The edition · Anaesthesiology
Reported lidocaine deaths have moved out of theatre, and a fall from baseline pressure tracks postoperative pneumonia better than a fixed number
Four decades of US poison-centre reports show local anaesthetic toxicity falling overall but intravenous lidocaine deaths rising; a 151,000-patient cohort favours relative over absolute hypotension thresholds; and an opioid-free technique cut oxycodone use after robotic prostatectomy.
The edition in brief
An analysis of US poison-centre reports from 1983 to 2022 found that reports of local anaesthetic poisoning fell in the decade after the 2010 toxicity advisories (reporting odds ratio 0.77), but reports of lidocaine poisoning and death rose (ROR 2.7), and the share of deaths linked to intravenous lidocaine went from 3% to 27% while deaths in the operating room fell from 47% to 15%. In 151,036 adults having non-cardiac surgery, a fall of 20% or more from baseline mean arterial pressure was associated with postoperative pneumonia (sHR 1.11), whereas fixed absolute thresholds were not consistently associated after adjustment. In a randomised trial of 149 men having robot-assisted prostatectomy with a quadratus lumborum block, opioid-free anaesthesia with dexmedetomidine and ketamine reduced 24-hour oxycodone use by a median of 6 mg without changing pain scores. In 4,358 cardiac surgical patients, each 10 mL/min/m² fall in oxygen delivery on bypass was associated with 16% higher odds of 30-day death. Warming epidural solution to 37°C halved intrapartum fever in a 220-woman trial (15.5% vs 30.9%), though short of the authors' prespecified clinically meaningful effect. The pearl: calculate the total lidocaine dose across every route before starting an infusion.
Postoperative pneumonia tracks a fall from baseline pressure, not a fixed MAP threshold
Consider individualised blood pressure targets based on each patient's baseline, avoiding falls of 20% or more, alongside an absolute floor.
Opioid-free anaesthesia trims oxycodone use after robotic prostatectomy
Opioid-free anaesthesia is a feasible option for robotic prostatectomy on a multimodal and regional background, with a modest reduction in postoperative opioid use.
Lower oxygen delivery on bypass associated with higher 30-day mortality
Monitor oxygen delivery during cardiopulmonary bypass as a combined marker of flow and haemoglobin; lower values were associated with higher mortality and kidney injury.
Warmed epidural solution halved intrapartum fever, short of its own target
Warmed epidural solution was associated with half the rate of intrapartum fever in one trial; consider it promising but unconfirmed.
Add up every milligram of lidocaine before starting an infusion
Calculate the cumulative lidocaine dose across all routes before an intravenous infusion, and keep lipid emulsion at hand wherever it runs.
Local anaesthetic toxicity: theatre deaths fell after 2010, intravenous lidocaine deaths rose
Extend toxicity safeguards to intravenous lidocaine outside theatre: cap the cumulative dose and keep lipid emulsion and a protocol wherever infusions run.
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