Dexmedetomidine combined with interscalene brachial plexus block has a synergistic effect on relieving postoperative pain after arthroscopic rotator cuff repair

Current Status and Global Trend of Rebound Pain After Regional Anesthesia: A Bibliometric Analysis

Purpose

Rebound pain after regional anesthesia, a common phenomenon when the analgesic effect wears off, has been recognized in the last a few years. The aim of this study is to analyze the status and tendency of this area in a macroscopic perspective.

Methods

Bibliometric analysis is the primary methodology of this study. Literature retrieval was conducted in Web of Science (WoS) Core Collection. WoS, Excel, VOSviewer and CiteSpace were employed to do the analyses and visualization. Parameters were analyzed, such as publications, citations, journals, and keywords, etc.

Results

In total, 70 articles in the past 10 years were identified eligible. Most articles (14 pieces) were published in 2021, followed by 2022 and 2023 with 13 articles. Researchers come from 134 institutions and 20 countries. Huang Jung-Taek, Hallym College, and USA are the most productive author, institution and country, respectively. The articles were mainly published on the top journals of anesthesiology, orthopedics and surgery. The topic of these articles is primarily about the clinical issues of rebound pain. Peripheral nerve block, brachial plexus block and femoral nerve block are the activist keywords in the area, while perioperative management, fracture surgery and outcome may become hotpots in the next years.

Conclusion

Our results show that the study of rebound pain after regional anesthesia starts relatively late and is in upward tendency, future studies can focus on the perioperative management and outcomes of fracture patients, and the definition and mechanism of rebound pain after regional anesthesia.

Utility of dexmedetomidine on surgical site wound pain undergoing thoracoscopic surgery: A meta-analysis

We conducted this study aimed to evaluate the analgesic effect of dexmedetomidine in thoracoscopic surgery on postoperative wound pain, and to provide a reference for clinical use of the drug. We searched PubMed, Embase, Cochrane Library, Web of Science, Wanfang, Chinese Biomedical Literature Database and China National Knowledge Infrastructure databases, and supplemented with manual searching. We searched from database inception to October 2023, to collect the randomised controlled trials (RCTs) on dexmedetomidine application in thoracoscopic surgery. Two researchers screened all the literature according to the inclusion and exclusion criteria and the literature included in the study was evaluated for quality, extracted information and required data. Stata 17.0 software was employed for data analysis and the outcomes were 2 6, 12, 24 and 48 h postoperative wound visual analog scores (VAS). Twenty-four RCTs totalling 2246 patients undergoing thoracoscopic surgery were finally included. The analysis revealed dexmedetomidine applied to thoracoscopic surgery significantly reduced the postoperative wound VAS scores at 2 h (SMD: -0.96, 95% CI: -1.57 to -0.36, p = 0.002), 6 h (SMD: -0.98, 95% CI: -1.27 to -0.69, p < 0.001), 12 h (SMD: -1.19, 95% CI: -1.44 to -0.94, p < 0.001), 24 h (SMD: -0.91, 95% CI: -1.16 to -0.66, p < 0.001) and 48 h (SMD: -0.75, 95% CI: -1.02 to -0.48, p < 0.001). Our results suggest dexmedetomidine applied to thoracoscopic surgery can significantly reduce postoperative wound pain, which is worthy of clinical application.

Advances in Anesthesia for Shoulder Surgery: A Comprehensive Review of Dexmedetomidine-Enhanced Interscalene Brachial Plexus Block

Surgical procedures on the shoulder pose distinctive challenges in managing pain during the perioperative period, underscoring the importance of exploring innovative anesthesia techniques. This comprehensive review article delves into integrating dexmedetomidine, an alpha-2 adrenergic agonist, within interscalene brachial plexus blocks for shoulder surgery. The review initiates by underscoring the pivotal role of effective anesthesia in shoulder surgery and elucidates the rationale behind investigating dexmedetomidine as an adjunct. It meticulously examines the anatomy and physiology of the brachial plexus, emphasizing its critical significance in shoulder surgery. Furthermore, the article expounds on dexmedetomidine's mechanisms of action and pharmacokinetics, encompassing its safety profile and potential side effects. The conventional interscalene brachial plexus block techniques, along with their limitations and challenges, are discussed, laying the foundation for the integration of dexmedetomidine. The review subsequently delves into exploring the role of dexmedetomidine in regional anesthesia, covering previous studies, mechanisms of action, and the potential advantages of incorporating it into nerve blocks. The review's core concentrates on the practical application of dexmedetomidine-enhanced interscalene brachial plexus blocks. This includes discussions on administration techniques, dosage guidelines, and compelling evidence supporting its utilization. Clinical scenarios where this approach proves most advantageous are thoroughly explored, comparing its effectiveness with traditional techniques in terms of pain control and patient outcomes. A comprehensive examination of relevant clinical trials and case studies highlights the evidence supporting its efficacy. The review also underscores safety considerations associated with dexmedetomidine. It proposes strategies for mitigating risks to ensure patient safety. Insights into future directions and research are provided, encompassing ongoing studies, areas necessitating further investigation, and potential refinements in technique. Finally, the article summarizes key findings, emphasizing the practicality of dexmedetomidine-enhanced interscalene brachial plexus blocks in shoulder surgery and its far-reaching implications for clinical practice and patient care.

Effects of esketamine on postoperative rebound pain in patients undergoing unilateral total knee arthroplasty: a single-center, randomized, double-blind, placebo-controlled trial protocol

Introduction

Rebound pain, transient and acute postoperative pain after the disappearance of regional block anesthesia, has been a concern in recent years. Insufficient preemptive analgesia and hyperalgesia induced by regional block are the main mechanisms. At present, the evidence for the treatment of rebound pain is limited. The esketamine, as an antagonist of the N-methyl-D-aspartate receptor, has been proven to prevent hyperalgesia. Therefore, this trial aims to evaluate the impact of esketamine on postoperative rebound pain in patients undergoing total knee arthroplasty.

Methods/design

This study is a single-center, prospective, double-blind, randomized, placebo-controlled trial. Participants who plan to undergo total knee arthroplasty will be randomly assigned to the esketamine group (N = 178) and placebo group (N = 178) in a ratio of 1:1. This trial aims to evaluate the impact of esketamine on postoperative rebound pain in patients undergoing total knee arthroplasty. The primary outcome of this trial is the incidence of rebound pain within 12 h after the operation in the esketamine group and the placebo group. The secondary outcome will be to compare (1) the incidence of rebound pain 24 h after the operation; (2) the time to enter the pain cycle for the first time within 24 h after the procedure; (3) the first time of rebound pain occurred within 24 h after surgery; (4) the modified rebound pain score; (5) NRS score under rest and exercise at different time points; (6) the cumulative opioid consumption at different time points; (7) patient's prognosis and knee joint function evaluation; (8) blood glucose and cortisol concentration; (9) patient's satisfaction score; (10) adverse reactions and adverse events.

Discussion

The effect of ketamine on preventing postoperative rebound pain is contradictory and uncertain. The affinity of esketamine to the N-methyl-D-aspartate receptor is about four times higher than levo-ketamine, the analgesic effect is 3 times higher than levo-ketamine, and there are fewer adverse mental reactions. To our knowledge, there is no randomized controlled trial to verify the impact of esketamine on postoperative rebound pain in patients undergoing total knee arthroplasty. Therefore, this trial is expected to fill an important gap in relevant fields and provide novel evidence for individualized pain management.

Clinical Trial Registration

http://www.chictr.org.cn, identifier ChiCTR2300069044.

Effect of Transauricular Vagus Nerve Stimulation on Rebound Pain After Ropivacaine Single Injection Femoral Nerve Block for Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial

Purpose

The aim of this study was to investigate whether transauricular vagus nerve stimulation (taVNS) could reduce the incidence of rebound pain in patients undergoing anterior cruciate ligament reconstruction (ACLR) under general anesthesia combined with preoperative femoral nerve block.

Methods

In total, 78 patients were enrolled in this prospective, randomized, double-blind, and sham-controlled study. Patients were randomly assigned to 2 groups (n=39): Group taVNS received taVNS (1h /1time, 6times) within the first 12 h after surgery; Group SS received sham stimulation (SS) in the same manner. Pain scores at 0, 4, 8, 12, 24, 48 h after surgery were assessed with Numeric Pain Rating Scale (NRS). The incidence, duration and onset of rebound pain were recorded. In addition, additional analgesic requirements and side effects in the first 48 h postoperatively, as well as sleep disturbance on the night of surgery, were examined.

Results

The incidence and duration of rebound pain were lower in the taVNS group than in the SS group (P=0.025 and P=0.015, respectively). Pain scores at 8 h and 12 h postoperatively were significantly lower in the taVNS group compared with the SS group (P<0.05). The number of times to press the patient-controlled analgesia (PCA) pump and the number of patients requiring additional analgesic were significantly lower in the taVNS group than in the SS group until 12 h after surgery (P=0.021 and P=0.004, respectively). The number of patients with sleep disturbance in the taVNS group was lower than that in the SS group (P=0.030).

Conclusion

The taVNS exerts beneficial effect on rebound pain after femoral nerve block in patients undergoing ACLR, which reduces the incidence and duration of rebound pain, the need for postoperative additional analgesic, and the number of complications.

A randomized comparison between interscalene block and dexmedetomidine for arthroscopic shoulder surgery

Introduction: Management of intraoperative hemodynamics and postoperative analgesia during arthroscopic shoulder surgeries remains a challenge. Although interscalene brachial plexus block (ISB) is considered ideal for shoulder anesthesia it requires skill and proficiency unlike intravenous (IV) dexmedetomidine. Objective: This randomized trial was performed to observe the efficacy of dexmedetomidine infusion which is less invasive and demands lesser skills than plexus block. Methodology: All patients scheduled for elective arthroscopic shoulder surgery under general anesthesia were assigned either to group DEX, which received an IV dexmedetomidine bolus of 0.5 mcg/kg over 20 minutes, followed by an infusion of 0.5 mcg/kg/hour that was stopped 30 minutes before surgery the end of surgery or to group BLOCK which received ultrasound guided ISB with 20ml of 0.25% bupivacaine. The primary outcome assessed was intraoperative hemodynamics; the secondary outcomes were immediate postoperative pain, operating condition as assessed by the surgeon, recovery time, and patient satisfaction after 24 hours. Blinded investigator and composite scores were used for the assessment. Results: Both groups displayed equivalent scores for intraoperative hemodynamics whereas ISB resulted in a better post-operative analgesia (p < 0.001). Surgeon’s opinion and recovery time were comparable. Overall, the patients had a satisfactory experience with both techniques, according to the quality assessment. Conclusion: IV dexmedetomidine infusion is an effective alternative to ISB for reconstructive shoulder surgeries under general anesthesia.

Optimal dose of perineural dexmedetomidine to prolong analgesia after brachial plexus blockade: a systematic review and Meta-analysis of 57 randomized clinical trials

Background and Objectives

Peripheral injection of dexmedetomidine (DEX) has been widely used in regional anesthesia to prolong the duration of analgesia. However, the optimal perineural dose of DEX is still uncertain. It is important to elucidate this characteristic because DEX may cause dose-dependent complications. The aim of this meta-analysis was to determine the optimal dose of perineural DEX for prolonged analgesia after brachial plexus block (BPB) in adult patients undergoing upper limb surgery.

Method

A search strategy was created to identify suitable randomized clinical trials (RCTs) in Embase, PubMed and The Cochrane Library from inception date to Jan, 2021. All adult patients undergoing upper limb surgery under BPB were eligible. The RCTs comparing DEX as an adjuvant to local anesthetic (LA) with LA alone for BPB were included. The primary outcome was duration of analgesia for perineural DEX. Secondary outcomes included visual analog scale (VAS) in 12 and 24 h, consumption of analgesics in 24 h, and adverse events.

Results

Fifty-seven RCTs, including 3332 patients, were identified. The subgroup analyses and regression analyses revealed that perineural DEX dose of 30-50 μg is an appropriate dosage. With short−/intermediate-acting LAs, the mean difference (95% confidence interval [CI]) of analgesia duration with less than and more than 60 μg doses was 220.31 (153.13–287.48) minutes and 68.01 (36.37–99.66) minutes, respectively. With long-acting LAs, the mean differences (95% CI) with less than and more than 60 μg doses were 332.45 (288.43–376.48) minutes and 284.85 (220.31–349.39) minutes.

Conclusion

30-50 μg DEX as adjuvant can provides a longer analgesic time compared to LA alone and it did not increase the risk of bradycardia and hypotension.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01452-0.

A Historical Analysis of Randomized Controlled Trials in the Management of Pain in Rotator Cuff Tears

The aim of this analysis was to assess the quality of reporting of randomized controlled trials (RCTs) relating to pain management in rotator cuff (RC) tears. This review evaluated the quality of the studies in the literature regarding this topic through the use of some factors and trends. The online databases used to search all RCTs on the topic of RC surgery were Medline, Scopus, CINAHL, EMBASE, and CENTRAL. This research was completed in September 2020. To assess the quality of reports, the Consolidated Standards of Reporting Trials (CONSORT) and the modified Coleman methodology score (MCMS) were used. From the research, 262 articles emerged. Finally, 79 studies were included in this historical analysis. There were no statistically significant changes in MCMS across trials that included or did not include a CONSORT diagram (p = 0.10). A statistically significant difference in MCMS was discovered between papers produced prior to 2009 and publications produced after 2015 (p = 0.03). There was no association between the number of checklist items for each article and the Coleman score. During the years there has been a significant increase in both quantity and quality of RCTs relating to pain in RC tears.

Adjuvant Drugs for Peripheral Nerve Blocks: The Role of Alpha-2 Agonists, Dexamethasone, Midazolam, and Non-steroidal Anti-inflammatory Drugs

Adjuvant drugs for peripheral nerve blocks are a promising solution to acute postoperative pain and the transition to chronic pain treatment. Peripheral nerve blocks (PNB) are used in the brachial plexus, lumbar plexus, femoral nerve, sciatic nerve, and many other anatomic locations for site-specific pain relief. However, the duration of action of a PNB is limited without an adjuvant drug. The use of non-opioid adjuvant drugs for single-shot peripheral nerve blocks (sPNB), such as alpha-2 agonists, dexamethasone, midazolam, and non-steroidal anti-inflammatory drugs, can extend the duration of local anesthetics and reduce the dose-dependent adverse effects of local anesthetics. Tramadol is a weak opioid that acts as a central analgesic. It can block voltage-dependent sodium and potassium channels, cause serotonin release, and inhibit norepinephrine reuptake and can also be used as an adjuvant in PNBs. However, tramadol's effectiveness and safety as an adjuvant to local anesthetic for PNB are inconsistent. The effects of the adjuvants on neurotoxicity must be further evaluated with further studies to delineate the safety in their use in PNB. Further research needs to be done. However, the use of adjuvants in PNB can be a way to help control postoperative pain.

Comparison of the Analgesic Duration of 0.5% Bupivacaine With 1:200,000 Epinephrine Versus 0.5% Ropivacaine Versus 1% Ropivacaine for Low-Volume Ultrasound-Guided Interscalene Brachial Plexus Block: A Randomized Controlled Trial

BACKGROUND

Bupivacaine and ropivacaine are the preferred long-acting local anesthetics for peripheral nerve blocks as they provide prolonged analgesia in the postoperative period. No studies have directly compared the analgesic duration of these commonly used local anesthetics in the setting of low-volume ultrasound-guided interscalene block (US-ISB). This study was designed to determine which local anesthetic and concentration provides superior analgesia (duration and quality) for low-volume US-ISB.

METHODS

Sixty eligible patients scheduled for arthroscopic shoulder surgery were randomized (1:1:1) to receive US-ISB (5 mL) with 0.5% bupivacaine with 1:200,000 epinephrine, 0.5% ropivacaine, or 1% ropivacaine. All individuals were blinded including study participants, anesthesiologists, surgeons, research personnel, and statistician. All participants received a standardized general anesthetic and multimodal analgesia. The primary outcome was duration of analgesia defined as the time from the end of injection to the time that the patients reported a significant increase in pain (>3 numeric rating scale [NRS]) at the surgical site.

RESULTS

The mean duration of analgesia for 0.5% bupivacaine with 1:200,000 epinephrine, 0.5% ropivacaine, or 1% ropivacaine was 14.1 ± 7.4, 13.8 ± 4.5, and 15.8 ± 6.3 hours, respectively (analysis of variance [ANOVA], P = .51). There were no observed differences in analgesic duration or other secondary outcomes between the 3 groups with the exception of a difference in cumulative opioid consumption up to 20h00 on the day of surgery in favor of ropivacaine 0.5% over bupivacaine of minimal clinical significance.

CONCLUSIONS

In the context of single-injection low-volume US-ISB, we have demonstrated a similar efficacy between equal concentrations of ropivacaine and bupivacaine. In addition, increasing the concentration of ropivacaine from 0.5% to 1% did not prolong the duration of US-ISB.

Dexmedetomidine combined with suprascapular nerve block and axillary nerve block has a synergistic effect on relieving postoperative pain after arthroscopic rotator cuff repair

PURPOSE

Suprascapular nerve block (SSNB) is the most commonly used block for the relief of postoperative pain from arthroscopic rotator cuff repair and can be used in combination with axillary nerve block (ANB). Dexmedetomidine (DEX) is a type of alpha agonist that can elongate the duration of regional block. The aim of this study was to compare the effects of the use of dexmedetomidine combined with SSNB and ANB with those of the use of SSNB and ANB alone on postoperative pain, satisfaction, and pain-related cytokines within the first 48 h after arthroscopic rotator cuff repair.

METHODS

Forty patients with rotator cuff tears who had undergone arthroscopic rotator cuff repair were enrolled in this single-center, double-blinded randomized controlled trial study. Twenty patients were randomly allocated to group 1 and received ultrasound-guided SSNB and ANB using a mixture of 0.5 ml (50 μg) of DEX and 9.5 ml of 0.75% ropivacaine preemptively. The other 20 patients were allocated to group 2 and underwent ultrasound-guided SSNB and ANB alone using a mixture of 0.5 ml of normal saline and 9.5 ml of ropivacaine. The visual analog scale (VAS) for pain and patient satisfaction (SAT) scores were postoperatively checked within 48 h. The plasma interleukin (IL)-6, IL-8, IL-1β, cortisol, and serotonin levels were also postoperatively measured within 48 h.

RESULTS

Group 1 showed a significantly lower mean VAS (visual analog scale of pain) score 1, 3, 6, 12, 18 and 24 h after operation, and a significantly higher mean SAT (patient satisfaction) score 1, 3, 6, 12, 18, 24 and 36 h after the operation than group 2. Group 1 showed a significantly lower mean plasma IL-8 level 1 and 48 h after the operation, and a significantly lower mean IL-1β level 48 h after the operation than group 2. Group 1 showed a significantly lower mean plasma serotonin level 12 h after the operation than group 2. The mean timing of rebound pain in group 1 was significantly later than that in group 2 (36 h > 23 h, p = 0.007). Six patients each in groups 1 and 2 showed rebound pain. The others did not show rebound pain.

CONCLUSIONS

Ultrasound-guided SSNA and ANB with DEX during arthroscopic rotator cuff repair resulted in a significantly lower mean VAS score and a significantly higher mean SAT score within 48 h after the operation than SSNB and ANB alone. Additionally, SSNB and ANB with DEX tended to result in a later mean timing of rebound pain accompanied by significant changes in IL-8, IL-1β, and serotonin levels within 48 h after the operation. The present study could provide the basis for selecting objective parameters of postoperative pain in deciding the optimal use of medication for relieving pain.

LEVEL OF EVIDENCE

Level I.

TRIAL REGISTRATION

2015-20, ClinicalTrials.gov Identifier: NCT04398589.

IRB NUMBER

2015-20, Hallym University Chuncheon Sacred Heart Hospital.

Editorial Commentary: Postoperative Pain Management After Arthroscopic Rotator Cuff Repair: The Journey to Pain Relief

Presently, interscalene block is the undisputed gold-standard procedure for postoperative pain management after arthroscopic rotator cuff surgery in patients experiencing considerable pain. However, the challenge is to make this short-term total pain relief long-term.