Sedative effect and safety of different doses of S-ketamine in combination with propofol during gastro-duodenoscopy in school-aged children: a prospective, randomized study

Abstract

Background Propofol combined with opioids can reduce the dosage of propofol and improve the safety of endoscopy. However, there are few studies on propofol combined with S-ketamine in children undergoing gastro-duodenoscopy. We aim to determine the sedative effect and safety of different doses of S-ketamine in combination with propofol in school-aged children undergoing gastro-duodenoscopy. Methods This is a prospective, randomized trial. Totally, 120 school-aged children who underwent gastro-duodenoscopy were randomly allocated into Group P, Group S0.3, Group S0.5 and Group S0.7. During induction, children in Group P, Group S0.3, Group S0.5 and Group S0.7 received 0, 0.3 mg.kg−1, 0.5 mg.kg−1 and 0.7 mg.kg−1 S-ketamine, respectively, following 3 mg.kg−1 propofol injection. During gastro-duodenoscopy, 1 mg.kg−1 of propofol was added according to the condition of the children and the BIS (bispectral index) value. The primary outcome was smooth placement rate of the first endoscope insertion. The secondary outcome was the times of additional propofol, the total amount of propofol, adverse events, recovery time, length of PACU (post anesthesia care unit) stay and endoscopist satisfaction. Results The smooth placement rate of the first endoscope insertion in Group P, Group S0.3 and Group S0.5 was significantly lower than that in Group S0.7 (16.70%, 34.50%, 50.00% vs. 83.30%, respectively, P < 0.001). The times of additional propofol in Group S0.3 (P = 0.018), Group S0.5 (P = 0.014) and Group S0.7 (P = 0.001) were significantly less than Group P. The total amount of propofol in Group S0.7 was significantly less than Group P (P < 0.001). The incidence of intraoperative hypotension in Group S0.5 and Group S0.7 was low. Group S0.7 had significantly higher incidence of postoperative dizziness (P = 0.003), longer PACU stay (P = 0.018) and higher endoscopist satisfaction (P = 0.001) than Group P. There was no difference in the recovery time among groups. Conclusion S-ketamine (0.7 mg.kg−1) in combination with propofol can provide satisfactory sedative effect and reduce the dosage of propofol in school-aged children undergoing gastro-duodenoscopy, but there are higher incidence of postoperative dizziness and longer PACU stay.

Efficacy and safety of esketamine for pediatric gastrointestinal endoscopy: a meta-analysis and trial sequential analysis

“…Among them, two studies were excluded due to non-randomized controlled design, one study was excluded due to duplicate data, and nine studies were excluded due to the inclusion of adults. Finally, we included five studies ( Wang et al, 2022 ; Zhang et al, 2023 ; Ding et al, 2023 ; Li et al, 2023 ; Zheng et al, 2023 ). As shown in Figure 1 .…”

“…The risk of bias for allocation concealment was unclear in four studies, the risk of bias for blinding of participants was unclear in two studies, and the risk of bias was low in the remaining areas. Among the five studies included, the overall risk of bias was assessed as low in three studies ( Wang et al, 2022 ; Zhang et al, 2023 ; Ding et al, 2023 ) and as high in two studies ( Li et al, 2023 ; Zheng et al, 2023 ).…”

“…Five RCTs compared recovery time between the esketamine combination group and the propofol group, and they included 549 children undergoing gastrointestinal endoscopy. Among them, three studies had a low risk of bias ( Wang et al, 2022 ; Zhang et al, 2023 ; Ding et al, 2023 ), and two studies had a high risk of bias due to lack of blinding of participants and allocation concealment ( Li et al, 2023 ; Zheng et al, 2023 ). The meta-analysis showed that compared to the propofol group, the esketamine combination group significantly reduced the recovery time by 2.34 min (WMD −2.34; 95% confidence interval [CI] −3.65, −1.02; p = 0.0005; I 2 = 92%).…”

“…The included studies also reported some other benefits of esketamine in gastrointestinal endoscopy in children. They found that esketamine significantly improves the success rate of first-dose anesthesia ( Ding et al, 2023 ), the success rate of the first endoscope insertion ( Wang et al, 2022 ), the satisfaction of endoscopists ( Wang et al, 2022 ) and the satisfaction of patients’ families ( Zheng et al, 2023 ). It suggests that the anesthesia regimen of esketamine in combination with propofol improves the success rate of pediatric gastrointestinal endoscopy and gains more support from physicians and children’s families.…”

Comparison of remimazolam and propofol combined with low dose esketamine for pediatric same-day painless bidirectional endoscopy: a randomized, controlled clinical trial

“…Esketamine, an antagonist of the N-methyl-D-aspartate receptor (NMDAR), provides 2-fold higher analgesic and anesthetic potency than ketamine ( Xu et al, 2022 ; Zhan et al, 2022 ). The sedative and analgesic effects of esketamine can alleviate throat irritation, and reduce consumption of sedatives and incidence of adverse events during endoscopy ( Chen et al, 2022 ; Wang et al, 2022 ; Xu et al, 2022 ; Zhan et al, 2022 ; Zheng et al, 2022 ). Thus, we conducted a randomized, controlled trial comparing the effect and safety profiles of remimazolam and propofol combined with low dose esketamine for pediatric BDE.…”