Prophylactic esketamine for postoperative sore throat: a meta-analysis of randomized evidence

Postoperative sore throat (POST) is a common and distressing complication following airway instrumentation under general anesthesia, with a significant impact on patient comfort and satisfaction. Esketamine, a potent N-methyl-D-aspartate (NMDA) receptor antagonist, has demonstrated analgesic and anti-inflammatory properties that may reduce airway irritation; however, its role in preventing POST remains unclear. This study aims to evaluate the efficacy and safety of prophylactic esketamine in reducing the incidence and severity of postoperative sore throat. A systematic review and meta-analysis were conducted in accordance with PRISMA 2020 guidelines. Randomized controlled trials assessing esketamine for the prevention of POST in patients undergoing surgery with airway instrumentation were included. Databases (PubMed, Scopus, and Web of Science) were searched from inception to 2026. The primary outcome was the incidence of POST, while secondary outcomes included severity of POST, cough or bucking during extubation, extubation time, and adverse events. Pooled risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI) were calculated using a random-effects model. Five randomized controlled trials involving 548 patients were included. Esketamine significantly reduced the incidence of POST compared with control interventions (RR 0.42, 95% CI 0.24-0.71; P = 0.001), with moderate heterogeneity (I² = 60%). Sensitivity analysis excluding one study with an active comparator demonstrated a greater reduction (RR 0.21, 95% CI 0.12-0.38) and no heterogeneity. Esketamine also significantly reduced the incidence of cough or bucking during extubation (RR 0.55, 95% CI 0.37-0.82; P = 0.003). There was no significant difference in extubation time between groups. No serious adverse events or psychomimetic effects were reported. Prophylactic esketamine significantly reduces the incidence of postoperative sore throat and airway reflexes during extubation, with a favorable safety profile. These findings support its use as part of multimodal strategies for POST prevention; however, further large-scale trials are needed to determine optimal dosing and administration routes.