Esketamine vs. placebo combined with erector spinae plane block vs. intercostal nerve block on quality of recovery following thoracoscopic lung resection: a randomized controlled factorial trial.

Adding a low dose of the anesthetic esketamine to a multimodal pain regimen improved the quality of recovery for patients after thoracoscopic lung surgery, while two different regional nerve blocks—erector spinae plane block and intercostal nerve block—provided similar benefits. In a randomized trial of 100 adults, those receiving intravenous esketamine (0.3 mg/kg) scored an average of 111.5 on the quality-of-recovery scale at 24 hours, compared with 105.4 for placebo, a difference exceeding the minimal clinically important threshold of 6.0 points. The esketamine group also had higher scores at 48 hours and hospital discharge. No significant interaction occurred between esketamine and the type of nerve block, and the two blocks yielded comparable recovery scores, suggesting they can be used interchangeably.

Study at a glance

Abstract

Multimodal analgesic strategy is pivotal for enhanced recovery after surgery. The objective of this trial was to assess the effect of subanesthetic esketamine vs. placebo combined with erector spinae plane block (ESPB) vs. intercostal nerve block (ICNB) on postoperative recovery following thoracoscopic lung resection. This randomized, controlled, 2×2 factorial trial was conducted at a university hospital in Suzhou, China. One hundred adult patients undergoing thoracoscopic lung surgery were randomized to one of four groups (esketamine-ESPB, esketamine-ICNB, placebo-ESPB, and placebo-ICNB) to receive i.v. esketamine 0.3 mg/kg or normal saline placebo combined with ESPB or ICNB using 0.375% ropivacaine 20 ml. All patients received flurbiprofen axetil and patient-controlled fentanyl. The primary outcome was quality of recovery (QoR) at 24 h postoperatively, assessed using the QoR-15 scale, with a minimal clinically important difference of 6.0. The median age was 57 years and 52% were female. No significant interaction effect was found between esketamine and regional blocks on QoR ( P =0.215). The QoR-15 score at 24 h was 111.5±5.8 in the esketamine group vs. 105.4±4.5 in the placebo group (difference=6.1, 95% CI: 4.0-8.1; P <0.001); 109.7±6.2 in the ESPB group vs. 107.2±5.6 in the ICNB group (difference=2.5, 95% CI: 0.2-4.9; P =0.033; not statistically significant after Bonferroni correction). Additionally, esketamine resulted in higher QoR-15 scores at 48 h (difference=4.6) and hospital discharge (difference=1.6), while ESPB led to a higher QoR-15 score at 48 h (difference=3.0). For patients undergoing thoracoscopic lung resection, subanesthetic esketamine improved QoR after surgery, while ICNB can be used interchangeably with ESPB as a component of multimodal analgesia.