Analysis of the efficacy of subclinical doses of esketamine in combination with propofol in non-intubated general anesthesia procedures - a systematic review and meta-analysis

Low-dose Esketamine combined with Propofol in microscopic pediatric strabismus surgery: a randomized controlled study

OBJECTIVE

To observe the effect of low-dose esketamine combined with propofol in pediatric strabismus surgery.

METHODS

A total of 84 children aged 3-15 years, regardless of gender, with a BMI of 13-26 kg/m2, ASA grade I or II, were selected for elective microscopic strabismus surgery and divided into two groups based on the randomized numerical table: esketamine group (group E) and propofol group (group C), with 42 patients in each group. Group E was pre-injected with esketamine 0.2 mg/kg, and propofol 2.5 mg/kg was slowly injected after one minute. Group C was pre-treated with an equal volume of saline, and propofol 2.5 mg/kg was administered slowly after one minute. The occurrence of propofol injection pain was assessed using the Verbal Rating Scale (VRS). HR and MAP were recorded in the two groups at 5 min before induction, after induction, at the start of the procedure, and at the end of the procedure. operative time, extubation time and post-anesthesia care unit (PACU) stay were recorded. The Pain Behaviour Scale for Children (Face, Legs, Activity, Cry, Consolability, FLACC) scores at the time of discharge from the PACU and at 1day, 3days and 7days postoperatively were recorded. perioperative tachycardia, emergence agitation, oculocardiac reflex, extubation cough and other adverse reactions were also recorded.

RESULTS

Compared with Group C, Group E exhibited significantly lower rates of propofol injection pain(cases (%), 87.5% VS 56.1%, P = 0.002), and moderate-to-severe pain during induction(75.0% VS 24.4%, P<0.001), reduced FLACC scores at PACU discharge(median and interquartile spacing [M(IQR)], 3.50(4) VS 3.00(2), P = 0.039) and 1 day postoperatively(M(IQR), 5.00(3) VS 3.00(2), P<0.001), and decreased incidences of adverse events including emergence agitation(32.5% VS 12.2%, P = 0.028), oculocardiac reflex(35.0% VS 14.6%, P = 0.034), and extubation cough(25.0% VS 7.3%, P = 0.030). However, no statistically significant differences were observed between the two groups in operative duration, extubation time, PACU stay duration, FLACC scores at 3 and 7 days postoperatively, or heart rate and mean arterial pressure at any measured time point.

CONCLUSION

General anesthesia with low-dose esketamine combined with propofol for pediatric strabismus correction surgery effectively alleviates propofol injection pain, reduces FLACC scores at PACU discharge and 1 day postoperatively, and decreases the incidence of adverse reactions such as emergence agitation, oculocardiac reflex, and extubation cough, demonstrating its safety for use in this procedure.

TRIAL REGISTRATION

This study was approved by the Scientific Research and Clinical Trials Ethics Committee of The First Affiliated Hospital of Zhengzhou University (Approval No. 2023-KY-1509), registered in the Chinese Clinical Trial Registry (Registration No. ChiCTR2400092266, registration date on 11/13/2024).

Effect of Esketamine Compared with Sufentanil Combined with Propofol in Patients Undergoing First Trimester Surgical Abortion: A Randomized, Double-Blinded Clinical Trial

Background

We explored whether esketamine anesthesia during first-trimester surgical abortion can reduce intraoperative hemodynamic fluctuations and improve patients' respiratory function.

Methods

A total of 197 patients who underwent a first-trimester surgical abortion were included in the analysis. Patients were randomly assigned to either the esketamine anesthesia group (group E, n=98) or sufentanil anesthesia group (group S, n=99). The primary outcomes were systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP), heart rate (HR), respiratory rate (RR) and end-tidal carbon dioxide partial pressure (PetCO2) during the surgery. Secondary outcomes included body movement, apnea, hypoxemia, postoperative nausea and vomiting (PONV), dizziness, anesthesia recovery time, Richmond Agitation and Sedation Scale (RASS) score, and postoperative pain.

Results

Patients in Group E had a more stable intraoperative SBP (p=0.001), DBP (p=0.014), MBP (p=0.003), and HR (p=0.001). There was no significant difference in intraoperative RR between the two groups (p=0.108); however, PetCO2 in group E remained at preoperative levels, whereas it increased in group S during surgery (p<0.001). The risk of apnea and hypoxemia in group E was lower (RR 0.32, 95% CI [0.13, 0.76], p=0.006; RR 0.13, 95% CI [0.03, 0.54], p=0.001). The incidence of intraoperative body movement (50% vs 27%, p=0.003), postoperative dizziness (45% vs 30%, p=0.024), and nausea (7% vs 0%, p=0.007) was higher in group E. There were no differences in anesthesia recovery time, postoperative RASS score, pain, or vomiting.

Conclusion

Compared with sufentanil, esketamine anesthesia during the first trimester surgical abortion can maintain stable intraoperative hemodynamics and respiratory function during surgery and reduce apnea and hypoxemia. Esketamine may increase the risk of dizziness and PONV after surgical abortion.

Efficacy and safety of S-ketamine in pain management for breast cancer patients undergoing modified radical mastectomy: a meta-analysis of randomized controlled trials

BACKGROUND

Breast cancer remains a leading cause of morbidity and mortality among women worldwide. According to the recent statistics by World Health Organization (WHO), it is the leading cause of death from cancer in women worldwide and it is the most frequently diagnosed cancer. This meta-analysis aims to systematically evaluate the efficacy and safety of S-ketamine in patients undergoing modified radical mastectomy.

METHOD

We searched five databases; PubMed, Scopus, Science Direct, Web of Science, and Medline Plus. We included six studies. The applicable outcomes for meta-analysis about efficacy and safety of S-ketamine in patients undergoing modified radical mastectomy.

RESULTS

Six RCTs included in our meta-analysis found that Esketamine group had a statistically significant lower VAS score after 4 h, after 6 h, after 24 h, after 48 h; (MD = -1.54; 95% CI [-1.65, -1.42], P < 0.00001), (MD = -0.55; 95% CI [-0.66, -0.45], P < 0.00001), (MD = -0.75; 95% CI [-0.84, -0.66], P < 0.00001,), (MD = -0.26; 95% CI [-0.48, -0.03], P = 0.03) P < 0.00001), respectively.

CONCLUSION

We conclude that S-ketamine is valuable for reducing pain and safe in patients undergoing modified radical mastectomy.

Intravenous esketamine as an adjuvant for sedation/analgesia outside the operating room: a systematic review and meta-analysis

Background

This study was conducted to evaluate the safety and efficacy of intravenous esketamine as an adjuvant for sedation or analgesia outside the operating room in adults and children.

Method

PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and Scopus were searched for potential randomized controlled studies randomized controlled trials comparing drug combinations of esketamine to any other single or combination drug regimens for sedation or analgesia outside the operating room.

Results

Twenty-five studies with a total of 3,455 participants were included in this review. The pooled results of adults showed that compared with drug regimens of the control group, intravenous esketamine combinations were significantly associated with decreased risk of oxygen desaturation (RR = 0.49, 95% CI = [0.34, 0.70]); hypotension (RR = 0.38, 95% CI = [0.31, 0.46]); bradycardia (RR = 0.23, 95% CI = [0.12, 0.43]); injection pain (RR = 0.37, 95% CI = [0.25, 0.53]); body movement (RR = 0.60, 95% CI = [0.41, 0.88]); and propofol consumption (SMD = -1.38, 95% CI = [-2.64, -0.11]), but an increased risk of psychiatric symptoms (RR = 3.10, 95% CI = [2.11, 4.54]) (RR = relative risk; CI = confidence intervals; SMD = standardized mean difference). Subgroup analysis showed that only the combination of esketamine and propofol significantly reduced the above incidence of respiratory and cardiovascular adverse events in adults. In addition, the pooled results of children showed that compared with drug regimens of the control group, esketamine and propofol co-administration significantly reduced the risk of hypotension (RR = 0.59, 95% CI = [0.37, 0.95]) but increased the risk of visual disturbance (RR = 6.62, 95% CI = [2.18, 20.13]) and dizziness (RR = 1.99, 95% CI = [1.17, 3,37]). Subgroup analysis indicated that esketamine>0.5 mg/kg significantly reduced the incidence of hypotension, but increased the risk of dizziness in children.

Conclusion

Intravenous use of esketamine, particularly in combination with propofol, may improve the safety and efficacy of sedation and analgesia outside the operating room, although the potential for psychiatric side effects warrants attention. Future research is recommended to investigate the role of esketamine with agents other than propofol.

Efficacy and safety of low-dose esketamine for painless gastrointestinal endoscopy in adults: a systematic evaluation and meta-analysis

Object: The benefits of low-dose esketamine for painless gastrointestinal endoscopy remain unclear. As such, the present study aimed to investigate the efficacy and safety of low-dose esketamine for this procedure. Methods: Seven common databases were searched for clinical studies investigating low-dose esketamine for painless gastrointestinal endoscopy. Subsequently, a meta-analysis was performed to synthesize and analyze the data extracted from studies fulfilling the inclusion criteria. Results: Meta-analysis revealed that, compared with propofol, low-dose esketamine in combination with propofol significantly reduced recovery time by 0.56 min (mean difference [MD] -0.56%, 95% confidence interval (CI) -1.08 to -0.05, p = 0.03), induction time by 9.84 s (MD -9.84, 95% CI -12.93 to -6.75, p < 0.00001), propofol dosage by 51.05 mg (MD -51.05, 95% CI -81.53 to -20.57, p = 0.01), and increased mean arterial pressure by 6.23 mmHg (MD 6.23, 95% CI 1.37 to 11.08, p = 0.01). Meanwhile, low-dose esketamine reduced injection pain by 63% (relative risk [RR] 0.37, 95% CI 0.28 to 0.49, p < 0.00001), involuntary movements by 40% (RR 0.60, 95% Cl 0.42 to 0.85, p < 0.005), choking by 42% (RR 0.58, 95% Cl 0.38 to 0.88, p = 0.01), bradycardia by 68% (RR 0.32, 95% Cl 0.18 to 0.58, p = 0.0002), hypotension by 71% (RR 0.29, 95% Cl 0.21 to 0.40, p < 0.00001), respiratory depression by 63% (RR 0.37, 95% 0.26 to 0.51, p < 0.00001), additional cases of propofol by 53% (RR 0.47, 95% Cl 0.29 to 0.77, p = 0.002), and increased hypertension by 1000% (RR 11.00, 95% Cl 1.45 to 83.28, p = 0.02). There were no significant differences in mean heart rate, mean oximetry saturation, delirium, dizziness, vomiting, tachycardia, and hypoxemia. Subgroup analyses revealed that, compared with other dose groups, 0.25 mg/kg esketamine afforded additional benefits in recovery and induction time, mean arterial pressure, involuntary movements, hypoxemia, and respiratory depression. Conclusion: Low-dose esketamine was found to be safe and effective for providing anesthesia during gastrointestinal endoscopy, with 0.25 mg/kg identified as the optimal dose within the dosage ranges examined. However, caution should be exercised when administering this drug to patients with inadequate preoperative blood pressure control.

Comparison of esketamine versus dexmedetomidine for attenuation of cardiovascular stress response to double-lumen tracheal tube intubation: a randomized controlled trial

Introduction

The insertion of a double-lumen tracheal tube may cause a transient but more intense sympathetic response. We examined the effects of esketamine vs. dexmedetomidine as an adjuvant to anesthesia induction to blunt double lumen tracheal (DLT) intubation induced cardiovascular stress response.

Methods

In a randomized, double-blind trial, 78 adult patients scheduled for elective thoracotomy under general anesthesia requiring DLT intubation were enrolled. The patients were randomly divided into three groups: each group received one of the following drugs prior to induction of anesthesia: dexmedetomidine 0.8 µg/kg (Group A), esketamine 0.5 mg/kg (Group B), or normal saline (group C). The primary outcome was the incidence of a DLT intubation-related cardiovascular stress response, defined as an increase in mean arterial pressure or heart rate of >30% above the baseline values. The secondary outcomes were changes in hemodynamic and cardiac function.

Results

The incidence of the response to cardiovascular stress was 23.1%, 30.8%, and 65.4% in groups A, B, and C, respectively. There was a significant decrease in intubation response in groups A and B in comparison with group C (P < 0.01); however, there was no significant difference between group A and group B (P > 0.05). Following the drug infusion and the induction of anesthesia, there was a significant decrease in HR and cardiac output in group A compared with group B. In contrast, no significant differences were observed in the left ventricular ejection fraction or in stroke volume between the three groups during induction of anesthesia.

Discussion

Esketamine 0.5 mg/kg and dexmedetomidine 0.8 µg/kg attenuate cardiovascular stress responses related to DLT intubation. As adjuvants to etomidate induction, they do not impair cardiac function (ChiCTR1900028030).