Esketamine combined with low-dose propofol induction strategy for category-1 cesarean section: a case series

General anesthesia (GA) is the most accepted option for category-1 emergency cesarean sections (CSs). A low dose of esketamine has been used as an excellent adjunct to neuraxial anesthesia (NA) with little effect on newborns. However, literature on the use of esketamine for GA induction in emergency CS is limited. This case series describes our experience with an esketamine-based combined low-dose propofol induction strategy for category-1 CS.

We retrospectively analyzed esketamine-based anesthesia induction for category-1 emergency CS at our hospital between November 2022 and November 2024. Modified rapid sequence induction included 0.5 mg/kg esketamine, 1 mg/kg propofol, and 1 mg/kg rocuronium, respectively. Anesthesia was maintained by propofol infusion at 4 mg/kg/h and inhalation of 1.5% sevoflurane. The dose of propofol and sevoflurane was adjusted to maintain the BIS value at 40-60.

The final cohort comprised 11 patients. The median 1-minute Apgar score was 9 points [range, 6-10], and the 5-minute Apgar score was 10 points for all newborns. The mean decision-to-delivery interval (DDI) was 10.9 ± 2.4 min. Only one newborn required temporary mask ventilation due to acute fetal distress, mainly caused by major placental abruption. No newborns were admitted to the intensive care unit (ICU). No episodes of hypotension (MAP < 70 mmHg) were observed from anesthesia induction to delivery of the newborns. In all cases, there was no intraoperative awareness, reflux aspiration, or adverse psychiatric effects.

The esketamine-based combination low-dose propofol induction strategy can effectively maintain maternal hemodynamic stability without causing neonatal depression, making it suitable for category-1 emergency CSs. However, further randomized controlled trials are needed to confirm these findings.