The impact of local anesthetic systemic toxicity advisories on reporting to the National Poison Data System (NPDS)

INTRODUCTION: In 2010, multiple anesthesia societies introduced recommendations for treating local anesthetic systemic toxicity, but the impact of those recommendations is uncertain. OBJECTIVE: To test the hypothesis that reports of local anesthetic-related poisoning and mortality have declined since the publication of advisories in 2010. METHODS: We analyzed reports of local anesthetic poisoning and mortality from the American Poison Centers National Poison Data System (NPDS) spanning 1983-2022. We conducted a case-non-case disproportionality analysis using the reporting odds ratio (ROR) to evaluate the effect of the 2010 recommendations on reports of poisoning and death to the NPDS by comparing reports of poisoning and death from 2011 to 2022 relative to 2001-2010. Multiple linear regression and Poisson regression were used for confirmation, together with exploratory analyses of individual cases of mortality. RESULTS: In the decade following the introduction of recommendations (2011-2022), reports of local anesthetic poisoning decreased relative the prior decade (2001-2010, ROR=0.77, 95% CI 0.76 to 0.78, p<0.0001), driven by a decrease in non-lidocaine-related reports. Conversely, reports of lidocaine poisoning and reports of lidocaine mortality increased after 2010 (ROR=2.7 95% CI 1.3 to 5.6, p=0.0094). Case analysis revealed a decrease in reports of death in the operating room from 47% before 2010 to 15% after 2010, but an increase in reports of death from intravenous lidocaine delivery (3% to 27%, respectively). DISCUSSION: The decrease in poisoning reports aligns with the implementation of professional recommendations and advancements, such as ultrasound-guided nerve blocks and lipid emulsion therapy. However, the rise in reports of lidocaine-related deaths-primarily in emergency settings-underscores significant risks. These findings emphasize the need for improved guidance on lidocaine use and dosing strategies to prevent lidocaine-related mortality.