American Society of Regional Anesthesia and Pain Medicine May 2018 - 22

retained neuronal memories associated with surgery. However,
as previously discussed, the duration of analgesia must be
significantly longer than a typical single-shot block to become
clinically effective in reducing rebound pain.2,11 Unfortunately, the
expected rehabilitation plan and patient preferences may not allow
for an extended period of motor blockade or diminished sensation.
Adjuvants may also play a role in decreasing rebound pain. Such
drugs not only prolong the duration of the local anesthetic but
also may modulate the block in a way that decreases rebound
pain through other unknown mechanisms. A recent case series
of perineural adjuvants found that a combination of clonidine,
buprenorphine, and dexamethasone was associated with reduced
severity of rebound pain when administered with bupivacaine or
ropivacaine, although optimal dosing is still unclear and varies with
extremity.14,17 Specifically, more buprenorphine was associated with
less rebound pain, whereas less dexamethasone was paradoxically
associated with less rebound pain. In this case series, however,
rebound pain was compared with preoperative pain scores with
movement, which may prove to be a more useful parameter than
when the block is fully functioning.17
In the end, educating patients may prove the most useful shortterm management strategy. Including rebound pain during the
risk-benefit discussion during the preoperative assessment can
inform patients regarding what to expect when the block wears off.
Baseline pain evaluations and psychological counseling for high-risk
patients may be beneficial.3 Patients and caregivers can also be
instructed to stay ahead of the pain by taking long-acting analgesics
while the block is still working.11 Common formulations such as
gabapentin, acetaminophen, ibuprofen, and dextromethorphan may
prove useful as rescue medications for rebound pain.
Although the concept of rebound pain requires consideration and
discussion, patients still express overall satisfaction from their
nerve block experience.5 Therefore, the multiple benefits of regional
anesthesia make this a technique that should continue to be offered
until further research can provide more clarity.
REFERENCES
1.

22

Joshi G, Gandhi K, Shah N, Gadsden J, Corman SL. Peripheral nerve blocks in
the management of postoperative pain: challenges and opportunities. J Clin
Anesth. 2016;35:524-529.

2.

Williams BA, Bottegal MT, Kentor ML, Irrgang JJ, Williams JP. Rebound pain
scores as a function of femoral nerve block duration after anterior cruciate
ligament reconstruction: retrospective analysis of a prospective, randomized
clinical trial. Reg Anesth Pain Med. 2007;32(3):186-192.

3.

Williams BA. Forecast for perineural analgesia procedures for ambulatory
surgery of the knee, foot, and ankle: applying patient-centered paradigm shifts.
Int Anesthesiol Clin. 2012;50(1):126-142.

4.

Borgeat A. Single-shot interscalene block: light and shadows. Anesth Analg.
2015;120(5):995-996.

5.

Henningsen MJ, Sort R, Møller AM, Herling SF. Peripheral nerve block in ankle
fracture surgery: a qualitative study of patients' experiences. Anaesthesia.
2018;73(1):49-58.

6.

Abdallah FW, Halpern SH, Aoyama K, Brull R. Will the real benefits of single-shot
interscalene block please stand up: a systematic review and meta-analysis.
Anesth Analg. 2015;120(5):1114-1129.

7.

Kirksey MA, Haskins SC, Cheng J, Liu SS. Local anesthetic peripheral nerve
block adjuvants for prolongation of analgesia: a systematic qualitative review.
PLoS One. 2015;10(9):e0137312.

8.

Youm YS, Cho SD, Cho HY, Hwang CH, Jung SH, Kim KH. Preemptive femoral
nerve block could reduce the rebound pain after periarticular injection in total
knee arthroplasty. J Arthroplasty. 2016;31(8):1722-1726.

9.

Kolarczyk LM, Williams BA. Transient heat hyperalgesia during resolution
of ropivacaine sciatic nerve block in the rat. Reg Anesth Pain Med.
2011;36(3):220-224.

10. Janda A, Lydic R, Welch KB, Brummett CM. Thermal hyperalgesia after sciatic
nerve block in rat is transient and clinically insignificant. Reg Anesth Pain Med.
2013;38(2):151-154.
11. Abdallah FW. What happens when the blocks wear off: strategies for rebound
pain after single-shot blocks. Paper presented at: 14th Annual Symposium on
Regional Anesthesia, Pain, and Perioperative Medicine; 2015; New York, NY.
12. Verlinde M, Hollmann MW, Stevens MF, Hermanns H, Werdehausen R, Lirk P.
Local anesthetic-induced neurotoxicity. Int J Mol Sci. 2016;17(3):339.
13. Goldstein RY, Montero N, Jain SK, Egol KA, Tejwani NC. Efficacy of popliteal
block in postoperative pain control after ankle fracture fixation: a prospective
randomized study. J Orthop Trauma. 2012;26(10):557-561.
14. Knight JB, Schott NJ, Kentor ML, Williams BA. Neurotoxicity of common
peripheral nerve block adjuvants. Curr Opin Anaesthesiol. 2015;28(5):598-604.
15. Malik OS, Kaye AD, Urman RD. Perioperative hyperalgesia and associated
clinical factors. Curr Pain Headache Rep. 2017;21(1):4.
16. Gelineau AM, King MR, Ladha KS, Burns SM, Houle T, Anderson TA. Intraoperative
esmolol as an adjunct for perioperative opioid and postoperative pain reduction:
a systematic review, meta-analysis, and meta-regression. Anesth Analg.
2018;126(3):1035-1049.
17. Williams BA, Ibinson JW, Mangione MP, et al. Research priorities regarding
multimodal peripheral nerve blocks for postoperative analgesia and anesthesia
based on hospital quality data extracted from over 1,300 cases (2011-2014).
Pain Med. 2015;16(1):7-12.

American Society of Regional Anesthesia and Pain Medicine
2018



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