Effect of Low-dose EsketaMine on dElirium in High-risk Elderly Patients uNdergoing elecTive Surgery (ELEMENT)

Effect of Perioperative Low-dose EsketaMine on dElirium in High-risk Elderly Patients uNdergoing elecTive Major Non-cardiac Surgery: a Multi-center Randomized Trial (ELEMENT Trial)

Delirium is an acutely occurred neurocognitive disorder characterized by fluctuating symptoms of inattention, altered consciousness and cognitive dysfunction. Delirium is reported to occur in 4% to 65% of postoperative patients depending on the population, and is especially common in older patients. Postoperative delirium is disturbing to patients and their families, and it is a strong predictor of both early and long-term worse outcomes including increased non-delirium complications, increased perioperative mortality, shortened overall survival, declined cognitive function, and lowered quality of life.

Although ketamine/esketamine has anti-inflammatory and neuroprotective effects, evidence on its efficacy in reducing postoperative delirium remains inconsistent and inconclusive. Existing studies are limited by heterogeneity, small sample sizes, single-center designs, and a focus on specific type of surgery. Research on elderly high-risk patients is lacking, and most studies administer the drug intraoperatively, with limited exploration of postoperative use. The optimal dosing and timing for POD prevention are unclear. This study aims to carry out a multicenter, single-blind, placebo-controlled, large-sample randomized controlled trial assessing the effect of low-dose esketamine, given intraoperatively and postoperatively, on delirium in elderly high-risk patients undergoing major non-cardiac surgery.

Study Overview

• Status: Recruiting
• Conditions: Pain, Postoperative; Cognitive Dysfunction; Anesthesia; Delirium in Old Age; Esketamine; Non-cardiac Surgery; Delirium, Postoperative
• Intervention / Treatment: Drug: Esketamine; Drug: Normal saline

Detailed Description

Delirium is an acutely occurred neurocognitive disorder characterized by fluctuating symptoms of inattention, altered consciousness and cognitive dysfunction. Delirium is reported to occur in 4% to 65% of postoperative patients depending on the population, and is especially common in older patients. Postoperative delirium is disturbing to patients and their families, and it is a strong predictor of both early and long-term worse outcomes including increased non-delirium complications, increased perioperative mortality, shortened overall survival, declined cognitive function, and lowered quality of life.

The mechanism of delirium remains unclear, with neuroinflammation playing a significant role. Emerging evidence suggests anesthetic drug selection may influence the incidence of delirium. Ketamine, a non-competitive NMDA receptor antagonist, exhibits anti-inflammatory and neuroprotective properties by reducing TNF-α, IL-6, IL-1β, p-TAU, and S100B levels, mitigating oxidative stress, and inhibiting neuronal autophagy via the PI3K/AKT/mTOR pathway, thereby potentially preserving cognitive function. Clinical studies exploring ketamine's role in postoperative delirium have yielded mixed results. A retrospective study involving ICU patients undergone abdominal surgery found low-dose ketamine reduced delirium risk by 43% after propensity score matching. In cardiac surgery patients, a single dose of ketamine during induction decreased delirium incidence from 31% to 3%. However, a large international multicenter RCT in patients aged ≥60 undergoing major surgery found no reduction in delirium with pre-induction ketamine. A meta-analysis of eight RCTs also reported no preventive effect, though significant heterogeneity and inconsistent diagnostic criteria were noted. Perioperative ketamine use was consistently found safe, with no increase in adverse events such as nausea, vomiting, respiratory depression, or psychiatric symptoms.

Esketamine, the S-(+)-enantiomer of ketamine, has higher bioavailability, a shorter elimination half-life, and fewer side effects. It is effective in general anesthesia, postoperative analgesia, and ICU sedation, and can be used alone for minor procedures or combined with general or regional anesthesia. As an adjunct, it reduces the need for sedatives (e.g., propofol, midazolam) and opioids, minimizes hemodynamic fluctuations and respiratory depression, and improves anesthesia safety. Esketamine may prevent postoperative delirium, as suggested by emerging evidence. A single dose (0.25 mg/kg) before induction reduced delirium incidence in cardiac surgery patients from 44.6% to 23.2%. In elderly patients undergone gastrointestinal cancer surgery, intraoperative infusion (0.25 mg/kg at induction, then 0.125 mg/kg/h until 20 minutes before the end of surgery) decreased delayed neurocognitive recovery but not delirium. Conversely, postoperative esketamine (1 mg/kg) reduced delirium incidence from 40% to 13.3% in another RCT involving elderly patients undergone gastrointestinal surgery. In patients after major abdominal surgery, mini-dose esketamine (0.015 mg/kg/h for 48 hours) significantly lowered ICU delirium scores compared to low-dose esketamine or placebo. Two meta-analyses of 13 and 17 RCTs, respectively, reported reduced delirium incidence with perioperative esketamine usage, though evidence quality was limited by small sample sizes and heterogeneity. Recent studies showed mixed results. A single-center RCT of 426 elderly surgical patients found no reduction in delirium with 0.2 mg/kg esketamine at induction. In 209 patients aged ≥60 undergone tumor resection, 0.5 mg/kg at induction and 2 mg/kg PCIA postoperatively did not reduce delirium but may improve 90-day cognitive function. Similarly, a single-center RCT of 260 elderly patients after arthroplasty surgery found no benefit with esketamine administered at induction (0.2 mg/kg), intraoperatively (0.125 mg/kg/h), and postoperatively (0.5 mg/kg PCIA). Despite inconsistent findings, esketamine is safe in total, with no increased risk of adverse effects such as respiratory depression, nausea, vomiting, or psychiatric symptoms.

Although ketamine/esketamine has anti-inflammatory and neuroprotective effects, evidence on its efficacy in reducing postoperative delirium remains inconsistent and inconclusive. Existing studies are limited by heterogeneity, small sample sizes, single-center designs, and a focus on specific type of surgery. Research on elderly high-risk patients is lacking, and most studies administer the drug intraoperatively, with limited exploration of postoperative use. The optimal dosing and timing for POD prevention are unclear. This study aims to carry out a multicenter, single-blind, placebo-controlled, large-sample randomized controlled trial assessing the effect of low-dose esketamine, given intraoperatively and postoperatively, on delirium in elderly high-risk patients undergoing major non-cardiac surgery.

• Study Type: Interventional
• Enrollment (Estimated): 1670
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Ke-Xuan Liu, MD; Phone Number: +86 13710684096; Email: liukexuan705@163.com
• Study Contact Backup: Name: Shuang-Jie Cao, MD; Phone Number: +86 13651119431; Email: caosjie1994@126.com

Study Locations

• China
  • Fujian
    • Fuzhou, Fujian, China, 350001
      • Recruiting
      • Fujian Provincial Hospital
      • Contact: Xiao-Dan Wu, MD
  • Guangdong
    • Guangzhou, Guangdong, China, 510060
      • Not yet recruiting
      • Sun Yat-sen University Cancer Center
      • Contact: Jing-Dun Xie, MD
    • Guangzhou, Guangdong, China, 510515
      • Recruiting
      • Nanfang Hospital, Southern Medical University
      • Contact: Ke-Xuan Liu, MD; Phone Number: +86 13710684096; Email: liukexuan705@163.com
    • Guangzhou, Guangdong, China, 510632
      • Active, not recruiting
      • The First Affiliated Hospital of Jinan University
    • Guangzhou, Guangdong, China, 528399
      • Recruiting
      • The Eighth Affliated Hospital of Southern Medical Universily
      • Contact: Yi-Wen Zhang, MD
  • Jiangxi
    • Ganzhou, Jiangxi, China, 341001
      • Active, not recruiting
      • Ganzhou People's Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Age ≥65 years and <90 years;
• Scheduled to undergo major non-cardiac surgery.
• Fulfill at least one of risk factors as follows: history of stroke; history of delirium; hypertension; congestive heart failure; coronary artery disease; atrial fibrillation; peripheral artery disease; chronic obstructive pulmonary disease; obstructive sleep apnea; diabetes; chronic kidney disease; anemia; malnutrition; hypoalbuminemia; chronic pain; anxiety and depression; poor sleep quality; smoke; alcoholism.
• Scheduled to receive patient-controlled intravenous analgesia (PCIA).

Exclusion Criteria:

• Refuse to participate;
• Preoperative history of epilepsy, myasthenia gravis, Parkinson's disease, intracranial hypertension, delirium, schizophrenia, or other psychiatric diseases;
• Inability to communicate in the preoperative period because of coma, profound dementia, or language barrier;
• Preoperative uncontrolled severe hypertension (baseline SBP>180 mmHg or DBP>110 mmHg);
• Preoperative history of hyperthyroidism and pheochromocytoma;
• Acute cardiovascular event occurring within 30 days before surgery;
• Severe hepatic dysfunction (Child-Pugh class C), renal dysfunction (required preoperative dialysis), or expected survival ≤24 hours;
• Scheduled to undergo organ transplantation, vascular surgery, neurosurgery;
• Receiving treatment with ketamine or esketamine;
• Contradiction to ketamine or esketamine;
• Other situations where the investigator or physician considers the patient ineligible for the study.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Esketamine; Esketamine (1mg/ml) will be administered at a loading dose of 0.2 mg/kg, namely at a infusion rate of 1.2ml/kg/h over 10 minutes after induction, then a maintenance infusion rate of 0.1 mg/kg/h until 40 minutes before the end of the surgery. For postoperative analgesia, patient-controlled intravenous analgesia (PCIA) is prepared with a formulation consisting of esketamine 50mg and sufentanil 200 μg, diluted to a total volume of 200 ml. The background dose is set at 2 ml/h, with a bolus dose of 2 ml and a lockout interval of 15 minutes.	Drug: Esketamine; Esketamine (1mg/ml) will be administered at a loading dose of 0.2 mg/kg, namely at a infusion rate of 1.2ml/kg/h over 10 minutes after induction, then a maintenance infusion rate of 0.1 mg/kg/h until 40 minutes before the end of the surgery. For postoperative analgesia, patient-controlled intravenous analgesia (PCIA) is prepared with a formulation consisting of esketamine 50mg and sufentanil 200 μg, diluted to a total volume of 200 ml. The background dose is set at 2 ml/h, with a bolus dose of 2 ml and a lockout interval of 15 minutes.
Placebo Comparator: Normal saline; Normal saline will be administered at a infusion rate of 1.2ml/kg/h over 10 minutes after induction, then a maintenance infusion rate of 0.1 mg/kg/h until 40 minutes before the end of the surgery. For postoperative analgesia, patient-controlled intravenous analgesia (PCIA) is prepared with sufentanil 200μg, diluted to a total volume of 200 ml. The background dose is set at 2 ml/h, with a bolus dose of 2 ml and a lockout interval of 15 minutes.	Drug: Normal saline; Normal saline will be administered at a infusion rate of 1.2ml/kg/h over 10 minutes after induction, then a maintenance infusion rate of 0.1 mg/kg/h until 40 minutes before the end of the surgery. For postoperative analgesia, patient-controlled intravenous analgesia (PCIA) is prepared with sufentanil 200μg, diluted to a total volume of 200 ml. The background dose is set at 2 ml/h, with a bolus dose of 2 ml and a lockout interval of 15 minutes.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
The incidence of delirium within 5 days after surgery	Delirium is assessed twice daily (8-10 am and 6-8 pm) with The Confusion Assessment Method (CAM) for non-intubated patients or The confusion assessment method for the Intensive Care Unit (CAM-ICU) for intubated patients.	Up to 5 days after surgery
Quality of recovery on postoperative day 1 (Sub-study)	Quality of recovery is assessed once daily (6-8 pm) with 15-item Quality of Recovery Scale (QoR-15).	On postoperative day 1

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Intensity of pain during the first 3 postoperative days	Intensity of pain will be assessed twice after surgery with the Behavioral Pain Scale and Numeric Rating Scale (an 11- point scale where 0 indicates no pain and 10 the worst pain).	Up to 3 days after surgery
Use of opioids during the first 3 postoperative days	Include opioids used for PCIA and supplemental analgesics.	Up to 3 days after surgery
The incidence of delayed neurocognitive recovery	A decline in the T-MoCA score by 1 standard deviation (SD) or more from the baseline is considered delayed neurocognitive recovery.	At the end of 30 days after surgery
Death rate at 30 days after surgery	Survival status is followed up at 30 days after surgery.	At the end of 30 days after surgery
Quality of recovery on postoperative day 3 (Sub-study)	Quality of recovery is assessed once daily (6-8 pm) with QoR-15.	On postoperative day 3
Postoperative gastrointestinal intolerance during the first 2 postoperative days (Sub-study)	Gastrointestinal intolerance is assessed once daily (6-8 pm) with Intake, Feeling nauseated, Emesis, Exam, and Duration of symptoms scoring system (I-FEED).	Up to 2 days after surgery
Postoperative gastrointestinal dysfunction during the first 2 postoperative days (Sub-study)	Gastrointestinal dysfunction is assessed once daily (6-8 pm) with Intake, Feeling nauseated, Emesis, Exam, and Duration of symptoms scoring system (I-FEED).	Up to 2 days after surgery
Quality of recovery at 30 days after surgery (Sub-study)	Quality of recovery is assessed with QoR-15.	At the end of 30 days after surgery
Cognitive function at 30 days after surgery	Cognitive function is assessed with the Telephone-Montreal Cognitive Assessment (T-MoCA) (a 22-point scale, with higher score indicating better function).	At the end of 30 days after surgery
HADS score at 30 days after surgery (Sub-study)	Anxiety and depression are assessed with Hospital Anxiety and Depression Scale (HADS).	At the end of 30 days after surgery
Sleep quality at 30 days after surgery (Sub-study)	Sleep quality is assessed with Pittsburgh Sleep Quality Index (PSQI).	At the end of 30 days after surgery

Collaborators and Investigators

• Sponsor: Nanfang Hospital, Southern Medical University
• Investigators: Principal Investigator: Ke-Xuan Liu, MD, Nanfang Hospital, Southern Medical University

Publications and helpful links

General Publications

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Study record dates

Study Major Dates

• Study Start (Actual): February 12, 2025
• Primary Completion (Estimated): June 1, 2027
• Study Completion (Estimated): July 1, 2027

Study Registration Dates

• First Submitted: February 4, 2025
• First Submitted That Met QC Criteria: February 4, 2025
• First Posted (Actual): February 10, 2025

Study Record Updates

• Last Update Posted (Actual): April 27, 2025
• Last Update Submitted That Met QC Criteria: April 23, 2025
• Last Verified: April 1, 2025

More Information

Terms related to this study

• Keywords: Elderly patients; Delirium; Esketamine; Non-cardiac surgery
• Additional Relevant MeSH Terms: Pain; Neurologic Manifestations; Nervous System Diseases; Mental Disorders; Postoperative Complications; Pathologic Processes; Confusion; Neurobehavioral Manifestations; Neurocognitive Disorders; Cognition Disorders; Pain, Postoperative; Delirium; Cognitive Dysfunction; Psychotropic Drugs; Antidepressive Agents; Esketamine
• Other Study ID Numbers: NFEC-2025-016

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No