The Impact of Intranasal Esketamine on Emergence Agitation in Children Undergoing Adenotonsillectomy: A Randomized Controlled Study

Abstract

Purpose: To investigate the efficacy of intranasal esketamine in reducing the incidence of emergence agitation (EA) in pediatric patients undergoing adenotonsillectomy and to determine the optimal dose of esketamine. Methods: A total of 204 children aged 3–6 years scheduled for adenotonsillectomy were randomly assigned to three groups. All participants received a standardized anesthetic induction protocol. Following tracheal intubation, they were administered intranasally 0.5 mg/kg esketamine (group LE), 1 mg/kg esketamine (group HE), or an equivalent volume of saline (group C). Anesthesia was maintained with sevoflurane during surgery, and the children were transferred to the post-anesthesia care unit (PACU) after extubation. The highest scores on the Pediatric Anesthesia Emergence Delirium (PAED) scale and the modified Children’s Hospital of Eastern Ontario Pain Scale (m-CHEOPS) in the PACU were recorded. The incidence of EA, defined as PAED ≥ 10, was calculated for each group. Additionally, changes in vital signs after intranasal administration, surgery time, anesthesia time, extubation time, eye-opening time, recovery time, and the incidence of adverse reactions were compared among the three groups. Results: Group LE demonstrated a significantly lower incidence of EA compared with group C (10.45% vs 29.85%, P = 0.005), while no significant difference was observed between group LE and HE (10.45% vs 12.12%, P = 0.760). Relative to Group C, children in Group LE also showed significantly lower PAED (P = 0.010) and m-CHEOPS scores (P = 0.023), along with reduced requirements for rescue propofol (P = 0.005) and rescue fentanyl (P = 0.013). Groups LE and HE demonstrated comparable performance across these secondary outcomes; however, extubation time was prolonged in Group HE (P = 0.025). Conclusion: Intranasal esketamine at a dose of 0.5 mg/kg significantly reduces the incidence of EA following pediatric adenotonsillectomy. Increasing the dose to 1 mg/kg does not confer additional benefit in preventing EA and may instead delay extubation.