Propofol Meets Esketamine: A Game-Changer for GA in Acute Cesarean Sections, states study

Recently published case series explored the utilization of an esketamine-based combined low-dose propofol induction strategy for general anesthesia during category-1 emergency cesarean sections (CSs). The study arose from the need for effective anesthesia protocols that minimize risks to both mother and neonate amidst urgent surgical scenarios. Methodology Approval was obtained with a waiver for written consent from the Ethics Committee of Taizhou Hospital, and a retrospective analysis of 11 women undergoing emergency CSs from November 2022 to November 2024 was conducted. Participants had a mean age of 30.7 years and a mean BMI of 25.3 kg/m². Reasons for CS included cases of placenta previa, placental abruption, acute fetal distress, and umbilical cord prolapse.

The induction protocol involved preoxygenation, the administration of 0.5 mg/kg esketamine, 1 mg/kg propofol, and 1 mg/kg rocuronium, followed by tracheal intubation using videolaryngoscopy. Anesthesia maintenance consisted of an intravenous propofol infusion and inhalation of sevoflurane, with continuous monitoring of vital signs. The decision-to-delivery interval (DDI) was evaluated via patient records, and neonatal Apgar scores were recorded at 1 and 5 minutes post-delivery. Maternal and neonatal outcomes, as well as any adverse effects associated with esketamine, were documented.

Results Notable findings included a mean DDI of 10.9 minutes. The median neonatal Apgar scores were 9 at 1 minute and 10 at 5 minutes, indicating favorable outcomes; only one newborn needed temporary mask ventilation due to asphyxia associated with placental abruption. Notably, no instances of intraoperative hypotension (MAP < 70 mmHg) occurred, and adverse effects related to esketamine were absent. Implications The esketamine and low-dose propofol combination demonstrated the potential to maintain maternal hemodynamic stability without compromising neonatal safety. It appears advantageous, particularly for patients at risk of hypotension. Limitations Limitations of the case series include a small sample size and its retrospective nature, which could hinder generalizability. Concerns remain about the long-term effects of esketamine on newborn development and the safety of sugammadex in pregnant women. ### Conclusion The esketamine-propofol induction strategy may serve as a viable option in urgent CS scenarios, warranting further randomized controlled trials to better assess maternal and neonatal outcomes.

Key Points

- -Study Design and Population-: A retrospective analysis was conducted on 11 women undergoing emergency cesarean sections (CSs) over a two-year period, with a mean age of 30.7 years and mean BMI of 25.3 kg/m². Indications for surgery included placenta previa, placental abruption, acute fetal distress, and umbilical cord prolapse, highlighting the varied clinical scenarios in which the anesthesia protocol was applied.

- -Induction Protocol-: The anesthesia induction involved preoxygenation, followed by the administration of 0.5 mg/kg esketamine, 1 mg/kg propofol, and 1 mg/kg rocuronium. Tracheal intubation was performed using videolaryngoscopy, emphasizing the use of modern techniques to ensure safety during urgent procedures.

- -Monitoring and Outcomes-: Monitoring of vital signs continued throughout the procedure. The average decision-to-delivery interval (DDI) was recorded as 10.9 minutes, which reflects the efficiency of the anesthesia and surgical team in managing emergency situations.

- -Neonatal Performance-: Apgar scores were favorable, with median scores of 9 at 1 minute and 10 at 5 minutes. Only one newborn required temporary mask ventilation due to asphyxia associated with placental abruption, indicating a generally positive outcome regarding neonatal health.

- -Maternal Safety-: No cases of intraoperative hypotension (mean arterial pressure < 70 mmHg) were reported, and there were no adverse effects linked to the administration of esketamine, suggesting that the combined use of esketamine and low-dose propofol is effective in maintaining maternal hemodynamic stability.

- -Study Limitations and Future Research-: The small sample size and retrospective nature limit the generalizability of the findings. There are concerns regarding the long-term effects of esketamine on newborn development and the safety of using sugammadex in pregnant patients. Further randomized controlled trials are suggested to validate this induction strategy and assess both maternal and neonatal outcomes more comprehensively.

Reference –

Guang-Qiu Zhu et al. (2025). Esketamine Combined With Low-Dose Propofol Induction Strategy For Category-1 Cesarean Section: A Case Series. *BMC Anesthesiology*, 25. https://doi.org/10.1186/s12871-025-03098-8.