American Society of Regional Anesthesia and Pain Medicine May 2018 - 20

Rebound Pain After a Nerve Block Wears Off

T

he benefits of regional anesthesia are well known and include
reduced postoperative pain, decreased perioperative opioid
administration, and improved patient satisfaction. Following
block resolution, rebound pain has been recently recognized as an
important complication related to the administration of peripheral
nerve blocks.1

Rebound pain is the quantifiable difference in pain scores when
a peripheral nerve block is working versus the acute pain that is
encountered when the block wears off.2,3 Rebound pain is often
considered out of proportion to the degree of the surgical stimulus,
and it may lead to an increased use of opioid analgesics and
decreased patient satisfaction, thus undermining the perceived and
real success and benefits associated with regional anesthesia.4
This article aims to describe the phenomenon of rebound pain, its
prevalence in the literature, and a suggested standard for reporting.
In addition, potential etiologies and strategies to prevent and/or
minimize rebound pain severity will be presented.
A recent qualitative study involving ankle surgery found that
rebound pain following block resolution is a real concern to
patients.5 Although the patients appreciated the mental alertness
and analgesia that the nerve blocks provided, they experienced
difficulty predicting their analgesic needs following dissipation of
these blocks and how to effectively prevent or manage rebound
pain. As such, handling these intensely painful moments, especially
with the potential for
occurring outside of a health
care setting, constitutes a
clinically relevant problem.5

Jason B. Ochroch, MD
Resident, CA-3
Department of Anesthesiology and
Critical Care
University of Pennsylvania
Philadelphia, Pennsylvania

Brian A. Williams, MD, MBA
Professor of Anesthesiology
University of Pittsburgh
Pittsburgh, Pennsylvania

acute increase in pain scores (2.0 on a 0-10 pain scale, 95% CI:
1.6-2.4, p < .05). Although increased nerve block duration (ie,
femoral catheter infusion vs single-shot block) reduced the severity
of rebound pain, it did so at a clinically insignificant rate: 0.03 units
on a 0-10 pain scale per hour of block duration (95% CI: 0.02-
0.05, p < .001).2 In other words, 33 hours of a nerve block duration
difference led to a rebound pain reduction of 1 (on a 0-10 scale).
Other studies have shown
that certain regional
techniques and surgeries
pose a higher risk for
causing rebound pain.
Following total knee
arthroplasty, periarticular
injections provided greater
immediate analgesia,
yet more rebound pain, than did femoral nerve blocks or the
combination of both blocks.8 Unpublished data from our group also
showed that associated rebound pain was higher after shoulder
surgery than after complex knee surgery.2

"Handling these intensely painful
moments, especially with the potential for
occurring outside of a health care setting,
constitutes a clinically relevant problem."

Rebound pain occurs across
a variety of surgeries, nerve
blocks, and local anesthetics
and has been corroborated
in animal models. A 2015
meta-analysis found that rebound pain may render single-shot
interscalene blockade less beneficial to patients undergoing
ambulatory shoulder surgery than previously believed.6 The patients
had improved pain control up to 8 hours and an opioid-sparing
effect up to 12 hours following surgery as compared to those
receiving no block. However, the patients who received the block
reported increased pain 16 hours postoperatively (1.16 on a 0-10
pain scale, 99% confidence interval [CI]: 0.02-2.30, p = .009), with
no difference beyond 24 hours. The rebound pain as the block wore
off was consistent across the meta-analysis, regardless of local
anesthetic type, volume, or concentration used.6 With the exception
of epinephrine, adjuvants capable of prolonging the single-shot
block were excluded from this study.7
In patients undergoing anterior cruciate ligament reconstruction,
single-shot femoral nerve blockade resolution led to an associated

20

Rebound pain has also been demonstrated in animal models,
although the clinical relevance of these findings is uncertain. In one
study, rats that underwent sciatic nerve blockade with ropivacaine
were found to have transient hyperalgesia to heat stimuli (but not
mechanical stimuli) as the block wore off (at 3 hours) as compared
to rats receiving placebo blocks, suggesting a potential nerve fiber
specificity in the pathophysiology of rebound pain.9 Transient heat
hyperalgesia was also found in a separate rat study at the 4-hour
mark.10 In rat studies, these interval findings regarding nerve block
duration and rebound pain could translate to hours of comfort then
discomfort for our patients.

American Society of Regional Anesthesia and Pain Medicine
2018



Table of Contents for the Digital Edition of American Society of Regional Anesthesia and Pain Medicine May 2018

No label
American Society of Regional Anesthesia and Pain Medicine May 2018 - No label
American Society of Regional Anesthesia and Pain Medicine May 2018 - 2
American Society of Regional Anesthesia and Pain Medicine May 2018 - 3
American Society of Regional Anesthesia and Pain Medicine May 2018 - 4
American Society of Regional Anesthesia and Pain Medicine May 2018 - 5
American Society of Regional Anesthesia and Pain Medicine May 2018 - 6
American Society of Regional Anesthesia and Pain Medicine May 2018 - 7
American Society of Regional Anesthesia and Pain Medicine May 2018 - 8
American Society of Regional Anesthesia and Pain Medicine May 2018 - 9
American Society of Regional Anesthesia and Pain Medicine May 2018 - 10
American Society of Regional Anesthesia and Pain Medicine May 2018 - 11
American Society of Regional Anesthesia and Pain Medicine May 2018 - 12
American Society of Regional Anesthesia and Pain Medicine May 2018 - 13
American Society of Regional Anesthesia and Pain Medicine May 2018 - 14
American Society of Regional Anesthesia and Pain Medicine May 2018 - 15
American Society of Regional Anesthesia and Pain Medicine May 2018 - 16
American Society of Regional Anesthesia and Pain Medicine May 2018 - 17
American Society of Regional Anesthesia and Pain Medicine May 2018 - 18
American Society of Regional Anesthesia and Pain Medicine May 2018 - 19
American Society of Regional Anesthesia and Pain Medicine May 2018 - 20
American Society of Regional Anesthesia and Pain Medicine May 2018 - 21
American Society of Regional Anesthesia and Pain Medicine May 2018 - 22
American Society of Regional Anesthesia and Pain Medicine May 2018 - 23
American Society of Regional Anesthesia and Pain Medicine May 2018 - 24
American Society of Regional Anesthesia and Pain Medicine May 2018 - 25
American Society of Regional Anesthesia and Pain Medicine May 2018 - 26
American Society of Regional Anesthesia and Pain Medicine May 2018 - 27
American Society of Regional Anesthesia and Pain Medicine May 2018 - 28
American Society of Regional Anesthesia and Pain Medicine May 2018 - 29
American Society of Regional Anesthesia and Pain Medicine May 2018 - 30
American Society of Regional Anesthesia and Pain Medicine May 2018 - 31
American Society of Regional Anesthesia and Pain Medicine May 2018 - 32
American Society of Regional Anesthesia and Pain Medicine May 2018 - 33
American Society of Regional Anesthesia and Pain Medicine May 2018 - 34
American Society of Regional Anesthesia and Pain Medicine May 2018 - 35
American Society of Regional Anesthesia and Pain Medicine May 2018 - 36
American Society of Regional Anesthesia and Pain Medicine May 2018 - 37
http://www.brightcopy.net/allen/asra/18-04
http://www.brightcopy.net/allen/asra/18-3
http://www.brightcopy.net/allen/asra/18-2
http://www.brightcopy.net/allen/asra/18-1
http://www.brightcopy.net/allen/asra/17-4
http://www.brightcopy.net/allen/asra/17-3
http://www.brightcopy.net/allen/asra/17-2
http://www.brightcopy.net/allen/asra/17-1
http://www.brightcopy.net/allen/asra/16-4
http://www.brightcopy.net/allen/asra/16-3
http://www.brightcopy.net/allen/asra/16-2
http://www.brightcopy.net/allen/asra/16-1
http://www.brightcopy.net/allen/asra/15-4
http://www.brightcopy.net/allen/asra/15-3
https://www.nxtbook.com/allen/asra/15-2
https://www.nxtbook.com/allen/asra/15-1
https://www.nxtbookmedia.com