Vasoactive-inotropic score and major cardiovascular events in patients undergoing esophagectomy: a retrospective analysis of intravenous lidocaine and thoracic epidural anesthesia

BACKGROUND: Esophagectomy is associated with clinically relevant perioperative morbidity and mortality. Analgesia may be provided using opioids in conjunction with thoracic epidural anesthesia (TEA) or lidocaine infusion. This study evaluates whether perioperative vasoactive requirements and cardiopulmonary outcomes differ between patients receiving these two analgesic regimens. METHODS: This retrospective single-center cohort study included 441 patients undergoing esophagectomy from 2013 to 2023. The primary endpoint was the intraoperative maximum vasoactive-inotropic score (VISmax OP). Propensity-score full matching used age, sex, body mass index, Lee Revised Cardiac Risk Index, operative time, surgical approach, and year of surgery, followed by covariate adjustment. Secondary endpoints included postoperative VISmax (VISmax ICU), major adverse cardiovascular events (MACE), pulmonary complications, postoperative arrhythmias (atrial fibrillation), and 30-day mortality. RESULTS: One hundred sixty-nine patients received lidocaine, and 272 received TEA. The lidocaine group demonstrated a significantly higher VISmax OP than the TEA group after propensity-score full matching and multivariable covariate adjustment (adjusted mean: 14.6 [95% CI: 13.0-16.3] vs. 12.5 [95% CI: 11.3-13.8]; adjusted mean difference: 2.14, 95% CI 0.22-4.10; p = 0.029). VISmax ICU was also significantly higher in the lidocaine group than in the TEA group (adjusted mean, 37.1 [95% CI, 26.1-48.1] vs. 22.7 [95% CI, 17.1-28.3]; adjusted mean difference, 14.4 [95% CI, 2.48-26.3]; p = 0.019). Postoperative atrial fibrillation occurred more frequently in the lidocaine group (40.4% vs. 21.4%; adjusted ratio 0.55, 95% CI 0.38-0.79; p = 0.001), whereas no significant differences were observed in pulmonary complications, 30-day mortality, or cardiopulmonary arrest after matching and adjustment. CONCLUSION: The lidocaine group demonstrated a significantly higher VISmax OP (intraoperative) and VISmax ICU (postoperative) compared to the TEA group after adjustment for BMI, age, sex, Lee RCI, operative time, surgical approach, and year of surgery. Higher VISmax was associated with significantly increased odds of postoperative arrhythmias. However, these findings should be interpreted cautiously and externally validated in future prospective studies on optimal perioperative analgesia strategies in esophagectomy.