against a real problem. Spontaneous breathing with fewer airway interventions is also a practical win for short cases.
I would keep a few limits in mind. It was a single center trial with a specific airway setup that most of us do not use, and the anesthesiologists could not be blinded. Pain was minimal because topical eye drops were used, which removes one common cause of agitation. And the blood pressure and eye pressure findings are not trivial. For a child with an open globe injury, glaucoma, or a heart condition, a sympathomimetic drug is a different conversation.
What it means for practice here
Here in Casper, much of our pediatric work is short outpatient cases where a calm wake up matters a lot to families. This trial does not mean everyone should switch away from sevoflurane, but it supports low dose esketamine or ketamine combined with dexmedetomidine as a reasonable option for brief procedures in healthy young children, as long as we pay attention to blood pressure and choose patients carefully. In the United States we generally use racemic ketamine rather than intravenous esketamine, so the dosing would need to be adapted. As always, the best plan is the one that fits the child and the procedure in front of us.
Source
- Yi W, Liu T, Chen J, Tan F. Esketamine-based versus sevoflurane-based anesthesia with dexmedetomidine for emergence agitation in pediatric corneal suture removal: a randomised controlled trial. Drug Des Devel Ther. 2026;20:634499. Published November 6, 2026. Article page
- Trial registration: NCT05321160
This post is clinician commentary for educational discussion. It is not medical advice for any reader's personal care. Anesthesia and perioperative decisions should be made with the treating clinician based on the individual patient's circumstances.