Low-Dose Esketamine Combined with Propofol for Sedation in Elderly Patients Undergoing Bidirectional Endoscopy: A single-centre, double-blind, randomised, placebo-controlled trial

For millions of older adults, a routine check of the digestive system involves two separate procedures: a look inside the stomach and a look inside the colon. Often, doctors perform these one after the other in a single visit to save time and reduce the burden on the patient. To make these examinations comfortable, patients are given medication to induce a deep sleep, a state known as sedation. The most common drug used for this is propofol, which works quickly to put people to sleep and wears off just as fast. However, as people age, their bodies become less able to handle the side effects of this powerful drug. In elderly patients, propofol can sometimes cause blood pressure to drop too low or breathing to become shallow, creating a delicate balancing act for the medical team. They need the patient to be still and unaware, but they also need to ensure the heart and lungs remain stable throughout the long procedure.

Researchers have long looked for a way to make this process safer for older adults without sacrificing the quality of the examination. One promising candidate is a drug called esketamine, a specific form of a well-known anesthetic that has the unique ability to stimulate the body's natural defenses against low blood pressure while also providing pain relief. The idea was that adding a small amount of esketamine to the standard sedation might act as a buffer, protecting the heart and lungs from the stress of the procedure. To test this theory, a team of doctors in China conducted a rigorous study involving hundreds of elderly patients. They wanted to see if this combination could prevent the dangerous drops in blood pressure and oxygen that sometimes occur during these dual examinations, and whether it could make the procedure itself run more smoothly.

The study enrolled 316 patients between the ages of 60 and 80 who were scheduled for both a stomach and colon examination on the same day. The researchers divided these patients into two groups using a method that ensured neither the patients nor the doctors knew who was receiving which treatment. One group received the standard dose of propofol mixed with a harmless saltwater solution, while the other group received the same dose of propofol mixed with a low dose of esketamine. The doctors then monitored the patients closely, tracking their heart rate, blood pressure, and oxygen levels from the moment the drugs were given until they woke up. They also recorded how long it took for the patients to fall asleep, how much propofol was needed to keep them asleep, and whether the patients moved or coughed during the exam, which can make the procedure difficult for the doctor.

When the results were analyzed, the researchers found that the combination of drugs did not completely eliminate the risk of low blood pressure or low oxygen levels. The number of patients who experienced these issues was slightly lower in the group that received esketamine, but the difference was not large enough to be considered statistically significant. In other words, the new combination did not prove to be a magic shield that stopped these complications from happening entirely. However, the story did not end there. While the overall number of complications was similar, the patients who received esketamine maintained a more stable rhythm throughout the entire procedure. Their blood pressure and oxygen levels fluctuated less, staying closer to their normal baseline compared to the group that received only propofol.

Beyond the vital signs, the combination of drugs offered several practical advantages that made the procedure better for everyone involved. The patients who received esketamine fell asleep faster, taking an average of 120 seconds compared to 140 seconds for the others. Because the esketamine helped deepen the sedation, the doctors needed to use less propofol overall, reducing the total amount of medication the patients received by about 16 percent. This efficiency translated directly into the quality of the exam. When the doctor attempted to insert the scope into the stomach for the first time, it was successful immediately in every single patient in the esketamine group, whereas a small number of patients in the other group required a second attempt. Furthermore, the patients receiving esketamine were much less likely to cough or gag during the exam, a reaction known as bucking, which can disrupt the doctor's view and increase the risk of injury.

Perhaps most importantly, the researchers found that these benefits came without a new set of problems. There was no increase in side effects such as dizziness, nausea, or the strange, dream-like feelings that can sometimes occur with ketamine-based drugs. The patients in both groups woke up at similar times and reported being just as satisfied with their experience. The study concluded that while adding a low dose of esketamine did not completely prevent the most serious risks of sedation in the elderly, it created a smoother, more stable environment for the procedure. It allowed the doctors to work more efficiently with less medication and fewer interruptions, all while keeping the patients safe and comfortable. This suggests that for older adults facing these necessary medical exams, a small adjustment to the sedation recipe could offer a meaningful improvement in care, even if it does not solve every challenge.