Authors: Inam K et al.
Source: A & A Practice. 2026;20(4):e02177.
Summary:
This systematic review and meta-analysis compared ketamine or esketamine plus propofol with fentanyl-class opioids plus propofol for sedation during gastrointestinal endoscopy.
Propofol is commonly used for GI endoscopy, but it can cause respiratory depression, hypotension, and hemodynamic instability. Because of this, clinicians often add another medication to reduce the total propofol dose and improve sedation quality. This study compared two common strategies: ketamine or esketamine with propofol versus fentanyl, alfentanil, or sufentanil with propofol.
The authors reviewed randomized controlled trials through February 2025 and included 15 studies with 1,492 total patients. They looked at propofol dose, sedation quality, pain scores, adverse events, recovery time, and procedure time.
The main finding was that ketamine or esketamine plus propofol significantly reduced total propofol use compared with fentanyl-class opioid plus propofol. The benefit appeared greater in studies using esketamine. Despite the lower propofol requirement, sedation scores and pain scores were similar between the two groups.
Safety outcomes were also generally comparable. There were no significant differences in desaturation, nausea and vomiting, bradycardia, or tachycardia. However, hypotension was significantly lower in the ketamine/esketamine plus propofol group. Recovery time and procedure time were similar between groups.
Clinical importance:
This article is useful for anesthesia providers who sedate patients for GI endoscopy. It suggests that ketamine or esketamine can reduce the amount of propofol needed while maintaining similar sedation and analgesia compared with opioid-propofol regimens.
The lower rate of hypotension is clinically important, especially in older patients, patients with cardiovascular disease, or patients who may not tolerate blood pressure drops well. Ketamine and esketamine may help preserve hemodynamic stability while still allowing effective endoscopy sedation.
Bottom line:
Ketamine or esketamine plus propofol appears to be an effective and safe alternative to fentanyl-class opioid plus propofol for GI endoscopy. It reduces total propofol use and lowers the risk of hypotension, while providing similar sedation quality, pain control, recovery time, and procedure time.