Esketamine-based opioid-reduced anesthesia in outpatient gynecological surgery: a randomized, double-blind, controlled study
1. In adult women undergoing gynecological day surgery, this randomized controlled trial found that opioid-reduced analgesia using esketamine did not lead to an improvement in postoperative nausea and vomiting (PONV) compared to to opioid analgesia.
2. There was no significant difference in subjective pain after surgery between patients who had opioid analgesia and opioid-reduced analgesia using esketamine.
Level of evidence assessment: 1 (Excellent)
Opioids are often used for intraoperative and postoperative pain management; however, perioperative opioid use has been associated with significant side effects, including nausea, gastrointestinal paralysis, delirium, and hypoxemia. Many non-opioid analgesics are currently available; intravenous ketamine has been established as an effective adjunctive analgesic. Esketamine, a dextroisomer of ketamine, has a strong analgesic effect and has been combined with other drugs in previous studies to implement non-opioid analgesia. Female gender has previously been shown to be an independent risk factor that significantly increases the risk of postoperative nausea and vomiting (PONV), and this parallel double-blind randomized controlled trial investigated whether reduced opioid-based anesthesia based on Esketamine Reduces Complications and Accelerates Rehabilitation in Patients Undergoing Gynecological Day Surgery. The study included adult women undergoing hysteroscopy and cervical conization. The primary endpoint was the incidence of postoperative nausea within 24 hours of surgery, with secondary endpoints being the incidence of postoperative vomiting, postoperative hospital stay, pain scores assessed by the visual scale analogue (EVA), the length of stay in the post-anaesthesia care unit. (PACU), adverse hemodynamic events and other adverse effects. Patients were randomized in a 1:1:1 ratio into three separate groups. During induction, the C and MO groups received alfentanil, while the LO group received a lower dose of alfentanil mixed with esektamine. For anesthetic maintenance, group C received alfentanil, while groups LO and MO received only esketamine. Throughout the surgery, mean arterial pressure (MAP) and heart rate (HR) were recorded at 9 separate time points. Additionally, the patients were followed up at two postoperative time points – in the recovery room and on the first day of discharge. 141 patients were available for the primary analysis, with no significant difference between the three groups regarding their preoperative PONV risk score. Regarding the primary endpoint, the incidence of nausea within 24 hours was 33.3% in group C, 18.4% in group MO and 43.2% in group LO. The incidence of nausea within 24 hours was significantly lower in the MO group than in the LO group (P < 0.05). Regarding secondary endpoints, the incidence of vomiting within 24 hours postoperatively was lower in the MO group than in the LO group (P < 0.05). Otherwise, the duration of stay in the recovery room was increased in the LO group compared to the C group (median 60 versus 42.5, P < 0.05). Postoperative pain VAS scores did not differ significantly between the three groups. Interestingly, the number of patients in the LO group with bradycardia and hypotension decreased significantly compared to group C. Overall, the results of this study suggest that the reduced analgesia by opioids using the esketamine did not significantly reduce PONV and may have contributed to more severe PONV and longer postoperative rehabilitation. However, esketamine showed a positive analgesic effect comparable to opioids and also showed more stable hemodynamics. A limitation of this study was the lack of other additional drugs to completely replace opioids in a non-opioid analgesia group. This is an important trial in exploring opioid-reduced analgesia as an effective alternative, and further research is needed to explore ideal combinations of analgesics and sedatives.
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