Authors: Neto EDS et al.
Anesthesia & Analgesia, 142(5):882–897, May 2026
This systematic review and meta-analysis evaluates the effectiveness of Esmolol as an adjunct in multimodal anesthesia, specifically focusing on its opioid-sparing and analgesic effects. Unlike prior reviews, this analysis included only placebo-controlled randomized trials to improve the reliability and generalizability of findings.
A total of 19 randomized trials involving 1,028 patients were analyzed. Esmolol was administered as a loading dose (0.5–1.0 mg/kg) followed by continuous intraoperative infusion (0.3–6 mg/kg/h). Outcomes assessed included intraoperative and postoperative opioid consumption (converted to IV morphine milligram equivalents) and postoperative pain scores at multiple time intervals within the first 24 hours.
The results demonstrated that esmolol significantly reduced intraoperative opioid use by approximately 32% and postoperative opioid consumption by 38.6%. In addition, pain scores were significantly lower in the esmolol group at all measured time points, with the greatest reduction observed in the immediate postoperative period (within 30 minutes), followed by smaller but still significant reductions at 2–4 hours and 24 hours. These findings suggest a meaningful opioid-sparing and analgesic effect.
From a hemodynamic standpoint, esmolol consistently reduced heart rate and lowered mean arterial pressure in several studies. Importantly, despite these effects, there was no significant increase in adverse events such as hypotension or bradycardia across the pooled data, although one study reported increased use of rescue medications such as ephedrine and atropine.
The analysis notes substantial heterogeneity among studies, reflecting differences in surgical types, anesthetic techniques, and dosing regimens. While subgroup analyses suggested the opioid-sparing effect remained consistent across various conditions, uncertainty persists regarding the durability of analgesic benefits beyond the early postoperative period.
The authors conclude that intraoperative esmolol infusion provides clinically meaningful reductions in opioid consumption and postoperative pain, supporting its role as a valuable component of multimodal anesthesia. However, further research is needed to refine dosing strategies and clarify its effectiveness across diverse surgical populations.
What You Should Know
Esmolol significantly reduces both intraoperative and postoperative opioid requirements while also lowering pain scores, especially in the immediate postoperative period. It appears safe from a hemodynamic standpoint in most patients and represents a strong option for opioid-sparing anesthesia, although variability across studies means it should still be used thoughtfully based on patient and surgical context.
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