Esketamine as an Adjuvant to Levobupivacaine in Thoracic Paravertebral Block for Thoracoscopic Lung Cancer Surgery: A Retrospective Propensity Score-Matched Cohort Study.

OBJECTIVE

This retrospective, propensity score-matched cohort study evaluated postoperative analgesic, recovery, and safety outcomes associated with esketamine added to levobupivacaine for thoracic paravertebral block after thoracoscopic lung cancer surgery.

METHODS

We analyzed patients undergoing thoracoscopic resection of non-small cell lung cancer between January 2020 and December 2024. Of 412 patients screened, 374 entered 1:1 propensity score matching. The esketamine group received 20 mL of 0.375% levobupivacaine with esketamine (0.5 mg/kg), whereas controls received levobupivacaine alone. The co-primary outcomes were 48-hour cumulative sufentanil consumption and postoperative pain intensity assessed by visual analog scale scores at 6, 24, and 48 hours. Secondary outcomes were time to first ambulation, chest tube duration, and hospital stay. Calendar-year-adjusted regression and a contemporaneous 2022-2024 analysis assessed sensitivity to temporal differences.

RESULTS

After matching, 328 patients (164 per group) were analyzed. Mean 48-hour sufentanil consumption was 30.2% lower with esketamine (55.2 ± 11.9 μg vs 79.1 ± 12.8 μg; P < 0.001), and pain scores at rest and during coughing were lower at all assessed times (all P < 0.001). Recorded times to first ambulation, chest tube removal, and discharge were shorter (all P < 0.001). The estimated association with sufentanil consumption was materially unchanged after calendar-year adjustment (β = -24.2 μg; 95% CI, -27.1 to -21.2) and in the contemporaneous subset (β = -24.3 μg; 95% CI, -27.6 to -21.0). Psychomimetic events occurred in 14/164 esketamine recipients (8.5%) and no controls.

CONCLUSION

Esketamine added to levobupivacaine for thoracic paravertebral block was associated with lower postoperative opioid consumption and pain scores and shorter recorded times to recovery milestones. However, residual confounding cannot be excluded, and the 8.5% psychomimetic event rate does not support routine adoption of the 0.5 mg/kg regimen. Prospective randomized dose-finding trials are warranted.