Development and internal validation of a multivariable risk prediction model for severe rebound pain after foot and ankle surgery involving single-shot popliteal sciatic nerve block

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.

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.

Efficacy of Intravenous Administration of Esketamine in Preventing and Treating Rebound Pain After Thoracic Paravertebral Nerve Block: A Prospective Randomized, Double-Blind, Placebo-Controlled Trial

Purpose

Investigating the efficacy of intraoperative fractionated intravenous esketamine in the prevention of rebound pain after cessation of thoracic paravertebral nerve blockade.

Methods

One hundred and twenty patients who underwent elective thoracoscopic lobectomy were selected for the study and were randomly divided into two groups, the esketamine group was given 0.5 mg/kg and 0.3 mg/kg of esketamine at the induction of anaesthesia and 30 minutes before the end of the operation, respectively, and the control group was given an equal amount of saline. The incidence of rebound pain (RP) 7 days after surgery and postoperative recovery were compared between the two groups.

Results

The NRS pain scores at 24 and 48 hours postoperatively in the esketamine group were significantly lower than those in the control group (P < 0.05). The incidence of postoperative rebound pain was significantly lower in the esketamine group than in the control group (P < 0.05). The consumption of sufentanil was less in the esketamine group in the postoperative 48 hours (P < 0.05). Postoperative recovery was compared between the two groups and the difference was not statistically significant.

Conclusion

Intravenous esketamine reduces postoperative pain scores, decreases the incidence of rebound pain after cessation of thoracic paravertebral block, and reduces opioid consumption.

Postoperative Rebound Pain: Our Current Understanding About the Role of Regional Anesthesia and Multimodal Approaches in Prevention and Treatment

PURPOSE OF REVIEW

Rebound pain (RP) is a common occurrence after peripheral nerve block placement, especially when blocks are used for orthopedic surgery. This literature review focuses on the incidence and risk factors for RP as well as preventative and treatment strategies.

RECENT FINDINGS

The addition of adjuvants to a block, when appropriate, and starting patients on oral analgesics prior to sensory resolution are reasonable approaches. Using continuous nerve block techniques can provide extended analgesia through the immediate postoperative phase when pain is the most intense. Peripheral nerve blocks (PNBs) are associated with RP, a frequent phenomenon that must be recognized and addressed to prevent short-term pain and patient dissatisfaction, as well as long-term complications and avoidable hospital resource utilization. Knowledge about the advantages and limitations of PNBs allows the anesthesiologists to anticipate, intervene, and hopefully mitigate or avoid the phenomenon of RP.

The Effects of Intravenous Dexamethasone on Rebound Pain After Nerve Block in Patients with Ankle Fracture: A Randomized Controlled Trial

Purpose

A single-injection nerve block provides excellent analgesia in a short time, but rebound pain after the nerve block disappears has attracted researchers' attention. The aim of this study is to evaluate the effect of intravenous dexamethasone on rebound pain after adductor canal block (ACB) and popliteal sciatic nerve block in patients with ankle fracture.

Methods

We recruited 130 patients with ankle fractures scheduled for open reduction and internal fixation (ORIF), each of whom received ACB and popliteal sciatic nerve block. Patients were divided into two groups: C (ropivacaine only) and IV (ropivacaine with intravenous dexamethasone). The primary outcome was the incidence of rebound pain. Secondary outcomes included the following: pain scores at 6 h (T₁), 12 h (T₂), 18 h (T₃), 24 h (T₄), and 48 h (T₅) after operation; duration of the nerve block; number of presses of the analgesia pump and rescue analgesic consumption in the three-day postoperative period; quality of recovery scale (QoR-15 score); postoperative sleep quality; satisfaction of patients; and levels of serum inflammatory markers (IL-1β, IL-6, and TNF-α) six hours after surgery.

Results

Compared with group C, the incidence of rebound pain in group IV was significantly reduced, and the duration of nerve block was extended by approximately nine hours (P<0.05). Moreover, patients in group IV had significantly lower pain scores at T₂-T₄, lower levels of serum inflammatory markers (IL-1β, IL-6, and TNF-α), higher QoR-15 score two days after the operation, and satisfactory sleep quality the night after surgery (P<0.05).

Conclusion

Intravenous dexamethasone can reduce the rebound pain after adductor block and sciatic popliteal nerve block in patients with ankle fracture surgery, prolong the duration of nerve block, and improve the quality of early postoperative recovery.

Measures to prolong duration of sensory block after regional anaesthesia

PURPOSE OF REVIEW

The duration of single-injection regional anaesthesia is limited due to the inherent pharmacological properties of local anaesthetics. The ideal duration of a regional anaesthesia block lasting for the first 24 h postoperatively can be stated, while a residual analgesic effect thereafter is desirable.The aim of this review is to present current options to prolong the duration of action of single-injection peripheral regional anaesthesia in the ambulatory setting. Secondly, this review outlines and discusses the latest evidence regarding the clinical use of adjuvants and sustained-release local anaesthetics.

RECENT FINDINGS

Extended-release formulations of local anaesthetics such as liposomal bupivacaine have been developed to prolong regional anaesthesia up to 96 h. Recent studies, however, show that the actual effects remain far behind expectations and that the efficacy is only marginally better than bupivacaine hydrochloride.Adjuvants to local anaesthetics have been studied extensively with heterogenous results. Dexamethasone and alpha-2 agonists range among the most effective measures to prolong single-injection nerve blocks.Continuous nerve blocks and catheter techniques may prolong regional anaesthesia very effectively, but are less cost-effective regarding block procedure, postoperative care and handling logistical issues especially in ambulatory surgery.

SUMMARY

In conclusion, adjuvants are the recommended measure to prolong regional anaesthesia where needed. With good evidence supporting it, dexamethasone is the most effective adjuvant, followed by dexmedetomidine. Both have few side effects and a favourable safety profile. However, a preferable duration of analgesia lasting for the first 24 h postoperatively is still not reliably achievable.