Can Low Dose Esketamine Help Patients Sleep After Surgery?
Poor sleep after an operation is more than an inconvenience. Patients who do not sleep well the first few nights often hurt more, feel more anxious, and recover more slowly. Esketamine, the S enantiomer of ketamine, has been studied for pain and mood. A November 2, 2026 review in BMC Anesthesiology asked a more specific question: does giving it around the time of surgery actually prevent postoperative sleep disturbance?
The study
The authors pooled 15 randomized trials with 1,863 adults. Each trial compared perioperative intravenous esketamine with a normal saline placebo and reported how often patients had sleep disturbance on the first and third days after surgery. They also looked at day 7 sleep, subjective sleep scores, pain, early anxiety, depression scores, remifentanil use, quality of recovery, and adverse events. Trial sequential analysis was used to check whether the main findings were already conclusive.
Esketamine lowered the rate of sleep disturbance on day 1 and day 3, and the sequential analysis supported those early results as conclusive. Day 7 also looked better with esketamine, but the authors said the sample for that later time point was still too small to call it settled. Patients reported better sleep quality and better overall recovery. Pain scores and early anxiety were lower, and less remifentanil was used during surgery. Depression scores did not improve. The benefit held in both older adults (60 and up) and younger patients. Continuous intraoperative infusion and other dosing approaches looked similar, and sub anesthetic infusion rates below 0.5 mg/kg/h were enough to see a clinical effect. Adverse event rates were not meaningfully different between groups.
How I read it
This is encouraging for a problem we see every week. Sleep after surgery is easy to overlook once the patient leaves the recovery room, yet it shapes how the next few days feel. Low dose esketamine already has a place in some of my pain plans. Seeing a consistent sleep signal across many trials, with trial sequential analysis behind the early endpoints, strengthens the case that the drug is doing more than dulling pain.
I would still keep expectations in check. The trials used different surgeries, different ways of defining sleep disturbance, and mostly short follow up. Day 7 evidence is thinner. Depression did not budge, so this is not a broad mood treatment. And as with any ketamine related drug, I watch for vivid dreams, nausea, and blood pressure changes, even when pooled adverse event rates look similar.
What it means for practice here
For patients in Casper who are likely to have a rough first night, such as those with chronic pain, anxiety, or a longer inpatient stay, a carefully dosed esketamine infusion is something I already consider for analgesia. This review gives me another reason to think about it when sleep is a real concern, especially at the modest rates below 0.5 mg/kg/h that the authors highlight. It does not replace the basics: good multimodal pain control, a quiet room when we can arrange one, limited nighttime interruptions, and clear expectations about the first few nights at home.
Source
- Chen F, Liu C, Wu Y, et al. Efficacy and safety of perioperative intravenous esketamine for the prevention of postoperative sleep disturbance and reduction of its incidence in adult surgical patients: a systematic review, meta-analysis, and trial sequential analysis of randomized controlled trials (RCTs). BMC Anesthesiology. Published online November 2, 2026. doi:10.1186/s12871-026-04319-4. Full text (DOI)
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.