The Effect of Esketamine Combined With Dexmedetomidine on Postoperative Recovery Quality in Patients Undergoing Thoracoscopic Surgery
Phase: NA
Conditions: Esketamine Plus Dexmedetomidine Affect Postoperative Quality, Thoracoscopy, Lung Neoplasms
Sponsor: First Affiliated Hospital of Kunming Medical University

Research Theme:The Effect of Esketamine Combined
with Dexmedetomidine on Postoperative Recovery
Quality
in
Patients
Undergoing
Thoracoscopic
Surgery
Ethical Review Number:(2025)Ethical Review L No.
81
Document Date:March 27, 2025

Introduction
Video-assisted thoracoscopic surgery (VATS) has a wide range of
applications, including the diagnosis and treatment of lung cancer, and
has gradually replaced traditional open thoracotomy. VATS must
routinely employ single-lung ventilation techniques. During single-lung
ventilation,
mechanical
injury,
lung
collapse,
imbalance
in
the
ventilation-perfusion ratio, ischemia-reperfusion, and other pathological
physiological changes may occur, leading to the release of a large number
of inflammatory factors, triggering local and systemic inflammatory
responses,increasing the incidence of postoperative complications, and
affecting patient outcomes. Additionally, most patients undergoing
thoracoscopic surgery experience acute postoperative pain. If acute
postoperative pain is not adequately controlled, it may progress to chronic
pain, affecting the quality of postoperative recovery. Currently, opioid
medications are the primary drugs used to treat moderate to severe
postoperative pain. However, adverse events associated with opioid
medications may also affect the quality of postoperative recovery.The use
of multimodal analgesia for postoperative pain management can control
pain and reduce the need for opioid medications.
Esketamine, a newly marketed intravenous anesthetic in China in
recent years, is the dextrorotatory isomer of ketamine, and acts as a
non-competitive
antagonist
of
the
N-methyl-D-aspartate
(NMDA)

receptor. Compared to ketamine, esketamine has higher potency, faster
recovery time, and fewer adverse effects. Some clinical studies have
shown that administration of esketamine reduces the intensity of
postoperative pain and decreases the need for postoperative analgesics.
Research has found that esketamine reduces the consumption of opioid
medications and hyperalgesia postoperatively. Additionally, studies have
shown that esketamine administration improves recovery quality by
alleviating postoperative pain. Dexmedetomidine (DEX) is a selectiveα2
adrenergic receptor agonist with sedative and analgesic effects. Studies
have
shown
that
dexmedetomidine
effectively
reduces
surgical
inflammation, oxidative stress, and postoperative pain, thereby promoting
postoperative recovery in surgical patients without increasing the risk of
adverse reactions or complications. A meta-analysis indicated that
dexmedetomidine
administration
alleviates
postoperative
pain
and
reduces postoperative nausea and vomiting (PONV). Current evidence
suggests that the use of dexmedetomidine improves postoperative
recovery quality. However, the effects of esketamine combined with
dexmedetomidine
on
postoperative
recovery
quality
in
patients
undergoing thoracoscopic surgery have not been reported. This study
aims to investigate whether the combined administration of esketamine
and dexmedetomidine can further improve postoperative recovery quality
in patients undergoing thoracoscopic surgery.

Materials and Methods
The study was approved by the Ethics Committee of the First Affiliated
Hospital of Kunming Medical University.
Study design and participants
This study is a single-center, prospective, randomized controlled,
double-blind trial. All patients were randomly assigned to three groups
using a computer-generated random sequence, and the randomization
process was selected. Anesthesia nurses were given sealed envelopes
containing the random assignment to prepare the corresponding saline
solution,
dexmedetomidine,
or
esketamine.
Therefore,
the
anesthesiologists, nurses, surgeons, and patients involved in the treatment
were unaware of the group assignments.The inclusion criteria were as
follows:(1) Age 18–65 years old;(2) BMI 18–30 kg/m2;(3) ASA
classification I–III;(4) Patients undergoing thoracoscopic surgery;(5) No
contraindications to the study drug;(6) Ability to express, communicate,
and understand normally;(7) Both the patient and their family members
agree to participate in this study and sign the informed consent
form.Exclusion Criteria:(1) Patients with poorly controlled or untreated
hypertension;(2) Patients with untreated hyperthyroidism;(3) Patients
with mental illness, cognitive impairment, or language barriers that
prevent communication;(4) Patients with severe cardiopulmonary, hepatic,
or renal dysfunction;(5) Patients with increased intracranial pressure;(6)

Patients with a history of allergic reactions to any of the drugs used in the
study;
Patients undergoing elective thoracoscopic surgery under general
anesthesia were randomly divided into 3 groups: Group D: 0.5 μg/kg
loading dose of ropivacaine administered 10 minutes before surgery,
followed by 0.4 μg/kg/h maintenance until 30 minutes before the end of
surgery; DE1 group: 0.5 μg/kg of ropivacaine was administered as a
loading dose 10 minutes before surgery, followed by maintenance at 0.4
μg/kg/hour after intubation until 30 minutes before the end of surgery; 0.2
mg/kg of esketamine was administered 1 minute after anesthesia
induction, followed by maintenance at 2 μg/kg/minute after intubation
until 30 minutes before the end of surgery; DE2 group: Administer 0.5
μg/kg of dexmedetomidine as a loading dose 10 minutes before surgery,
then maintain at 0.4 μg/kg/h after intubation until 30 minutes before the
end of surgery; administer 0.2 mg/kg of esketamine 1 minute after
anesthesia induction, then maintain at 4 μg/kg/min after intubation until
30 minutes before the end of surgery.
Anaesthesia, perioperative care
On the day before surgery, visit the patient to gain a comprehensive and
detailed understanding of their current physiological and pathological
status, assess their preoperative cardiopulmonary function, and explain
the use of esketamine in anesthesia. Provide instructions on surgical

precautions, including no drinking for 6 hours and no eating for 8 hours,
and have the patient sign the anesthesia informed consent form and the
clinical trial informed consent form.
After the patient enters the room, routine monitoring of vital signs is
conducted using a multi-functional monitor, including heart rate (HR),
pulse rate (PR), electrocardiogram (ECG), and pulse oximetry (SpO₂);
prepare
emergency
medications:
atropine
1
mg,
epinephrine
hydrochloride 1 mg, ephedrine 30 mg; prepare a set of general anesthesia
induction medications: etomidate, fentanyl, rocuronium bromide, and
pentobarbital hydrochloride; check the anesthesia machine for power
supply, gas supply, and functionality; prepare a set of endotracheal
intubation equipment: laryngoscope, double-lumen endotracheal tube,
suction catheter, etc.; after the patient enters the room, establish a
peripheral intravenous access and administer oxygen at a flow rate of 5
L/min.Under local anesthesia, radial artery puncture and catheterization
(heparin water flushing) were performed, and invasive arterial blood
pressure (ABP) was monitored.
Prior to anesthesia induction: After establishing peripheral venous
access upon admission to the operating room, patients were divided into
three groups: D, DE1, and DE2. received a loading dose of 0.5 μg/kg of
dexmedetomidine 10 minutes before surgery, followed by maintenance at
0.4 μg/kg/h after intubation until 30 minutes before surgery; the DE1

group received a loading dose of 0.5 μg/kg of dexmedetomidine 10
minutes before surgery, followed by maintenance at 0.4 μg/kg/h after
intubation until 30 minutes before the end of surgery. One minute after
induction of anesthesia, esketamine 0.2 mg/kg was administered,
followed by maintenance at 2 μg/kg/min after intubation until 30 minutes
before the end of surgery. The DE2 group received a loading dose of
dexmedetomidine 0.5 μg/kg 10 minutes before surgery, followed by 0.4
μg/kg/h maintenance until 30 minutes before the end of surgery. One
minute after induction of anesthesia, administer esketamine 0.2 mg/kg,
followed by 4 μg/kg/min maintenance until 30 minutes before the end of
surgery. At the start of anesthesia induction, after 3 minutes of pure
oxygen via a face mask, the three groups were sequentially administered
0.5 mg of pentobarbital hydrochloride, 3–5 µg/kg of fentanyl, 0.2–0.4
mg/kg of etomidate, and 0.9 mg/kg of rocuronium bromide.
After 5 minutes of oxygen via a face mask, once the jaw muscles
had relaxed, a double-lumen endotracheal tube (DLT) was inserted. After
5 minutes of oxygen administration via a face mask, once the mandibular
muscles have relaxed, a double-lumen endobronchial tube (DLT) is
inserted to ensure proper positioning. Set the anesthesia machine to
volume-controlled ventilation (VCV) and adjust respiratory parameters:
tidal
volume
6–8
ml/kg,
respiratory
rate
10–12
breaths/minute,
inspiratory-to-expiratory ratio 1:2, maintain end-tidal CO₂ pressure 35–45

mmHg, and maintain airway pressure ≤30 cmH₂O during surgery. After
anesthesia is stable, perform
internal jugular vein catheterization.
Anesthesia maintenance: Intraoperative anesthesia was maintained via
intravenous administration, with continuous infusion of propofol at 4–6
mg/kg/h and remifentanil at 6–12 µg/kg/h to maintain anesthesia depth.
Rocuronium bromide 0.4 mg/kg was administered as needed to maintain
muscle relaxation during surgery. Continuous monitoring of the bispectral
index (BIS) was performed during surgery, maintaining a value of 40–60.
Anesthetic drug dosage was adjusted based on BIS values and
fluctuations in vital signs. Prior to skin incision, 50 mg of flurbiprofen
ester was administered; 30 minutes before the end of surgery , administer
0.1 mg/kg dexmedetomidine; cease propofol infusion 10 minutes prior to
surgery, cease remifentanil infusion 5 minutes prior to surgery, and
connect the PCIA pump upon completion of surgery (analgesia regimen:
2 μg/kg sufentanil + 0.9% sodium chloride injection, total volume 100 ml
).Intraoperative management: (1) All three groups of patients were
managed using a target-directed fluid infusion strategy, with compound
electrolyte injection solution and succinyl gelatin injection solution
administered intraoperatively to maintain patient volume, and infusion
rates adjusted based on intraoperative hemodynamic characteristics. (2)
Intraoperative heart rate (HR) was maintained between 50–100 beats per
minute, and blood pressure was maintained within a 20% range of

preoperative resting blood pressure. If intraoperative bradycardia (HR <
50 beats per minute) or hypotension (mean arterial pressure < 60 mmHg)
occurred,intravenous bolus administration of atropine sulfate or ephedrine
hydrochloride was administered as appropriate based on the situation.
After anesthesia, the patient is transferred to the PACU with the tube
in place. Once spontaneous breathing and consciousness are restored,
suctioning and extubation are performed. Before discharge from the
PACU, assess respiratory variables of inhaled air: respiratory rate, arterial
blood gas analysis.
Primary and Secondary Outcomes
Anesthesiologist who was not participated in this study evaluated the total
postoperative recovery quality scores based on the QoR-15 scale before
surgery, on the first day after surgery (POD1), and on the third day after
surgery (POD3). The QoR-15 questionnaire is composed of 15 questions,
including physical comfort (5 items), emotional state (4 items), physical
independence (2 items), psychological support (2 items), and pain (2
items). The higher of the QoR-15 scores, the better of the quality of
recovery after surgery.
Secondary observation indicators:(1) Record the blood pressure and
heart rate of the three groups of patients at T0 (pre-anesthesia), T1
(intubation), T2 (incision), T3 (end of surgery), T4 (awakening), and T5
(extubation);(2) Record the intraoperative doses of propofol, remifentanil,

ephedrine,
and
atropine,
surgical
duration,
anesthetic
duration,
intraoperative fluid balance, recovery time, and PACU stay duration for
the three groups of patients; (3) Use the VAS score to assess the pain
intensity of the three groups of patients at rest and during coughing at 2h,
6h, 12h, and 24h postoperatively; (4) Record respiratory variables
(respiratory rate, PaO₂, PaCO₂) of inhaled air in the PACU for the three
groups of patients;
Statistical Analysis
We completed statistical analyses based on SPSS v.27 in the present study.
Quantitative data were expressed as mean ± standard. Comparisons
between multiple groups of quantitative data were performed using
analysis of variance. Count data were expressed as counts and
percentages (%). Comparisons between count data were performed using
χ2. The P value <0.05 was viewed as statistical significance.