Safety and tolerability of esketamine in propofol based sedation for endoscopic variceal ligation with or without injection sclerotherapy: Randomized controlled trial

Chen, Yuanjing; Chen, Jie; Wang, Quankai; Lyu, Hongyao; Chen, Xuehan; Li, Rui; Wang, Ting; Dan, Ling; Huang, He; Duan, Guangyou

doi:10.1111/den.14539

Cited by 14 publications

(13 citation statements)

References 29 publications

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“…[14,15] Previous studies observed that this effect of esketamine can be used to improve hemodynamic stability in patients undergoing procedures under general anesthesia. [15][16][17][18][19][20][21][22] In light of the evidence from previous studies, we hypothesize that esketamine may improve blood pressure during the induction phase of the procedure since it stimulates the sympathetic nervous system, making it an ideal drug for the induction of anesthesia in unstable patients. [23,24]…”

Section: Introductionmentioning

confidence: 99%

The effects of esketamine on blood pressure and hypotension incidence during induction of bariatric surgery: A randomized controlled trial

Yang,

Mudabbar,

et al. 2023

Medicine

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Background: The prevalence of obesity is high. Bariatric surgery is an effective treatment for severe obesity; however, the induction phase of anesthesia in these patients poses a risk of hypotension. Esketamine, known for its sympathetic nervous system stimulation, may stabilize blood pressure during induction. This study aimed to investigate the effects of esketamine on blood pressure in bariatric surgery patients. Methods: This randomized controlled trial included 145 patients undergoing bariatric surgery. Patients were randomly assigned to receive esketamine or a control intervention during induction. Blood pressure and other vital signs were measured and compared between the 2 groups using statistical analyses. Results: Administration of esketamine increased blood pressure before intubation (T2). The incidence of hypotension was lower in the esketamine group at multiple time points during induction. Postoperatively, the esketamine group exhibited lower pain scores at 24 hours and a reduced need for rescue analgesics. Conclusion: A single dose of 0.2 mg/kg esketamine during the induction phase of bariatric surgery can improve blood pressure stability and decrease the incidence of hypotension. Furthermore, it is associated with reduced postoperative pain. Future studies could explore the effects of higher esketamine doses and validate these findings in a larger and more diverse patient population.

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Section: Introductionmentioning

confidence: 99%

The effects of esketamine on blood pressure and hypotension incidence during induction of bariatric surgery: A randomized controlled trial

Yang,

Mudabbar,

et al. 2023

Medicine

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“…One promising alternative is esketamine, an N -methyl- d -aspartate receptor antagonist and the dextrorotatory isomer of ketamine. Esketamine possesses twice the potency of ketamine in terms of hypnotic and analgesic effects, with fewer psychiatric adverse effects . Previous studies have also indicated that a subanesthetic dose of esketamine can maintain hemodynamic stability and reduce respiratory depression in surgical patients .…”

Section: Introductionmentioning

confidence: 99%

Effect of Esketamine Added to Propofol Sedation on Desaturation and Hypotension in Bidirectional Endoscopy

Song,

Yang,

Zheng

et al. 2023

JAMA Netw Open

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ImportancePropofol sedation is widely used for endoscopic procedures, but it poses risks of hemodynamic and respiratory depression. The addition of esketamine as an adjuvant may reduce propofol requirements and associated adverse events.ObjectiveTo evaluate the effects of low-dose esketamine added to propofol-based sedation on desaturation and hypotension during same-visit bidirectional endoscopy.Design, Setting, and ParticipantsThis multicenter, double-blind, placebo-controlled randomized clinical trial assessed patients from 3 teaching hospitals in China who were scheduled for same-visit bidirectional endoscopy between February 8 and November 30, 2022, and randomly assigned to receive esketamine or normal saline (placebo).InterventionsAfter induction of sedation with 0.1 μg/kg of sufentanil and 0.5 mg/kg of propofol, patients in the esketamine group received 0.15 mg/kg of intravenous esketamine, whereas patients in the placebo group received an equivalent volume of saline. Sedation was achieved through propofol titration.Main Outcomes and MeasuresThe primary outcome was the composite of desaturation and hypotension during the procedures. Secondary outcomes included desaturation, hypotension, propofol requirements, postprocedure pain and fatigue, nausea or vomiting, dizziness or headache, hallucination or nightmare, endoscopist satisfaction, and patient satisfaction.ResultsAmong the 663 initially enrolled patients, 660 completed the study (median [IQR] age, 48 [36-57] years; 355 [53.8%] female), with 331 randomized to the esketamine group and 329 to the placebo group. The administration of esketamine compared with placebo significantly reduced the incidence of the composite outcome of desaturation and hypotension (8.2% vs 21.0%; difference, −12.8 percentage points; odds ratio [OR], 0.34; 95% CI, 0.21-0.54; P &lt; .001). Additionally, esketamine led to significantly lower incidences of desaturation (OR, 0.36; 95% CI, 0.18-0.72; false discovery rate q = .01) and hypotension (OR, 0.33; 95% CI, 0.18-0.60; q &lt; .001) and reduced propofol requirements (difference, −58.9 mg; 95% CI, −65.7 to −52.2 mg; q &lt; .001), without significant effects on other secondary outcomes.Conclusions and RelevanceIn this randomized clinical trial of patients undergoing same-visit bidirectional endoscopy, the administration of low-dose esketamine resulted in an approximately 61% reduction in the incidence of desaturation and hypotension, accompanied by decreased propofol requirements. These findings support the use of esketamine as an adjuvant to propofol-based sedation in endoscopic procedures.Trial RegistrationChinese Clinical Trial Registry Identifier: ChiCTR2200055938

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“…Recent studies on new analgesics such as sufentanil and esketamine in gastrointestinal endoscopy have been conducted mainly in China. 1,8,9 However, it is not known which analgesics can be added to propofol to reduce adverse events, such as hypotension. In this issue of Digestive Endoscopy, Chen et al 1 investigated the efficacy and safety of propofol plus esketamine sedation compared with sufentanil during endoscopic variceal ligation (EVL) with or without injection sclerotherapy in patients with liver cirrhosis.…”

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confidence: 99%

“…A balance between efficacy and safety is important. Chen et al 1 . investigated the efficacy and safety of sedation during esophageal endoscopy in patients with liver cirrhosis.…”

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What is the best sedation method for high‐risk patients such as those with cirrhosis?

Ichijima

2023

Digestive Endoscopy

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Gastrointestinal endoscopy is an essential diagnostic examination for gastrointestinal diseases. However, gastrointestinal endoscopy is invasive and painful; therefore, sedatives and analgesics are required. Moreover, these drugs are essential for endoscopic treatment. When using sedatives and analgesics during endoscopic treatment, especially for high-risk patients, attention must be paid not only to efficacy but also to safety. A balance between efficacy and safety is important. Chen et al. 1 investigated the efficacy and safety of sedation during esophageal endoscopy in patients with liver cirrhosis. Patients with an esophageal procedure and/or with decreased liver function, such as cirrhosis, are at high risk of sedation complications.There are several types of sedatives used in endoscopic procedures. Benzodiazepines, such as midazolam, are commonly used as sedatives in Japan, although their disadvantages include their prolonged effects and half-life (approximately 3 h), which are inappropriate for short endoscopic procedures. Remimazolam, an ultrashort-acting benzodiazepine, was developed recently. Although remimazolam is metabolized in the liver, unlike other benzodiazepine drugs, it is not mediated by cytochrome P450 enzymes (CYP). Because CYP expression in the liver is suppressed in patients with liver cirrhosis, midazolam metabolism decreases when administered to patients with liver damage, resulting in delayed excretion and prolonged sedation. 2 Therefore, sedation endoscopy with remimazolam may be beneficial for patients with cirrhosis. Remimazolam combines better safety with rapid recovery and early restoration of cognitive function. Recent reports also show its usefulness in the field of gastrointestinal endoscopy. 3 Propofol is another fast-acting drug with a short recovery and ambulation time. However, it has a narrow sedation threshold and causes hypotension, bradycardia, and hypoxemia, requiring continuous monitoring with an anesthesiologist during endoscopy. In the treatment of esophageal disease, use of benzodiazepines such as midazolam may make it difficult to continue the procedure due to body movement; in contrast, propofol reduces body movement.

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Safety and tolerability of esketamine in propofol based sedation for endoscopic variceal ligation with or without injection sclerotherapy: Randomized controlled trial

Cited by 14 publications

References 29 publications

The effects of esketamine on blood pressure and hypotension incidence during induction of bariatric surgery: A randomized controlled trial

The effects of esketamine on blood pressure and hypotension incidence during induction of bariatric surgery: A randomized controlled trial

Effect of Esketamine Added to Propofol Sedation on Desaturation and Hypotension in Bidirectional Endoscopy

What is the best sedation method for high‐risk patients such as those with cirrhosis?

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