Rebound pain: distinct pain phenomenon or nonentity?

Evaluation of the effect of intraoperative tropisetron on postoperative rebound pain after brachial plexus block: a randomized controlled trial

Introduction

Postoperative rebound pain after peripheral nerve block increases patient suffering and delays recovery after surgery.

Objectives

We tested whether the 5HT-3 receptor antagonist and α7nAChR agonist tropisetron could prevent postoperative rebound pain.

Methods

A total of 115 patients were randomized to receive 5-mg/5-mL tropisetron or the same volume of normal saline. Pain intensity was measured with the numerical rating scale of pain (NRS). Rebound pain was defined as a change from mild pain (NRS ≤ 3) measured in the postanesthesia care unit to severe pain (NRS ≥ 7) within 24 hours after peripheral nerve blockade. Logistic regression was used to identify relevant factors associated with postoperative rebound pain.

Results

Tropisetron did not affect the NRS score or the incidence of rebound pain after peripheral nerve block. Logistic regression revealed that preoperative pain, bone surgery, and length of incision were risk factors for postoperative rebound pain, and patient-controlled analgesia was protective against postoperative rebound pain.

Conclusion

Tropisetron does not affect the incidence of rebound pain after peripheral nerve block. Patients at high risk of postoperative rebound pain should be identified for appropriate management. Registration site: www.chictr.org.cn (ChiCTR2300069994).

Advancing pain management for extremity trauma: the evolution of ultrasound-guided nerve blocks for patients in the supine position in trauma centers

PURPOSE

Trauma, particularly extremity trauma, poses a considerable challenge in healthcare, especially among young adults. Given the severity of patient pain and the risks associated with excessive opioid use, managing acute pain in trauma centers is inherently complex. This study aims to investigate the application and benefits of ultrasound-guided nerve blocks for early pain management in patients with extremity trauma positioned supine.

METHODS

A comprehensive literature review was conducted to assess the effectiveness and advantages of ultrasound-guided peripheral nerve blocks in the acute pain management of extremity trauma patients in the supine position. Special emphasis was placed on evaluating the selection criteria, indications, contraindications, adverse reactions, and potential complications associated with these nerve block techniques.

RESULTS

Ultrasound-guided nerve blocks represent a safer and more precise option for managing pain in extremity trauma patients placed in the supine position. These techniques offer significant advantages in terms of reducing healthcare expenses, diminishing reliance on opioid medications, and mitigating opioid-related complications. Nonetheless, challenges may arise due to the necessity for patient cooperation during specific nerve block procedures.

CONCLUSION

Ultrasound-guided nerve blocks present a promising avenue for early pain management in extremity trauma patients positioned supinely. Their implementation can lead to improved patient outcomes by alleviating pain severity, reducing opioid consumption, and cutting down healthcare costs. Further research and clinical integration of these techniques is imperative to enhance pain management protocols in trauma centers.

Intravenous injection of dexamethasone is non-inferior to perineural administration for popliteal sciatic nerve and saphenous nerve blocks: A randomized, controlled, triple-blind study

Background

The aim of this study was to assess whether intravenous dexamethasone was noninferior to perineural dexamethasone as an adjuvant to ropivacaine for a combination of saphenous and sciatic nerve blocks in patients undergoing foot and ankle surgery.

Methods

This was a prospective, blinded, randomized noninferiority study. Seventy-five patients, aged 18-75 years, with an American Society of Anesthesiologists (ASA) physical status I-III who underwent foot and ankle surgery were involved. Patients scheduled for ultrasound-guided popliteal sciatic nerve block and saphenous nerve block were randomized to receive 0.375% ropivacaine with 7.5 mg of dexamethasone perineurally (Dex-PN), 10 mg of dexamethasone intravenously (Dex-IV) or neither (Placebo). The primary outcome was the duration of analgesia. The major secondary outcomes were the composite pain intensity and opioid consumption score at 0-48 h intervals after anesthesia.

Results

The mean analgesic duration was 26.2 h in the Dex-IV group and 27.9 h in the Dex-PN group (duration difference, -1.7; 95% CI, -3.8 to 0.43; P = 0.117), and both durations were significantly longer than that in the placebo group (17.6 h, P < 0.001). Conditions for establishing non-inferiority were met.

Conclusions

Our findings indicate that a single 10-mg intravenous dose of dexamethasone was noninferior to the combined dose of ropivacaine plus deaxmethasone in terms of duration of analgesia for foot and ankle surgery.

Cocktail of Ropivacaine, Morphine, and Diprospan Reduces Pain and Prolongs Analgesic Effects after Total Knee Arthroplasty: A Prospective Randomized Controlled Trial

Background

Local infiltration analgesia (LIA) provides postoperative analgesia for total knee arthroplasty (TKA). The purpose of this study was to evaluate the analgesic effect of a cocktail of ropivacaine, morphine, and Diprospan for TKA.

Methods

A total of 100 patients from September 2018 to February 2019 were randomized into 2 groups. Group A (control group, 50 patients) received LIA of ropivacaine alone (80 ml, 0.25% ropivacaine). Group B (LIA group, 50 patients) received an LIA cocktail of ropivacaine, morphine, and Diprospan (80 ml, 0.25% ropivacaine, 0.125 mg/ml morphine, and 62.5 μg/ml compound betamethasone). The primary outcomes were the levels of inflammatory markers C-reactive protein (CRP) and interleukin-6 (IL-6), pain visual analog scale (VAS) scores, opioid consumption, range of motion (ROM), functional tests, and sleeping quality. The secondary outcomes were adverse events, satisfaction rates, HSS scores, and SF-12 scores. The longest follow-up was 2 years.

Results

The two groups showed no differences in terms of characteristics (P  >  0.05). Group B had lower resting VAS pain scores (1.54 ± 0.60, 95% CI = 1.37 to 1.70 vs. 2.00 ± 0.63, 95% CI = 2.05 to 2.34) and active VAS pain scores (2.64 ± 0.62, 95% CI = 2.46 to 2.81 vs. 3.16 ± 0.75, 95% CI = 2.95 to 3.36) within 48 h postoperatively than Group A (P < 0.001), while none of the pain differences exceeded the minimal clinically important difference (MCID). Group B had significantly lower CRP levels (59.49 ± 13.01, 95% CI = 55.88 to 63.09 vs. 65.95 ± 14.41, 95% CI = 61.95 to 69.94) and IL-6 levels (44.11 ± 13.67, 95% CI = 40.32 to 47.89 vs. 60.72 ± 15.49, 95% CI = 56.42 to 65.01), lower opioid consumption (7.60 ± 11.10, 95% CI = 4.52 to 10.67 vs. 13.80 ± 14.68, 95% CI = 9.73 to 17.86), better ROM (110.20 ± 10.46, 95% CI = 107.30 to 113.09 vs. 105.30 ± 10.02, 95% CI = 102.52 to 108.07), better sleep quality (3.40 ± 1.03, 95% CI = 3.11 to 3.68 vs. 4.20 ± 1.06, 95% CI = 3.90 to 4.49), and higher satisfaction rates than Group A within 48 h postoperatively (P  <  0.05). Adverse events, HSS scores, and SF-12 scores were not significantly different within 2 years postoperatively.

Conclusions

A cocktail of ropivacaine, morphine, and Diprospan prolongs the analgesic effect up to 48 h postoperatively. Although the small statistical benefit may not result in MCID, the LIA cocktail still reduces opioid consumption, results in better sleeping quality and faster rehabilitation, and does not increase adverse events. Therefore, cocktails of ropivacaine, morphine, and Diprospan have good application value for pain control in TKA. This trial is registered with ChiCTR1800018372.

Ultrasound-Guided peripheral nerve blocks for major amputation in critically ill patients with peripheral artery disease

OBJECTIVE

The aim of this study was to assess the safety and efficacy of major amputation under ultrasound-guided peripheral nerve blocks in critical peripheral artery disease (PAD) patients.

METHODS

We reviewed the medical records of consecutive patients who underwent major amputation at our center between December 2012 and December 2020. The patients' baseline demographics and comorbidities were collected. The primary outcomes were 30-day and 12-month mortality. The secondary outcomes were intraoperative events, complications and intensive care unit (ICU) admission.

RESULTS

Fifteen patients classified as American Society of Anesthesiologist (ASA) III and 13 ASA IV (mean age: 76.07 ± 11.78 years) were included in the study. These patients were critically ill and had many comorbidities, such as coronary artery disease. All amputations were successfully performed under ultrasound-guided PNB without conversion to GA, but intravenous analgesia was given in 7 patients during the operation. The majority of the patients had stable hemodynamics except for 2 patients who had hypoxia, so none of the patients were transferred to the ICU postoperatively. None of the patients suffered from acute cardio-cerebral events. However, 5 patients had wound infections, and 4 of 5 patients had to receive reamputation. None of the patients died within 48 h after amputation. However, the 30-day mortality was 3.57%, and the 12-month mortality was up to 35.71%.

CONCLUSION

This study demonstrates that major amputation could be safely and effectively performed under ultrasound-guided peripheral nerve blocks for critically ill patients, and ultrasound-guided peripheral nerve blocks could be an alternative for patients at high risk of general anesthesia or spinal anesthesia.

Rebound pain and postoperative pain profile following brachial plexus block compared to general anaesthesia-An observational study

BACKGROUND

Regional anaesthesia has the benefit of reducing the need for systemic analgesia and therefore, potentially reducing undesired side effects. With the end of the sensory nerve block however, many patients report severe pain that requires therapy with opioids and often compromise the initial opioid sparing effect. This study aimed to characterise the postoperative pain profile and the phenomenon of rebound pain after axillary brachial plexus anaesthesia (RA) compared to general anaesthesia (GA).

DESIGN

Single-centre observational, stratified cohort study.

SETTING

The study was conducted at University Hospital Marburg from May 2020 until September 2022.

PARTICIPANTS

One hundred thirty-two patients receiving elective hand and forearm surgery were enrolled in this study.

INTERVENTIONS

Group RA received ultrasound-guided brachial plexus anaesthesia via the axillary approach with 30 mL of prilocaine 1% and 10 mL ropivacaine 0.2%. Group GA received balanced or total intravenous general anaesthesia.

MAIN OUTCOME MEASURES

Primary endpoint were integrated pain scores (IPS) within 24 h postoperatively. Secondary endpoints were pain scores (NRS 0-10), morphine equivalents, patient satisfaction, quality of recovery and opioid-related side effects.

RESULTS

One hundred thirty-two patients were analysed of which 66 patients received brachial plexus block and 66 patients received general anaesthesia. Following RA significantly lower IPS were seen directly after surgery (p < .001) and during the post-anaesthesia care unit interval (p < .001) but equalised after 3 h at the ward. No overshoot in pain scores or increased opioid consumption could be detected. Patient satisfaction and postoperative recovery were comparable between both groups.

CONCLUSION

The IPS and NRS was initially lower in the RA group, increased with fading of the block until equal to the GA group and equal thereafter. Although various definitions of rebound pain were met during this phase, the opioid sparing effect of regional anaesthesia was not counteracted by it. The incidence of episodes with uncontrolled, severe pain did not differ between groups. We found no clinical implications of rebound pain in this setting, since the RA group did not show higher pain scores than the GA group at any time point.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00021764).

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.

Rebound Pain After Peripheral Nerve Blockade-Bad Timing or Rude Awakening?

Patients who have perioperatively benefited from regional anesthesia frequently report moderate to severe pain when the nerve block effects fade away. Over the past years, the term "rebound pain" has been introduced, suggesting a specific pathologic process. It is debated whether significant pain on block resolution reflects a separate and distinct pathologic mechanism potentially involving proinflammatory and neurotoxic effects of local anesthetics, or is simply caused by the recovery of sensory function at a timepoint when nociceptive stimuli are still intense, and moderate to severe pain should be anticipated. In that latter case, the phenomenon referred to as rebound pain could be considered a failure of pain management providers to devise an adequate analgesia plan. Whatever the ultimate designation, management of rebound pain should be proactive, by implementing multimodal analgesia, or tailoring the blockade to the expected trajectory of postoperative pain and managing patient expectations accordingly. Until we know more about the etiology and impact of this phenomenon, the authors suggest a more neutral designation such as "pain on block resolution."

[Rebound pain-From definition to treatment]

Hintergrund

Rebound pain als Nebenwirkung einer Regionalanästhesie ist ein übermäßiges Schmerzempfinden nach Abklingen der Wirkung der lokalen Betäubung, welches deutlich über den normalen Wundschmerz nach einer Operation hinausgeht. Dieses Phänomen rückt seit ca. 10 Jahren stärker in den Fokus der Forschung. Die konkreten Ursachen sind bisher unklar, und es existieren auch noch keine zielgerichteten Therapieempfehlungen.

Ziel der Arbeit

Dieser Übersichtsartikel soll der Leserschaft einen Überblick über den aktuellen Stand der Forschung geben. Es werden die Theorien zur Pathophysiologie vorgestellt und Prophylaxe- sowie Behandlungsstrategien erläutert.

Material und Methoden

Für diese Übersichtsarbeit wurden die von 2005 bis Mai 2021 auf PubMed erschienenen Publikationen zum Thema Rebound pain durchgesehen und die Definitionen der Autoren zu Rebound pain sowie die Annahmen zur Pathophysiologie und Therapieempfehlungen zusammengefasst.

Ergebnisse und Diskussion

Insgesamt wurden 22 Originalarbeiten im Hinblick auf die Definition von Rebound pain, die Annahme der Entstehung sowie Therapieoptionen ausgewertet. Dabei zeigt sich, dass keine einheitliche Definition existiert, die Pathophysiologie nicht eindeutig geklärt ist und zum aktuellen Zeitpunkt auch noch keine klaren Empfehlungen zu Prophylaxe sowie Therapie gegeben werden können.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00101-022-01120-z) enthält eine tabellarische Zusammenstellung über Studiendesign sowie Kernaussagen der vorgestellten Studien.

Evaluation of intraoperative ketamine on the prevention of severe rebound pain upon cessation of peripheral nerve block: a prospective randomised, double-blind, placebo-controlled study

BACKGROUND

Pain after resolution of peripheral nerve block, known as 'rebound pain' (RP), is a major problem in outpatient surgery. The primary objective was to evaluate the benefit of intraoperative ketamine at an anti-hyperalgesic dose on the incidence of rebound pain after upper limb surgery under axillary plexus block in ambulatory patients. The secondary objective was to better understand the rebound pain phenomenon (individual risk factors).

METHODS

In this prospective, double-blind study, patients were randomised to receive either a single dose of i.v. ketamine (0.3 mg kg^-1) or a placebo. Preoperative mechanical temporal summation and central sensitization inventory were applied to question underlying central sensitisation. Pain catastrophising and Douleur Neuropathique 4 questionnaires were used. Rebound pain was defined as pain intensity score >7 (numeric rating scale, 0-10) after block resolution. Postoperative pain was recorded at Days 1, 4, and 30 after discharge.

RESULTS

A total of 109 subjects completed the study, and 40.4% presented with rebound pain. Ketamine administration did not reduce rebound pain incidence or intensity. Temporal summation and central sensitisation inventory scores did not differ between subjects with and without rebound pain. The predictive risk factors were bone surgery (odds ratio [OR]=5.2; confidence interval [CI], 1.9-14.6), severe preoperative pain (OR=4.2; CI, 1.5-11.7), and high pain catastrophising (OR=4.8; CI, 1.0-22.3). At Day 30, the average daily pain was higher in the rebound pain group involving neuropathic characteristics.

CONCLUSION

Ketamine at an anti-hyperalgesic dose showed no benefit on rebound pain development. Although central sensitisation might not be involved, preoperative pain intensity, and catastrophising stand as risk factors. Because rebound pain remains frequent despite adequate procedure-specific postoperative analgesia, future studies should focus on patient-specific pain management.