Illinois College

In 2010, multiple anesthesia societies introduced recommendations for treating local anesthetic systemic toxicity, but the impact of those recommendations is uncertain. To test the hypothesis that reports of local anesthetic-related poisoning and mortality have declined since the publication of advisories in 2010. 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. 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). 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.

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Effectiveness of Lidocaine Infusion Versus Valproate Infusion for Pediatric Status Migrainosus.

Ayulo MA, Jenkins S, Le T, Tripathi S

Hospital pediatrics • 2024-Jul-01

To compare the efficacy (as measured by time to resolution of pain) and safety of valproate infusion and lidocaine infusion in the treatment of pediatric status migrainosus. We conducted a single-center retrospective cohort study from March 2014 to June 2021 evaluating children and adolescents who received a lidocaine or sodium valproate infusion for the treatment of status migrainosus. During the study period, lidocaine infusion was exclusively used before March 2016, whereas sodium valproate infusion was exclusively used afterward. A total of 31 patients received lidocaine and 63 received sodium valproate infusion. Patients in the lidocaine group achieved significantly faster control of pain with median hours to pain free of 11.7 (interquartile range, 3.8-32.3) hours compared with 43.4 (interquartile range 13.8-68.7) hours in the valproate group (P = .002). At discharge, 21 of 31 (67.7%) of patients receiving lidocaine were pain-free compared with 26 of 59 (44.1%) of patients receiving valproate (P = .03). There were significantly more infusion interruptions of valproate compared with lidocaine for various patient-related factors (16/63, 25.4% vs 1/31, 3.2%; P = .009). More adverse effects were observed with valproate (42/63, 67%) compared with lidocaine (1/31, 3.2%; P < .001). The significant difference in hours to pain control persisted after adjustment for sex, race, age, BMI, presence of comorbidities, and pain score at admission. All patients in both groups completed the infusions and were discharged from the hospital. Intravenous lidocaine infusion is associated with superior pain control and a better safety profile compared with intravenous sodium valproate infusion in status migrainosus.

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