The Anxious Older Patient at Extubation: Preoperative Anxiety and Age Modulate Lidocaine's Efficacy in Emergency Laparoscopy

Emergency laparoscopic cholecystectomy poses significant risks during emergence from anesthesia, including cough, bronchospasm, and hemodynamic instability. While intravenous lidocaine is used to mitigate these responses, the influence of preoperative anxiety and its interaction with patient age on lidocaine's effectiveness remains unquantified in the emergency setting. This study aimed to determine whether preoperative state anxiety modifies the impact of a pre-extubation lidocaine bolus on airway and hemodynamic outcomes and to assess if this relationship is stratified by patient age. In a single-center randomized controlled trial, 90 adults undergoing emergency laparoscopic cholecystectomy were assigned to receive intravenous lidocaine (1 mg/kg) or a placebo 90 seconds before extubation. Preoperative anxiety was quantitatively assessed using the State-Trait Anxiety Inventory (STAI). Primary outcomes included cough severity, incidence of bronchospasm and laryngospasm, post-extubation sore throat (VAS), and hemodynamic parameters. Multivariate regression models analyzed interactions between anxiety, age, and treatment group. Higher preoperative anxiety was independently associated with increased cough severity, bronchospasm, laryngospasm, sore throat, and hemodynamic instability. A significant anxiety × age interaction was identified, demonstrating that these adverse effects were markedly amplified in patients aged 50 years and older. Lidocaine provided an overall benefit, but its effectiveness in blunting anxiety-driven complications was most pronounced in this older, high-anxiety subgroup. Pre-operative anxiety is a significant, modifiable risk factor for emergence complications, with effects potentiated by advanced age. These findings advocate for routine anxiety screening and the development of age-tailored, integrated psychological and pharmacological strategies to optimize safety during extubation in emergency surgery.