Esketamine effective intranasal premedication in children with congenital heart disease

Preoperative pediatric anxiety is a serious disorder and seen in approximately 50-60% of children, especially those aged 1-5 years. This may have a negative psychological impact on children undergoing surgery. Esketamine is made from a drug called ketamine, an anesthetic that has also been used for many years to treat depression.

Recently esketamine, a more potent version of ketamine, earned FDA approval specifically for use as a nasal spray for those with treatment-resistant depression. However, the proper dosage for intranasal use in children with congenital heart disease (CHD) has not been determined.

The current study in BMC Anesthesiology by Jiajia Huang, and team aimed to study the median effective dose (ED50) of esketamine for intranasal premedication in children with CHD and found that 0.7mg/kg was an effective sedation in pediatric patients.

A total of thirty-four children with CHD who needed premedication in March 2021 were enrolled. Intranasal esketamine was initiated at a dose of 1 mg/kg. Based on the outcome of sedation in the previous patient, the dose for the subsequent patient was either increased or reduced by 0.1 mg/kg, which was adjusted between each child.

Successful sedation was defined as a Ramsay Sedation Scale score ≥ 3 and Parental Separation Anxiety Scale score ≤ 2. The required ED50 of esketamine was calculated using the modified sequential method. Non-invasive blood pressure, heart rate, saturation of peripheral oxygen, sedation onset time, and adverse reactions were recorded at 5 min intervals after drug administration.

The key findings of the study are

• The 34 children enrolled had a mean age of 22.5 ± 16.4 (4–54) months and a mean weight of 11.2 ± 3.6 (5.5–20.5) kg; American Society of Anesthesiologists classification I–III.

• The ED50 of intranasal S(+)-ketamine (esketamine) required for preoperative sedation in pediatric patients with CHD was 0.7 (95% confidence interval: 0.54–0.86) mg/kg.

• The mean sedation onset time was 16.39 ± 7.24 min. No serious adverse events, such as respiratory distress, nausea, and vomiting were observed.

Jiajia Huang and team, concluded that "The ED50 of intranasal esketamine was 0.7 mg/kg, which was safe and effective for preoperative sedation in pediatric patients with CHD."

Reference: Huang, J., Liu, D., Bai, J. et al. Median effective dose of esketamine for intranasal premedication in children with congenital heart disease. BMC Anesthesiol 23, 129 (2023). https://doi.org/10.1186/s12871-023-02077-1