The effect of esketamine on emergence delirium or agitation in children after anesthesia-a systematic review and meta-analysis

Abstract Background This systematic review and meta-analysis aim to evaluate esketamine on emergence delirium or emergence agitation (ED/EA) in pediatric children in contrast to the control group. Methods The PubMed, Web of Science, and Cochrane Library databases were systematically searched until August 2024, employing inclusion criteria focused on studies involving children under the age of 18 comparing esketamine to control groups. The exclusion criteria encompassed participants aged 18 years and older, reviews or meta-analyses, fundamental animal studies, articles published solely in abstract form, letters to the editor, case reports, editorial notes, methodological protocols, and publications not in English. Results A total of 1142 children were included in ten randomized controlled trials (RCTs) and one cohort study, revealing that esketamine significantly reduces the risk of ED/EA in pediatric patients following surgery when compared to the control group (OR = 0.70, 95% CI: (0.51, 0.97), I 2 = 80%, P for effect = 0.03). Subgroup analysis indicated that low-dose esketamine was particularly effective in mitigating postoperative ED or EA (OR = 0.33, 95% CI: (0.20, 0.53), I 2 = 19%, P for effect < 0.00001), as well as reducing postoperative pain scores (SMD = -1.30, 95% CI: (-2.28, -0.32), I 2 = 95%, P for effect = 0.009). Furthermore, it did not elevate the incidence of postoperative nausea and vomiting (PONV) (OR: [0.44–1.19], I 2 = 27%, P for effect = 0.20). Conclusions In comparison to the control group, esketamine significantly decreases the incidence of emergence delirium or emergence agitation (ED/EA) in pediatric patients, with a markedly lower heterogeneity (I 2 ) observed at lower dosages(esketamine < 0.5 mg/kg). Additionally, esketamine effectively mitigates postoperative pain scores in children without elevating the occurrence of PONV. Trial registration Prospero registration ID:CRD42024583287. Link:PROSPERO (york.ac.uk).