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

Rebound Pain-Management Strategies for Transitional Analgesia: A Narrative Review

Peripheral nerve blocks (PNBs), while effective in reducing postoperative opioid use and side effects, are often associated with rebound pain (RP), a significant clinical issue requiring proactive management. Methods: A systematic search of electronic databases (e.g., PubMed, EMBASE, Cochrane Library) was conducted for studies investigating rebound pain following regional anaesthesia. Recent findings: RP has a high incidence in ambulatory patients and is influenced by patient, surgical, and anaesthetic factors. Preoperative education, multimodal analgesia, continuous nerve blocks, and intravenous dexamethasone may mitigate RP. Although RP does not typically affect overall opioid use, recovery, or patient satisfaction, the majority of patients experiencing RP would still choose PNBs for future surgery.

Admixture of Liposomal Bupivacaine and Bupivacaine Hydrochloride for Peripheral Nerve Blocks in Adolescents Undergoing Orthopedic Surgery: An Observational Cohort Study

Background/Objectives: In 2021, the Food and Drug Administration approved liposomal bupivacaine injectable suspension for single-dose infiltration in patients ≥ 6 years of age. Liposomal bupivacaine and bupivacaine hydrochloride admixtures may also be administered off-label for pediatric regional anesthesia including peripheral nerve blocks (PNBs). This single-injection, long-acting technique is not well described in pediatrics but may have benefits over traditional continuous catheter-based systems. The purpose of this investigation was to examine an adolescent cohort who received liposomal bupivacaine/bupivacaine hydrochloride PNBs for orthopedic surgery. Methods: Patient, surgical, anesthetic, block characteristics, and post-anesthesia care unit (PACU) outcomes were retrospectively reviewed from February 2020 to June 2024. From February to December 2022, a short follow-up survey was conducted to assess post-discharge patient-reported outcomes. Results: There were 524 liposomal bupivacaine/bupivacaine hydrochloride PNBs (106 upper-extremity and 418 lower-extremity) performed in 374 patients with a mean (standard deviation, range) age of 16 (1.2, 11-17) years. Two unilateral PNBs were performed in 150 (40%) patients to ensure an adequate sensory neural blockade. The interscalene (n = 81, 15%) and adductor canal (n = 140, 27%) blocks were the most common upper- and lower-extremity PNBs, respectively. Intraoperatively, the majority of the cohort (n = 258, 69%) underwent monitored anesthesia care (MAC). No patient required conversion from MAC to general anesthesia due to pain. In PACU, 288 (77%) patients reported no pain. Mild and moderate pain were reported by 56 (15%) and 30 (8%) patients, respectively. No patients developed local anesthetic toxicity. The survey results (n = 66) indicate that the majority of patients (96%) were satisfied with block analgesia postoperatively. Conclusion: Liposomal bupivacaine/bupivacaine hydrochloride PNBs were used successfully in adolescents undergoing a variety of orthopedic surgeries.

No clinically significant difference in postoperative pain and side effects comparing conventional and enhanced recovery total hip arthroplasty with early mobilization

INTRODUCTION

Enhanced recovery after surgery (ERAS) leads to less morbidity, faster recovery, and, therefore, shorter hospital stays. The expected increment of primary total hip arthroplasty (THA) in the U.S. highlights the need for sufficient pain management. The favorable use of short-lasting spinal anesthesia enables early mobilization but may lead to increased opioid consumption the first 24 h (h) postoperatively.

METHODS

In a retrospective study design, we compared conventional THA with postoperative immobilization for two days (non-ERAS) and enhanced recovery THA with early mobilization (ERAS group). Data assessment took place as part of the "Quality Improvement in Postoperative Pain Treatment project" (QUIPS). Initially, 2161 patients were enrolled, resulting in 630 after performing a matched pair analysis for sex, age, ASA score (American-Society-of-Anesthesiology) and preoperative pain score. Patient-reported pain scores, objectified by a numerical rating scale (NRS), opioid consumption and side effects were evaluated 24 h postoperatively.

RESULTS

The ERAS group revealed higher activity-related pain (p = 0.002), accompanied by significantly higher opioid consumption (p < 0.001). Maximum and minimum pain as well as side effects did not show significant differences (p > 0.05).

CONCLUSION

This study is the first to analyze pain scores, opioid consumption, and side effects in a matched pair analyses at this early stage and supports the implementation of an ERAS concept for THA. Taking into consideration the early postoperative mobilization, we were not able to detect a difference regarding postoperative pain. Although opioid consumption appeared to be higher in ERAS group, occurrence of side effects ranged among comparable percentages.

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.

No Success without Effort: Follow-Up at Six Years after Implementing a Benchmarking and Feedback Concept for Postoperative Pain after Total Hip Arthroplasty

BACKGROUND

Total hip arthroplasty (THA) is still ranked among the operations with the highest postoperative pain scores. Uncontrolled postsurgical pain leads to prolongated hospital stays, causes more frequent adverse reactions and can induce chronical pain syndromes. In 2014, we implemented a standardized, multidisciplinary pain management concept with continuous benchmarking at our tertiary referral center by using the "Quality Improvement in Postoperative Pain Management" (QUIPS) program with excellent results over a period of two years. The initial study ended in 2016 and we aimed to evaluate if it was possible to obtain the excellent short-term results over a period of six years without any extra effort within the daily clinical routine.

MATERIALS AND METHODS

In a retrospective study design, we compared postoperative pain, side effects and functional outcome after primary THA for 2015 and 2021, using validated questionnaires from the QUIPS project. In contrast to the implementation of the pain management concept in 2014, the weekly meetings of the multidisciplinary health care team and special education for nurses were stopped in 2021. Data assessment was performed by an independent pain nurse who was not involved in pain management.

RESULTS

Altogether, 491 patients received primary THA in 2015 and 2021 at our tertiary referral center. Collected data revealed significantly worse maximum and activity-related pain (both p < 0.001) in combination with significantly higher opioid consumption in comparison to implementation in 2015. Though the patients reported to be less involved in pain management (p < 0.001), the worse pain scores were not reflected by patient satisfaction which remained high. While the participation rate in this benchmarking program dropped, we still fell behind in terms of maximum and activity-related pain in comparison to 24 clinics.

CONCLUSION

Significantly worse pain scores in combination with higher opioid usage and a lower hospital participation rate resemble a reduced awareness in postoperative pain management. The significantly lower patient participation in pain management is in line with the worse pain scores and indirectly highlights the need for special education in pain management. The fact patient satisfaction appeared to remain high and did not differ significantly from 2015, as well as the fact we still achieved an acceptable ranking in comparison to other clinics, highlight the value of the implemented multidisciplinary pain management concept.

Analgesic benefit of metamizole and ibuprofen vs. either medication alone: a randomized clinical trial

BACKGROUND

Postoperative pain relief remains a key problem after surgery. Multimodal pain therapy has proven beneficial in alleviating pain to a certain extent. However, when combining non-opioids, the focus has been on NSAIDs and paracetamol, but effects of combined use are only moderate. Metamizole could be a potent adjunct, due to its preclusion in several countries, data on its combined use are sparse, despite its common use in many countries. The aim of this study was to examine whether the combination of metamizole and ibuprofen is superior in relieving postoperative pain to either drug alone.

METHODS

For this randomized, placebo-controlled, cross-over study, 35 patients undergoing bilateral lower third molar extraction were randomized. Each patient received three applications of 1000mg metamizole + 400mg ibuprofen for surgery on one side and either 1000mg metamizole + placebo or 400mg ibuprofen + placebo on the other side. Pain ratings, rescue-medication (tramadol), and sleep were assessed for 18 hours.

RESULTS

The combined treatment of metamizole and ibuprofen showed lower mean pain scores over 12 hours than ibuprofen (2.4±1.3 vs 3.8±1.6; P=0.005)). Further, combined treatment showed lower mean pain scores over 6 hours than ibuprofen (2.0±1.2 vs. 3.1±1.6; P=0.022) or metamizole alone (2.0±1.2 vs. 3.3±1.7; P=0.015). Consumption of rescue medication was lowest in the combination-group (25% vs. 46%-metamizole; 50%-ibuprofen). The trial was stopped prematurely as the COVID-pandemic halted elective surgeries.

CONCLUSIONS

Combined use enables superior pain control compared to ibuprofen after molar extraction and tends to be superior to metamizole alone. The premature study-termination may overestimate this effect.