The effect of esketamine as adjuvant to ropivacaine for unilateral paravertebral block on postoperative pain and sensitization in adult patients undergoing video-assisted thoracoscopic surgery: a randomized clinical trial.

Abstract

<h4>Purpose</h4>Video-assisted thoracoscopic surgery (VATS) is accompanied by substantial acute postoperative pain, which may trigger sensitization and chronic postsurgical pain (CPSP). Despite multimodal analgesia, postoperative pain remains inadequately controlled. This study investigated whether low-dose esketamine as an adjuvant to paravertebral block (PVB) attenuates pain sensitization after VATS.<h4>Methods</h4>119 patients scheduled for elective VATS lobectomy were randomly allocated to two groups. Group K received PVB with 0.25% ropivacaine plus esketamine (0.5 mg/kg) after skin closure, whereas Group C received ropivacaine alone. Peripheral and central sensitization were assessed using mechanical pain thresholds on postoperative days (POD) 1 and 3. Postoperative pain was evaluated using the numerical rating scale (NRS) scores. CPSP and neuropathic components were assessed at 1 and 3 months postoperatively.<h4>Results</h4>Group K showed lower rates of peripheral sensitization on POD 1 and POD 3 compared with group C (POD 1: 28.8% vs 58.3%, absolute risk reduction (ARR): 29.5%, RR 0.55, 95% CI 0.39-0.80, P = 0.001; POD 3: 25.4% vs 48.3%, ARR:22.9%, RR 0.63, 95% CI 0.44-0.88, P = 0.010). On POD 1, NRS scores in motion were lower in Group K (3.0 [2.0,4.0] vs 3.5 [3.0,5.0], P < 0.001). At 3 months, Group K showed a lower incidence of CPSP (20.4% vs 39.6%; ARR: 19.2%, RR 0.52, 95% CI 0.27-0.99, P = 0.039).<h4>Conclusion</h4>Low-dose esketamine as an adjuvant to PVB reduced postoperative pain, attenuated pain sensitization, and lowered the incidence of CPSP following VATS. This regimen may have potential clinical value but warrants further validation in larger studies.

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