Local Anesthetic Systemic Toxicity in Total Joint Arthroplasty: Incidence and Risk Factors in the United States From the National Inpatient Sample 1998–2013
Daniel S. Rubin, MD,† Monica Matsumoto, BA,‡ Guy Weinberg, MD,° and Steven Roth, MD, FARVO#Background
Local anesthetic systemic toxicity is a rare and potentially devastating complication of regional anesthesia. Single institution registries have reported a decreasing incidence, but these results have limited broad applicability. A recent study using a United States database found a relatively high incidence of local anesthetic systemic toxicity. We used the National Inpatient Sample, a United States database of inpatient admissions, to identify the national incidence and associated risk factors for local anesthetic systemic toxicity in total joint arthroplasties.
Methods
In this retrospective study, we studied patients undergoing hip, knee, or shoulder arthroplasty, from 1998 to 2013 with an adjunct peripheral nerve blockade. We used a multivariable logistic regression to identify patient conditions, hospital level variables, and procedure sites associated with local anesthetic systemic toxicity.
Results
710,327 discharges met inclusion criteria. The average adjusted incidence was 1.04/1,000 peripheral nerve blocks, with decreasing trend over the 15-year study period (OR: 0.90, P = 0.002). Shoulder arthroplasty [OR: 4.35, P = 0.0001] compared with knee or hip arthroplasty, and medium [OR: 3.34 P = 0.003] and large [OR: 2.40 P = 0.025] sized hospitals as compared with small hospitals were associated with increased odds of local anesthetic systemic toxicity.
Conclusion
The incidence of local anesthetic systemic toxicity nationally in total joint arthroplasty with adjunct nerve blocks is similar to recent estimates from academic centers, with a small decreasing trend through the study period. Despite an overall low incidence rate practitioners should continue to maintain vigilance for manifestations of local anesthetic systemic toxicity, especially as the use of regional anesthesia continues to increase.
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