Comparison of Anesthetic Effects between Esketamine Combined with Propofol and Remifentanil Combined with Propofol in Pediatric Painless Gastrointestinal Endoscopy

Abstract Background Pediatric gastrointestinal endoscopy often requires deep sedation while maintaining spontaneous ventilation and hemodynamic stability. Propofol is widely used but lacks analgesic properties and may cause dose-dependent respiratory and cardiovascular depression. This randomized controlled study compared esketamine–propofol with remifentanil–propofol for sedation in children undergoing painless gastrointestinal endoscopy. Methods In this single-center randomized controlled study, 83 children undergoing elective painless gastrointestinal endoscopy were allocated to an esketamine–propofol group (PE group, n = 43) or a remifentanil–propofol group (PR group, n = 40). The primary outcome was the incidence of hypoxemia, defined as any peripheral oxygen saturation (SpO₂) < 95% during the peri-procedural period. Secondary outcomes included peri-procedural heart rate, mean arterial pressure, SpO₂, awakening time, propofol consumption, physician satisfaction, and adverse events. Results Hypoxemia occurred less frequently in the PE group than in the PR group (4/43, 9.3% vs. 13/40, 32.5%; P = 0.019). The PE group also had a shorter awakening time (9.95 ± 3.19 vs. 14.22 ± 4.70 min; P < 0.001) and lower total propofol consumption (190.47 ± 54.38 vs. 242.75 ± 72.64 mg; P < 0.001). SpO₂ was higher in the PE group at T1 (97.58 ± 1.80% vs. 96.05 ± 3.01%; P = 0.007), heart rate was higher at T2 (87.44 ± 14.37 vs. 74.65 ± 14.18 beats/min; P < 0.001), and mean arterial pressure was higher at T3 (68.46 ± 7.95 vs. 64.49 ± 6.44 mmHg; P = 0.014). Hypotension requiring ephedrine was less frequent in the PE group (2.3% vs. 30.0%; P = 0.002), and anesthesiologist satisfaction was higher (8.40 ± 0.69 vs. 7.93 ± 0.66; P = 0.002). No significant between-group differences were observed in endoscopist satisfaction, bradycardia requiring atropine, body movement, nausea or vomiting, or the requirement for supplementary propofol. Conclusions In children undergoing painless gastrointestinal endoscopy, esketamine–propofol was associated with a lower incidence of hypoxemia, reduced propofol consumption, less frequent hypotension requiring ephedrine, and shorter awakening time than remifentanil–propofol, without increasing procedural movement or nausea and vomiting. These findings suggest that esketamine–propofol may be a useful alternative sedation regimen for pediatric gastrointestinal endoscopy, although larger multicenter studies are warranted. Trial registration Chinese Clinical Trial Registry, ChiCTR2600133316. Date of registration: 24 September 2026. Retrospectively registered.