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Severe rebound pain after peripheral nerve block for ambulatory extremity surgery is an underappreciated problem. Comment on Br J Anaesth 2021; 126: 862–71

2021; Elsevier BV; Volume: 126; Issue: 6 Linguagem: Inglês

10.1016/j.bja.2021.02.017

1471-6771

Steven Dawson, Scott N. Loewenstein,

Nausea and vomiting management

Editor—We read with great interest the article by Barry and colleagues1Barry G.S. Bailey J.G. Sardinha J. Brousseau P. Uppal V. Factors associated with rebound pain after peripheral nerve block for ambulatory surgery.Br J Anaesth. 2021; 126: 862-871Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar in which they identified factors associated with rebound pain after peripheral nerve block for ambulatory surgery as younger age, female sex, bone surgery, and absence of perioperative i.v. dexamethasone administration. We were surprised to learn that 482 of the 972 patients in their study who received a peripheral nerve block experienced severe rebound pain, with a mean rebound pain score of 8.24 out of 10. The prevalence of severe rebound pain after regional anaesthesia has otherwise been reported between 35% and 41%.2Sunderland S. Yarnold C.H. Head S.J. et al.Regional versus general anesthesia and the incidence of unplanned health care resource utilization for postoperative pain after wrist fracture surgery: results from a retrospective quality improvement project.Reg Anesth Pain Med. 2016; 41: 22-27Crossref PubMed Scopus (52) Google Scholar,3Sort R. Brorson S. Gögenur I. Nielsen J.K. Møller A.M. Rebound pain following peripheral nerve block anaesthesia in acute ankle fracture surgery: an exploratory pilot study.Acta Anaesthesiol Scand. 2019; 63: 396-402Crossref PubMed Scopus (34) Google Scholar Therefore, Barry and colleagues1Barry G.S. Bailey J.G. Sardinha J. Brousseau P. Uppal V. Factors associated with rebound pain after peripheral nerve block for ambulatory surgery.Br J Anaesth. 2021; 126: 862-871Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar corroborate that rebound pain is a problem for a large portion of patients who receive a regional anaesthesia, a point that may be underappreciated by many anaesthetists and surgeons. Rebound pain is not just a cause of patient dissatisfaction, but may also negatively affect patient outcomes. de Oliveira and colleagues4de Oliveira R.M. Tenório S.B. Tanaka P.P. Precoma D. Control of pain through epidural block and incidence of cardiac dysrhythmias in postoperative period of thoracic and major abdominal surgical procedures: a comparative study.Rev Bras Anestesiol. 2012; 62: 10-18Crossref PubMed Scopus (12) Google Scholar showed that inadequate postoperative analgesia in the first 24 h, in general, is associated with an increased incidence of cardiovascular complications, and Shea and colleagues5Shea R.A. Brooks J.A. Dayhoff N.E. Keck J. Pain intensity and postoperative pulmonary complications among the elderly after abdominal surgery.Heart Lung. 2002; 31: 440-449Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar found that increased pain scores postoperatively can contribute to pulmonary complications. Fletcher and colleagues6Fletcher D. Stamer U.M. Pogatzki-Zahn E. et al.Chronic postsurgical pain in Europe: an observational study.Eur J Anaesthesiol. 2015; 32: 725-734Crossref PubMed Scopus (251) Google Scholar showed that severe postoperative pain in the first 24 h after surgery (although not specifically rebound pain) is a risk factor for developing chronic postsurgical pain. Moreover, rebound pain after peripheral nerve block has even been shown to independently nearly double the odds of emergency department utilisation in the first few days after ambulatory upper extremity surgery.7Loewenstein S.N. Bamba R. Adkinson J.M. Emergency department utilization after administration of peripheral nerve blocks for upper extremity surgery.HAND. October 14 2020; (Online ahead of print)https://doi.org/10.1177/1558944720963867Crossref PubMed Scopus (2) Google Scholar Therefore, rebound pain is not just a burden for the patient, anaesthetist, and surgeon, but also for the healthcare system. Identifying risk factors for severe rebound pain after regional anaesthesia allows targeting preventative strategies for those at greatest risk. An approach to prevent rebound pain should be multidisciplinary, especially for outpatient surgery, since in many centres postoperative pain management is transitioned to the surgical team upon discharge. Oral pain medications can start immediately after surgery, with the intent of achieving steady state before regional anaesthesia wears off. A multimodal oral pain medication regimen can include paracetamol, a non-steroidal anti-inflammatory medication, an opioid analgesic, and a gabapentinoid.8Neumeister E.L. Beason A.M. Thayer J.A. El Bitar Y. Perioperative pain management in hand and upper extremity surgery.Clin Plast Surg. 2020; 47: 323-334Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Our preferred regimen is presented in Table 1. Most patients are prescribed opioids at our institution since peripheral nerve block is reserved only for major extremity procedures. For minor procedures not requiring peripheral nerve block (e.g. carpal tunnel release, trigger finger release), opioids are not routinely prescribed. Adjuvants that decrease postoperative pain should also be used when possible. Dexamethasone, for example, prolongs the duration of the sensory block and reduces rebound pain9Pehora C. Pearson A.M. Kaushal A. Crawford M.W. Johnston B. Dexamethasone as an adjuvant to peripheral nerve block.Cochrane Database Syst Rev. 2017; 11: CD011770PubMed Google Scholar; accordingly, it was identified as a protective factor by Barry and colleagues.1Barry G.S. Bailey J.G. Sardinha J. Brousseau P. Uppal V. Factors associated with rebound pain after peripheral nerve block for ambulatory surgery.Br J Anaesth. 2021; 126: 862-871Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar Setting patient expectations with proper education about potential rebound pain will also help patients cope with the pain.10Shih Y.W. Tsai H.Y. Lin F.S. et al.Effects of positive and negative expectations on human pain perception engage separate but interrelated and dependently regulated cerebral mechanisms.J Neurosci. 2019; 39: 1261-1274Crossref PubMed Scopus (13) Google ScholarTable 1Postoperative pain regimen for adult patients receiving peripheral nerve block for ambulatory upper extremity surgery.∗Medications are started immediately postoperatively, administered on schedule for the first 24 h, and tapered thereafter.MedicationFrequencyDosageParacetamolEvery 6 h1000 mgIbuprofenEvery 6 h600–800 mgGabapentinThree times per day100–300 mg†Gabapentin is used for peripheral nerve procedures.OxycodoneEvery 6 h5–10 mg‡Most patients are prescribed oxycodone since peripheral nerve block is reserved only for major extremity procedures. A stool softener, laxative, or both is co-prescribed with oxycodone use.∗ Medications are started immediately postoperatively, administered on schedule for the first 24 h, and tapered thereafter.† Gabapentin is used for peripheral nerve procedures.‡ Most patients are prescribed oxycodone since peripheral nerve block is reserved only for major extremity procedures. A stool softener, laxative, or both is co-prescribed with oxycodone use. Open table in a new tab We appreciate Barry and colleagues1Barry G.S. Bailey J.G. Sardinha J. Brousseau P. Uppal V. Factors associated with rebound pain after peripheral nerve block for ambulatory surgery.Br J Anaesth. 2021; 126: 862-871Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar determining factors that we can use to identify and treat patients at greatest risk for experiencing rebound pain from regional anaesthesia. Regional anaesthesia offers excellent pain control in the acute perioperative period, but as currently administered for outpatient surgery in many centres, actually results in more intense pain after discharge.2Sunderland S. Yarnold C.H. Head S.J. et al.Regional versus general anesthesia and the incidence of unplanned health care resource utilization for postoperative pain after wrist fracture surgery: results from a retrospective quality improvement project.Reg Anesth Pain Med. 2016; 41: 22-27Crossref PubMed Scopus (52) Google Scholar,3Sort R. Brorson S. Gögenur I. Nielsen J.K. Møller A.M. Rebound pain following peripheral nerve block anaesthesia in acute ankle fracture surgery: an exploratory pilot study.Acta Anaesthesiol Scand. 2019; 63: 396-402Crossref PubMed Scopus (34) Google Scholar Through collaboration between anaesthetists and surgeons, we can decrease the prevalence of severe rebound pain, optimise outcomes, and prevent unnecessary resource utilisation. The authors declare that they have no conflicts of interest. Factors associated with rebound pain after peripheral nerve block for ambulatory surgeryBritish Journal of AnaesthesiaVol. 126Issue 4PreviewRebound pain is a common, yet under-recognised acute increase in pain severity after a peripheral nerve block (PNB) has receded, typically manifesting within 24 h after the block was performed. This retrospective cohort study investigated the incidence and factors associated with rebound pain in patients who received a PNB for ambulatory surgery. Full-Text PDF Open Access