American Society of Regional Anesthesia and Pain Medicine May 2018 - 21
Figure 1: Proposal for standardized reporting of rebound pain scores (RPS) after peripheral
nerve block resolution in outpatients.2,17
With the increased attention and research that has evaluated
rebound pain, several patterns have become apparent. Typically,
rebound pain occurs 16-24 hours postoperatively, is experienced
commonly at night, and negatively affects quality of sleep. Patients
also commonly describe rebound pain as a burning sensation.
Rebound pain can profoundly impact the patient recovery
experience and ultimately affect overall opioid consumption,
emergency department visits, and patient satisfaction.5,11
To better quantify this problem, Williams and colleagues2 have
proposed a standardized method of reporting rebound pain
scores (Figure 1). Given the clinical implications, it is necessary
to understand the pathophysiology of rebound pain as more
than just the resolution of the nerve block. Although early animal
models have pointed to potential modality- and nociceptor-specific
mechanisms, other potential processes have emerged.9
Local anesthetics are widely known to be neurotoxic and may be
the source of neuronal damage or altered conduction that could
manifest as rebound pain.12 Another theory proposes that although
nerve blockade prevents signal transduction, nociceptive signal
memories are retained and amplified when the block ultimately
wears off.11 Patient noncompliance or confusion can lead to poor
transitioning from nerve block to oral analgesics.13 Finally, patients
may have catastrophizing misconceptions about the block, worry
about permanent nerve damage, or develop a falsely low pain
tolerance.5 Acute opioid-induced hyperalgesia (ie, from either
opioids used in the operating room or before the block wears off) is
another hypothesis that we introduce here.
Regardless of cause, potential methods may minimize the effect
of rebound pain on patients undergoing peripheral nerve blockade.
Regional anesthesiologists can supplement their blocks with
preoperative, intraoperative, and postoperative multimodalenhanced, recovery-driven protocols with oral and intravenous
analgesics.11 This method may help cover the transition period
as the nerve block wears off. Additionally, if local anesthetic
concentrations are what drive the severity of rebound pain in
vivo (yet unstudied) for blocks that are combined with a general
anesthetic and intended to be used more for analgesia than surgical
anesthesia, lower local anesthetic concentrations could be used in
combination with perineural adjuvants.14 When general anesthesia
is required, two strategies are avoiding use of hyperalgesic agents
such as volatile gases and short-acting opioids and including use of
agents that modulate the pain response such as esmolol.15,16
Rebound pain can also be theoretically attenuated by prolonging
the duration of the block, whether through the use of a continuous
infusion via peripheral catheter or long-acting, single-shot
injectates. In theory, this could reduce the inflammation and
American Society of Regional Anesthesia and Pain Medicine
2018
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