Effect of Dexmedetomidine and Two Different Doses of Esketamine Combined Infusion on the Quality of Recovery in Patients Undergoing Modified Radical Mastectomy for Breast Cancer - A Randomised Controlled Study

Esketamine reduces postoperative depression in breast cancer through TREK-1 channel inhibition and neurotransmitter modulation

Postoperative depression significantly affects the quality of life of breast cancer patients. This study explores the potential therapeutic effects of esketamine on postoperative depression through modulation of the TREK-1 two-pore domain potassium channel. We analyzed data from 54 female breast cancer patients who underwent surgery at our hospital between 2019 and 2023, dividing them into experimental and control groups based on esketamine treatment. Transcriptomic sequencing of hippocampal neurons from rats identified potassium ion-related pathways and key regulatory genes, including TREK-1, influenced by esketamine. In vitro studies showed that esketamine primarily alleviates depressive symptoms by inhibiting TREK-1 protein expression, enhancing GABA neurotransmitter release, and improving neuronal activity, while overexpression of TREK-1 reversed these effects. Esketamine's inhibition of TREK-1 channels and promotion of hippocampal neuron activity effectively alleviate postoperative depression in breast cancer patients, suggesting a novel therapeutic strategy.

The neuroscience in breast cancer: Current insights and clinical opportunities

The involvement of nerves in the development of breast cancer has emerged as a significant factor. Interaction between the nervous system and breast cancer can influence tumor initiation, growth, invasion, metastasis, reverse resistance to drugs, promote inflammation in tumors, and impair the immune system's ability to combat cancer. This review examined the intricate relationship linking the nervous system with breast cancer, emphasizing both central and peripheral aspects of the nervous system. Moreover, we reviewed neural cell factors and their impact on breast cancer progression, alongside the interactions between nerves and immunology, microbiota in breast cancer. Furthermore, the study discussed the potential of nerves as biomarkers for diagnosing and prognosticating breast cancer, and evaluated prospects for improving chemotherapy and immunotherapy therapeutic outcomes in breast cancer treatment. We hope to provide a deeper understanding of the neurobiological underpinnings of breast cancer and pave the way for the discovery of innovative therapeutic targets and prognostic markers.

Efficacy and safety of S-ketamine in pain management for breast cancer patients undergoing modified radical mastectomy: a meta-analysis of randomized controlled trials

BACKGROUND

Breast cancer remains a leading cause of morbidity and mortality among women worldwide. According to the recent statistics by World Health Organization (WHO), it is the leading cause of death from cancer in women worldwide and it is the most frequently diagnosed cancer. This meta-analysis aims to systematically evaluate the efficacy and safety of S-ketamine in patients undergoing modified radical mastectomy.

METHOD

We searched five databases; PubMed, Scopus, Science Direct, Web of Science, and Medline Plus. We included six studies. The applicable outcomes for meta-analysis about efficacy and safety of S-ketamine in patients undergoing modified radical mastectomy.

RESULTS

Six RCTs included in our meta-analysis found that Esketamine group had a statistically significant lower VAS score after 4 h, after 6 h, after 24 h, after 48 h; (MD = -1.54; 95% CI [-1.65, -1.42], P < 0.00001), (MD = -0.55; 95% CI [-0.66, -0.45], P < 0.00001), (MD = -0.75; 95% CI [-0.84, -0.66], P < 0.00001,), (MD = -0.26; 95% CI [-0.48, -0.03], P = 0.03) P < 0.00001), respectively.

CONCLUSION

We conclude that S-ketamine is valuable for reducing pain and safe in patients undergoing modified radical mastectomy.

Perioperative esketamine combined with butorphanol versus butorphanol alone for pain management following video-assisted lobectomy: a randomized controlled trial

BACKGROUND

The analgesic efficacy of esketamine combined with butorphanol in thoracoscopic surgery remains unclear.

AIM

This study explored the effects of perioperative esketamine combined with butorphanol versus butorphanol alone on acute and chronic postoperative pain in patients who underwent video-assisted lobectomy.

METHOD

A total of 181 patients were enrolled, with 90 in the esketamine-butorphanol group (Group BK) receiving intraoperative esketamine infusion and postoperative patient-controlled intravenous analgesia (PCIA) (esketamine 1.5 mg/kg, butorphanol 0.15 mg/kg, azasetron 20 mg). The remaining 91 patients in the butorphanol group (Group B) received normal saline and PCIA with butorphanol (0.15 mg/kg) and azasetron (20 mg). Primary endpoints included Visual Analog Scale (VAS) scores in the first week and chronic pain incidence at three months. Secondary endpoints included intraoperative vital signs, morphine consumption, postoperative adverse events, and 15-item Quality of Recovery-15 (QoR-15) scores.

RESULTS

Group BK demonstrated significantly lower VAS scores within 48 h at rest and within 24 h during coughing postoperatively (P < 0.001). However, no significant differences were observed in VAS scores [(Group B, 5 (0-12)) vs. (Group BK, 5 (0-9)), P = 0.517] or chronic pain incidence [(Group B, 34.1%) vs. (Group BK, 23.3%), P = 0.111] between the two groups at the three-month follow-up. Patients in Group BK exhibited improved postoperative stability of vital signs and higher QoR-15 scores.

CONCLUSION

Perioperative administration of esketamine significantly mitigates acute postoperative pain and enhances recovery quality in patients undergoing video-assisted lung resection.

TRIAL REGISTRATION

This trial protocol is registered with ClinicalTrials.gov (NCT06398834, date: 2024-05-01).

Effects of Esketamine Combined with Dexmedetomidine on Early Postoperative Cognitive Function in Elderly Patients Undergoing Lumbar Spinal Surgery: A Double-Blind Randomized Controlled Clinical Trial

Background

Postoperative cognitive dysfunction (POCD) is a common complication after surgery in elderly patients, and its prevalence can be up to 25.6% at one week after noncardiac surgery. This study mainly evaluates the combined effects of esketamine and dexmedetomidine on the incidence of POCD in elderly patients undergoing lumbar spine surgery and explores the underlying mechanisms.

Methods

A total of 162 elderly patients undergoing lumbar spine surgery were randomized into three groups: esketamine combined with dexmedetomidine group (ED group), esketamine group (E group), and dexmedetomidine group (D group). Primary outcome measures included the incidence of POCD on the first postoperative day. Secondary outcomes included the incidence of POCD on the third postoperative day, first postoperative day serum levels of neuron-specific enolase (NSE) and calcium-binding protein β (S100β), patient visual analog scale (VAS) scores at 2, 24, and 48 hours postoperatively, and the incidence of adverse events.

Results

The incidence of POCD on the first postoperative day was significantly lower in the ED group compared to the E group (P = 0.017), with no significant differences when compared to the D group (P = 0.064). The levels of serum NSE in patients in the ED group on the first postoperative day were significantly lower than those in E group and D group (ED group vs E group, P = 0.028; ED group vs D group, P = 0.048). The results for the S100β were similar to those for the NSE (ED group vs E group, P = 0.005; ED group vs D group, P = 0.011).

Conclusion

The combination of esketamine and dexmedetomidine effectively reduces the incidence of POCD on the first postoperative day in elderly patients undergoing lumbar spine surgery.

Superiority of opioid free anesthesia with regional block over opioid anesthesia with regional block in the quality of recovery after retroperitoneiscopic renal surgery: a randomized controlled trial

BACKGROUND

Opioids are the main analgesic drugs used in the perioperative period, but they often have various adverse effects. Recent studies have shown that quadratus lumborum block (QLB) has an opioid sparing effect. The aim of this study was to further evaluate the effect of opioid-free anesthesia (OFA) combined with regional block on the quality of recovery in patients undergoing retroperitoneoscopic renal surgery.

METHODS

Sixty patients undergoing elective retroperitoneoscopic renal surgery were divided into the opioid-free anesthesia with quadratus lumborum block group (OFA group, N.=30) and opioid anesthesia with quadratus lumborum block group (OA group, N.=30) using the random number table method. The main outcome measures were the quality of recovery assessed by Quality of Recover-40 (QoR-40) at the 24th postoperative hour. Secondary outcomes were postoperative pain score, postoperative opioid consumption, postoperative nausea and vomiting, time to ambulate, and time to readiness for discharge.

RESULTS

The QoR-40 score on the first postoperative day was significantly higher in the OFA group than that in the OA group (175.41±6.74 vs. 165.07±4.55; P<0.05). OFA also significantly reduced postoperative pain (P<0.05) and morphine consumption at both the 24th and 48th postoperative hour (P<0.05), as well as time to ambulate, and time to readiness for discharge (P<0.05).

CONCLUSIONS

OFA with regional block is superior to opioid anesthesia with regional block in the quality of recovery after retroperitoneiscopic renal surgery.

Effect of esketamine combined with dexmedetomidine on delirium in sedation for mechanically ventilated ICU patients: protocol for a nested substudy within a randomized controlled trial

BACKGROUND

Use of sedatives and analgesics is associated with the occurrence of delirium in critically ill patients receiving mechanical ventilation. Dexmedetomidine reduces the occurrence of delirium but may cause hypotension, bradycardia, and insufficient sedation. This substudy aims to determine whether the combination of esketamine with dexmedetomidine can reduce the side effects and risk of delirium than dexmedetomidine alone in mechanically ventilated patients.

METHODS

This single-center, randomized, active-controlled, superiority trial will be conducted at The First Affiliated Hospital of Nanjing Medical University. A total of 134 mechanically ventilated patients will be recruited and randomized to receive either dexmedetomidine alone or esketamine combined with dexmedetomidine, until extubation or for a maximum of 14 days. The primary outcome is the occurrence of delirium, while the second outcomes include the number of delirium-free days; subtype, severity, and duration of delirium; time to first onset of delirium; total dose of vasopressors and antipsychotics; duration of mechanical ventilation; ICU and hospital length of stay (LOS); accidental extubation, re-intubation, re-admission; and mortality in the ICU at 14 and 28 days.

DISCUSSION

There is an urgent need for a new combination regimen of dexmedetomidine due to its evident side effects. The combination of esketamine and dexmedetomidine has been applied throughout the perioperative period. However, there is still a lack of evidence on the effects of this regimen on delirium in mechanically ventilated ICU patients. This substudy will evaluate the effects of the combination of esketamine and dexmedetomidine in reducing the risk of delirium for mechanically ventilated patients in ICU, thus providing evidence of this combination to improve the short-term prognosis. The study protocol has obtained approval from the Medical Ethics Committee (ID: 2022-SR-450).

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05466708, registered on 20 July 2022.

Effect of Continuous Infusion of Different Doses of Esketamine on the Bispectral Index During Sevoflurane Anesthesia: A Randomized Controlled Trial

Purpose

To investigate and quantify the effect of continuous esketamine infusion at different doses on the bispectral index (BIS) during sevoflurane anesthesia.

Methods

A total of 120 patients scheduled for elective laparoscopic renal surgery were randomly divided into three groups. Under steady anesthesia and surgical situations, the patient was started on continuous infusion of the study drug: 0.125 mg/kg/h esketamine (group E1), 0.25 mg/kg/h esketamine (group E2), and the same volume of saline (group C). The primary outcome was changes in BIS value after 15 min (T15), 30 min (T30), 45 min (T45), and 60 min (T60) of drug infusion. The secondary outcomes were 95% spectral edge frequency (SEF95), electromyogram (EMG), heart rate (HR), and mean arterial pressure (MAP) from T0 to T60. Furthermore, postoperative pain, postoperative recovery, and perioperative adverse events were evaluated.

Results

Compared with group C, group E1 exhibited significant BIS elevation at T30-T60 and group E2 at T15-T60 (P < 0.001). Compared with group E1, group E2 showed a more significant BIS elevation at T15-T60 (P < 0.001). The area under the curve (AUC) of BIS and SEF95 were significantly higher in group E2 than in groups C and E1 (P < 0.05). BIS value for any of the three groups was significantly correlated with SEF95 (P < 0.001). No significant differences were observed in the AUC of EMG, HR, and MAP among the three groups. Intraoperative remifentanil consumption and postoperative NRS of pain on movement were significantly reduced in group E2 compared with groups C and E1 (P < 0.05).

Conclusion

Continuous infusion of both 0.125 and 0.25 mg/kg/h of esketamine increased the BIS value during sevoflurane anesthesia, and the BIS value gradually stabilized with the prolongation of the infusion time.

Impact of Opioid-Free Anesthesia on Postoperative Quality of Recovery in Patients After Laparoscopic Cholecystectomy-A Randomized Controlled Trial

Purpose

Opioid analgesics may delay discharge and affect postoperative quality of recovery because of their significant adverse effects, such as hyperalgesia, postoperative nausea and vomiting (PONV), shivering and urine retention. We aimed to compare the quality of postoperative recovery (QoR) between patients undergoing laparoscopic cholecystectomy surgeries with opioid-free anesthesia (OFA) and those with opioid-based anesthesia (OA).

Patients and Methods

80 adult patients undergoing laparoscopic cholecystectomy were randomly allocated to an opioid-free anesthesia group (Group OFA) or an opioid-based anesthesia group (Group OA). The primary outcome was the quality of postoperative recovery using QoR-15 scale on postoperative day 1 (POD 1) and 2 (POD 2). The secondary outcomes included the incidence of opioid-related adverse symptoms, perioperative hemodynamic data, duration of post-anesthesia care unit (PACU) stay and duration of extubation, and the incidences of hypotension and bradycardia.

Results

A statistically significant difference in total QoR-15 was observed between the two groups on POD 1 and POD 2 (91.00 (90.00, 92.00) vs 113.00 (108.25, 115.00), 106.00 (104.00, 112.00) vs 133.00 (130.00, 135.00), P < 0.001). The incidence of opioid-related symptoms was significantly different between the two groups on POD 1 (P < 0.05). There were between-group differences in systolic blood pressure (SBP) and diastolic blood pressure (DBP) at T3 (P < 0.001). There was also a significant difference in the incidence of hypotension between the two groups (P = 0.001). However, there were no significant differences in the duration of PACU stay, duration of extubation and the incidence of bradycardia (P > 0.05). There was no difference in heart rate between the two groups at all observed time points, either (P > 0.05).

Conclusion

We concluded that the quality of recovery of patients receiving OFA was superior to those receiving OA after laparoscopic cholecystectomy.