Intravenous esketamine for the prevention of emergence delirium and negative behavioural changes after paediatric adenotonsillectomy: a randomised controlled trial.

Abstract

Emergence delirium affects 25-60% of children after surgery, manifesting as acute confusion, disorientation and agitation. This condition is particularly common following adenotonsillectomy and can lead to negative behavioural changes that persist for weeks in approximately 50% of affected children. We conducted a single-centre, prospective, double-blind, randomised controlled trial in children aged 3-7 y undergoing adenotonsillectomy. Patients received either intravenous esketamine 0.2 mg.kg^-1 or an equivalent volume of 0.9% saline after adenoid tissue resection. The co-primary outcomes were the incidence of emergence delirium and negative behavioural changes on postoperative day 7. A total of 228 patients were allocated randomly. Emergence delirium was less frequent in children allocated to the esketamine group compared with those allocated to the 0.9% saline group (19/114, 17% vs. 49/114, 43%; relative risk 0.40, 97.5%CI 0.23-0.68, p < 0.001). Negative behavioural changes on postoperative day 7 were lower in children allocated to the esketamine group compared with those allocated to the 0.9% saline group (48/114, 42% vs. 70/114, 61%; relative risk 0.70, 97.5%CI 0.51-0.95, p = 0.009). Benefits extended to postoperative day 30, with improved analgesia and greater parental satisfaction. Adverse event rates were similar between groups. In children undergoing adenotonsillectomy, intra-operative low-dose intravenous esketamine significantly reduced emergence delirium and negative behavioural changes without increasing adverse events. This intervention offers a safe, effective approach to improving paediatric surgical outcomes.