The esketamine-based multimodal low-opioid anaesthesia improves quality of recovery in elderly patients undergoing radical lung cancer surgery: a randomized controlled trial.

Background: The elderly population experiences diminished physiological function and reduced tolerance to surgery and anesthesia. This study explored the role of the esketamine-based multimodal low-opioid anaesthesia during the perioperative period in improving the quality of postoperative recovery in elderly patients undergoing thoracoscopic radical lung cancer resection. Materials and methods: This randomized controlled clinical trial enrolled 144 patients aged 60 years or older, with American Society of Anesthesiologists physical status grades II or III, undergoing elective thoracoscopic radical lung cancer resection. Participants were randomly assigned to the multimodal low-opioid strategy incorporating esketamine​ group (K Group)​ and the conventional opioid-based strategy group (C Group). The multimodal low-opioid strategy incorporating esketamine group received 0.5 mg/kg esketamine during anesthesia induction and 0.25 mg/kg/h for anesthesia maintenance. The conventional opioid-based strategy group received an equivalent volume of saline. Prior to thoracic closure, all patients received direct visualization-assisted intercostal nerve block corresponding to the surgical incision site as well as the adjacent upper and lower spaces. Postoperatively, the multimodal low-opioid strategy incorporating esketamine group received patient-controlled intravenous analgesia with 0.015 mg/kg/h esketamine and 0.015 ug/kg/h sufentanil, while the conventional opioid-based strategy group received 0.03 ug/kg/h sufentanil. The primary outcome was the Quality of Recovery Scale-15 (QoR-15) score on postoperative day 3. Secondary outcomes included QoR-15 score on postoperative day 1-2, postoperative NRS score at rest and movement, analgesic data, intraoperative hemodynamics, anesthetic drugs consumption, extubation time, PACU stay duration, and adverse events. Results: The multimodal low-opioid strategy incorporating esketamine group indicated significantly higher QoR-15 scores on postoperative day 3 compared to the conventional opioid-based strategy group (121 [117.75-124] vs. 115 [111.75-118.25], p < 0.001), primarily reflected in the physiological comfort, emotional state, and pain. Statistically significant differences in QoR-15 scores between the K and C groups were also observed on postoperative days 1 and 2 (P < 0.01). The multimodal low-opioid strategy incorporating esketamine group had significantly lower rest and dynamic NRS scores on postoperative days 1-3, fewer PCIA demands, a lower rescue analgesia rate, and less rescue analgesic consumption than the conventional opioid-based strategy group (all P < 0.05), indicating superior postoperative pain control. Compared with the conventional opioid-based strategy group, the multimodal low-opioid strategy incorporating esketamine group exhibited a significant reduction in perioperative opioid requirement (sufentanil plus remifentanil: 25 ± 4.62 ug vs. 38 ± 8.60 ug; 2.1 ± 0.35 mg vs. 2.5 ± 0.72 mg, p < 0.001) and propofol consumption (866.56 ± 76.44 mg vs. 968.36 ± 68.87 mg, p < 0.001). Esketamine provides dynamic and bidirectional regulation of blood pressure throughout different surgical phases in elderly patients undergoing radical lung cancer resection. Apart from a significantly lower incidence of postoperative nausea and vomiting in the multimodal low-opioid strategy incorporating esketamine group (10.0% vs. 21.4%, p < 0.05), the two groups showed comparable rates of other adverse effects, such as dizziness, headache, drowsiness, and restlessness (p > 0.05). Conclusion: The results of this study indicate that esketamine-based multimodal low-opioid anaesthesia effectively improves the quality of postoperative recovery in elderly patients undergoing thoracoscopic radical lung cancer resection (www.chictr.org.cn, registration number: ChiCTR2100051000).