Esketamine attenuates hemodynamic oscillations during anesthesia induction in elderly gastrointestinal surgical patients: a randomized trial.

BACKGROUND

Patients undergoing gastrointestinal tumor surgery face heightened susceptibility to hemodynamic instability during anesthesia induction, a risk further exacerbated by preoperative fasting. Oscillatory blood pressure fluctuations increase perioperative risks. Esketamine's sympathomimetic properties may counteract propofol-induced hypotension. This study aimed to evaluate the impact of adjunctive esketamine on hemodynamic instability incidence during induction.

METHODS

This prospective, double-blind RCT (ChiCTR2200060641, registered on June 6, 2022) enrolled ASA I-III patients (18-75 years) scheduled for gastrointestinal tumor surgery at Foshan First People's Hospital (Jun 2022-May 2023). Patients were randomized 1:1 to receive IV esketamine (0.2 mg/kg) or saline placebo during induction. Anesthesia was induced with propofol (1.5-2.0 mg/kg), sufentanil (0.2 µg/kg), and cisatracurium (0.3 mg/kg). The primary outcome was the incidence of hemodynamic instability (defined as hypertension [MAP > 20% baseline], hypotension [MAP < 65 mmHg or > 20% decrease], tachycardia [HR > 100 bpm], bradycardia [HR < 50 bpm], or vasopressor use) from induction to 5 min post-intubation. The secondary outcomes included intraoperative ephedrine consumption, postoperative recovery time, extubation time, duration of post-anaesthesia care unit (PACU) stay, emergence agitation, cough during intubation, and other adverse effects.

RESULTS

The incidence of hemodynamic instability was significantly lower in the esketamine group than in the control group during induction (29.3% vs. 55.9%; OR = 0.33, 95% CI: 0.18-0.60; P < 0.001). Specifically, esketamine reduced hypotension (27.2% vs. 44.1%; P = 0.016) and hypertension (3.3% vs. 12.9%; P = 0.016). Ephedrine use was lower (12.0% vs. 24.7%; P = 0.025). CO was preserved in the esketamine group but declined significantly in the control group post-induction (P < 0.05). Cough incidence was reduced with esketamine (8.7% vs. 32.3%; P < 0.001). No differences existed in recovery times, emergence agitation, or PONV.

CONCLUSIONS

Adjunctive low-dose esketamine (0.2 mg/kg) during propofol-based induction significantly attenuates hemodynamic instability and preserves cardiac output in gastrointestinal surgery patients, without delaying recovery. This approach enhances cardiovascular safety during high-risk induction.

TRIAL REGISTRATION: This study was registered with the Chinese Clinical Trial Registry (ChiCTR2200060641) on June 6, 2022.