Can Low Dose Esketamine Prevent Lingering Pain After Lung Surgery?
Most people expect pain after chest surgery to fade within a few weeks. For a good share of patients it does not. Even with minimally invasive thoracoscopic surgery, a meaningful number of people still have pain at the incision sites months later. A large trial published October 28, 2026 in the British Journal of Anaesthesia asked whether a low dose esketamine infusion around the time of surgery could lower that number.
The study
Investigators at ten hospitals in Jiangsu, China randomized 914 adults having video-assisted thoracoscopic lung resection to esketamine or saline. The esketamine group got a small bolus at induction (0.1 mg/kg), a matching infusion during surgery (0.1 mg/kg per hour), and a very low infusion for 48 hours afterward (0.015 mg/kg per hour). Patients and clinicians were blinded.
The main outcome was chronic pain at 3 months, defined as any pain at the surgical site with coughing (a score of 1 or more out of 10). Among the 873 patients analyzed, chronic pain occurred in 14.7% of the esketamine group and 21.2% of the saline group, an adjusted odds ratio of 0.62 (95% CI 0.43 to 0.90). Using a stricter post hoc cutoff of 3 or more out of 10, the benefit held. Esketamine also lowered pain scores and rescue analgesic use in the first 48 hours, and the authors report no increase in adverse effects.
How I read it
This is a well sized, blinded, multicenter trial, and the result fits with what many of us have seen at the bedside: ketamine type drugs seem to take the edge off the way the nervous system gets sensitized after surgery. An absolute drop of about six percentage points means roughly one fewer patient with lingering pain for every 16 treated, which is a real benefit for a cheap drug given at a low dose.
A few caveats are worth keeping in mind. The primary definition of chronic pain was generous, since any pain at all with coughing counted, and many of those patients likely had mild pain that did not change their daily life. The stricter definition was added after the fact. Esketamine is the S isomer of ketamine and is not widely used during surgery in the United States, so the closest practical option here is racemic ketamine, which is not quite the same drug. The trial also needed a 48 hour infusion, which takes pumps, monitoring, and nursing comfort on the ward.
What it means for practice here
For chest and other major surgery in Casper, I already think about low dose ketamine as part of a plan that also includes regional blocks, acetaminophen, and anti-inflammatory drugs when they are safe. This trial adds to the case for continuing a low dose infusion into the first day or two after surgery, not just using it in the operating room. I would still choose patients with care, watching for those with a history of psychosis, poorly controlled high blood pressure, or significant heart disease. Most of all, it is a reminder that what we do in the first hours after surgery can shape how a patient feels months later.
Source
- Wang QY, Zhang JY, Gu JQ, et al. Effects of perioperative esketamine infusion on chronic pain after video-assisted thoracoscopic lung resection: a multicentre, randomised, double-blind clinical trial. British Journal of Anaesthesia. Published online October 28, 2026. doi:10.1016/j.bja.2026.08.039. PMID 42951789. Abstract (PubMed)
This post is clinician commentary for educational discussion. It is not medical advice for any reader's personal care. Anesthesia and perioperative decisions should be made with the treating clinician based on the individual patient's circumstances.