Intravenous Esketamine Versus Erector Spinae Plane Block for Postoperative Recovery Quality Following Video-Assisted Thoracoscopic Surgery: A Randomized Controlled Non-Inferiority Trial

OBJECTIVES: This non-inferiority trial compared intravenous esketamine with erector spinae plane block (ESPB) for postoperative recovery quality and analgesic efficacy in patients undergoing video-assisted thoracoscopic surgery (VATS). DESIGN: Randomized controlled non-inferiority study. SETTING: Single-center, university hospital. PARTICIPANTS: One hundred twelve patients undergoing VATS. INTERVENTIONS: The esketamine group received intravenous esketamine (0.25-mg/kg bolus + 0.25-mg/kg/h infusion) combined with a sham ESPB (25 mL of saline solution). The ESPB group received active ESPB (25 mL of 0.375% ropivacaine) plus intravenous saline solution. MEASUREMENTS AND MAIN RESULTS: Outcomes included 15-item quality of recovery (Quality of Recovery-15 [QoR-15]) scores, postoperative pain scores, Hospital Anxiety and Depression Scale (HADS) scores, and perioperative hemodynamic changes. The differences in the QoR-15 scores between the groups on postoperative day 1 (mean difference, 1.0; 95% confidence interval [CI], -2.9 to 4.8; p = 0.622) and postoperative day 2 (mean difference, 0.4; 95% CI, -3.4 to 4.3; p = 0.833) met the non-inferiority criterion (-6 points). The ESPB group showed significantly lower pain scores during coughing at 4 hours (p = 0.026) and 8 hours (p = 0.006) postoperatively. The esketamine group had lower HADS scores and a lower incidence of hypotension. CONCLUSIONS: Intravenous esketamine provides postoperative recovery quality that is non-inferior to ESPB after VATS, primarily because of its beneficial effects on mood, which compensates for its weaker early analgesia. Thus, esketamine may serve not as a direct analgesic substitute for ESPB, but as a rescue option when ESPB is not feasible, or as an analgesic adjunct with anxiolytic and antidepressant effects.