Lin Xing, Liu Xin, Huang Huoming, Xu Xiaohui, Zhang Tianhong, Gao Ju
Yangzhou University Medical College, Yangzhou, 225000, China.
Central Health Center of Yishan Town, Lianyungang, Jiangsu, 222200, China.
BMC Anesthesiol. 2024 Dec 5;24(1):448. doi: 10.1186/s12871-024-02803-3.
Prior meta-analyses have established the potential of intravenous ketamine in safeguarding against neurocognitive impairment, but the efficacy of intravenous esketamine for the prevention of perioperative neurocognitive disorders (PND) remains uncertain. The primary aim of this meta-analysis was to conduct a comprehensive evaluation of the effects of esketamine on PND in adult surgical patients undergoing general anesthesia.
We searched several electronic databases and clinical trial registries to find relevant trials. Randomized controlled trials of perioperative use of esketamine adjuvant were included in the analysis. The main outcome measured was the risk of postoperative delirium(POD) and postoperative cognitive dysfunction (POCD). Secondary outcomes included the assessment of postoperative cognitive status, pain scores (VAS/NRS), remifentanil consumption and the occurrence of postoperative nausea and vomiting (PONV).
Thirteen studies encompassing procedures such as abdominal, thoracoscopic lung, gastrointestinal, laparoscopic gynecological, spinal surgery, and modified radical mastectomy, were included in the analysis. A cohort comprising 1068 adult patients underwent general anesthesia, with 584 patients assigned to the esketamine group and 484 patients designated to the placebo group. The administration of general anesthesia was augmented by intravenous infusion of esketamine, and a comparative analysis was conducted in relation to alternative pharmacological interventions or a placebo. The application of esketamine during the perioperative period was observed to decrease the risk of POD ( RR 0.46; 95% CI: 0.32, 0.66, p < 0.0001, GRADE = High) and exhibited a protective influence on POCD (RR = 0.50; 95%CI: 0.30, 0.84, p = 0.009, I = 0%, GRADE = Moderate). Significant improvements were observed at 4, 24 and 48 h post-surgery when comparing esketamine to a placebo (4 h: SMD -0.78, 95% CI: -1.24, -0.32, p = 0.0009, I = 58%, GRADE = Low; 24 h: SMD -0.92, 95% CI: -1.40, -0.44, p = 0.0002, I2 = 86%, GRADE = Low; 48 h: SMD -0.9, 95% CI: -1.68, -0.12, p = 0.02, I = 89%, GRADE = Low), and intraoperative remifentanil consumption was significantly reduced in the esketamine group (SMD -0.56; 95%CI: - 0.86, - 0.27, p = 0.0002, I = 62%, GRADE = moderate). A notable reduction in the risk of PONV was observed in the esketamine group(RR = 0.64; 95%CI: 0.49, 0.84, p = 0.001, I = 0%, GRADE = High).
The use of intravenous esketamine as an adjuvant in general anesthesia may represent a potentially beneficial strategy for reducing susceptibility to PND, with potential benefits for preventing POD and POCD. Furthermore, it can decrease intraoperative opioid consumption and alleviate postoperative pain intensity without increasing the incidence of PONV.
This meta-analysis was registered on PROSPERO (CRD42023453714).
先前的荟萃分析已证实静脉注射氯胺酮在预防神经认知障碍方面的潜力，但静脉注射艾司氯胺酮预防围手术期神经认知障碍（PND）的疗效仍不确定。本荟萃分析的主要目的是全面评估艾司氯胺酮对接受全身麻醉的成年手术患者PND的影响。
我们检索了多个电子数据库和临床试验注册库以查找相关试验。围手术期使用艾司氯胺酮辅助治疗的随机对照试验纳入分析。主要测量结果是术后谵妄（POD）和术后认知功能障碍（POCD）的风险。次要结果包括术后认知状态评估、疼痛评分（VAS/NRS）、瑞芬太尼消耗量以及术后恶心呕吐（PONV）的发生率。
分析纳入了13项研究，涵盖腹部、胸腔镜肺、胃肠道、腹腔镜妇科、脊柱手术和改良根治性乳房切除术等手术。一个由1068名成年患者组成的队列接受了全身麻醉，其中584名患者被分配到艾司氯胺酮组，484名患者被分配到安慰剂组。通过静脉输注艾司氯胺酮增强全身麻醉，并与其他药物干预或安慰剂进行比较分析。观察到围手术期应用艾司氯胺酮可降低POD风险（RR 0.46；95%CI：0.32，0.66，p<0.0001，GRADE=高），并对POCD有保护作用（RR=0.50；95%CI：0.30，0.84，p=0.009，I=0%，GRADE=中等）。与安慰剂相比，术后4、24和48小时观察到显著改善（4小时：SMD -0.78，95%CI：-1.24，-0.32，p=0.0009，I=58%，GRADE=低；24小时：SMD -0.92，95%CI：-1.40，-0.44，p=0.0002，I2=86%，GRADE=低；48小时：SMD -0.9，95%CI：-1.68，-0.12，p=0.02，I=89%，GRADE=低），并且艾司氯胺酮组术中瑞芬太尼消耗量显著降低（SMD -0.56；95%CI：-0.86，-0.27，p=0.0002,I=62%，GRADE=中等）。艾司氯胺酮组观察到PONV风险显著降低（RR=0.64；95%CI：0.49，0.84，p=0.001，I=0%，GRADE=高）。
在全身麻醉中使用静脉注射艾司氯胺酮作为辅助药物可能是一种潜在有益的策略，可降低对PND的易感性，对预防POD和POCD有潜在益处。此外，它可以减少术中阿片类药物的消耗量并减轻术后疼痛强度，而不会增加PONV的发生率。
本荟萃分析已在PROSPERO（CRD42023453714）上注册。
