Perioperative intravenous lidocaine plus esketamine and patient-reported recovery after functional endoscopic sinus surgery.

Abstract

Background: Functional endoscopic sinus surgery (FESS) may be followed by poor early QoR-40-assessed patient-reported recovery and emergence agitation. We performed a secondary analysis to evaluate whether perioperative lidocaine plus esketamine was associated with improved early QoR-40-assessed patient-reported recovery. Inflammatory biomarkers, mood-related symptom scores, and peri-emergence neurobehavioral outcomes were assessed as supportive outcomes.

Methods: This secondary analysis included 140 adults (18-65 years) from a single-center randomized four-arm study of FESS: lidocaine + esketamine (LA), lidocaine (L), esketamine (A), or saline (N), 35 per group. Study infusions were administered from 10 min before induction until the end of surgery. The primary endpoint was QoR-40 total score on postoperative day 1 (POD1), defined as the first assessment 24 ± 6 h after extubation; QoR-40 POD2 was the key secondary endpoint; SAS/SDS, emergence agitation (Riker ≥ 5), Nu-DESC-defined PACU delirium-like symptoms, and IL-6/TNF-α (T1-T4) were supportive secondary outcomes. QoR-40 POD7 total score and comparisons of the five QoR-40 domains (Physical, comfort, emotional state, self-care ability/physical independence, social support/patient support, and pain) were exploratory. QoR-40 total/domain scores and SAS/SDS were analyzed using baseline-adjusted ANCOVA.

Results: POD1 QoR-40 was available for 137/140 participants, and exploratory POD7 QoR-40 for 136/140. LA was associated with higher QoR-40 than N on POD1 (adjusted mean difference 10.5; 95% CI 5.7-15.3; P = 3.36 × 10^-5) and POD2 (adjusted mean difference 8.2; 95% CI 4.6-11.8; P = 1.56 × 10^-5). Exploratory POD7 total-score and domain analyses were directionally favorable but are interpreted descriptively.In supportive secondary analyses, LA had lower POD1 SAS and SDS (-4.9 and -5.7 points). Agitation was numerically less frequent in LA than N (11.4% vs 31.4%), but the confidence interval crossed unity (RR 0.36; 95% CI 0.13-1.03). At 24 h, IL-6 and TNF-α were lower in LA than N (ratios 0.77 [0.69-0.86] and 0.70 [0.64-0.77]). No serious drug-related adverse events occurred; dreams/hallucinations occurred in 17.1% (LA) and 14.3% (A).

Conclusions: In this secondary analysis, perioperative lidocaine plus esketamine during FESS was associated with higher QoR-40-assessed patient-reported recovery on POD1 and POD2, lower early anxiety/depression symptom scores, and lower postoperative inflammatory biomarkers. Exploratory POD7 and QoR-40 domain analyses were supportive but should be interpreted descriptively.