Managing rebound pain after regional anesthesia

Abstract

Rebound pain after regional anesthesia can be defined as transient acute postoperative pain that ensues following resolution of sensory blockade, and is clinically significant, either with regard to the intensity of pain or the impact on psychological well-being, quality of recovery, and activities of daily living. Current evidence suggests that it represents an unmasking of the expected nociceptive response in the absence of adequate systemic analgesia, rather than an exaggerated hyperalgesic phenomenon induced by local anesthetic neural blockade. In the majority of patients, it does not appear to significantly impact cumulative postoperative opioid consumption, quality of recovery, or patient satisfaction, and is not associated with longer-term sequelae such as persistent post-surgical pain. Nevertheless, it must be considered whenever regional anesthesia is incorporated into perioperative management. Strategies to mitigate the impact of rebound pain include routine prescribing of a systemic multimodal analgesic regimen, as well as patient education on appropriate expectations regarding block offset and expected surgical pain, and timely initiation of analgesic medication. Prolonging the duration of action of regional anesthesia with continuous catheter techniques or local anesthetic adjuncts may also help alleviate rebound pain, although further research is required to confirm this.

Keywords: Multimodal analgesia; Opioid consumption; Postoperative analgesia; Postoperative pain; Rebound pain; Regional anesthesia..

Fig. 1.

Graph showing typical expected pain trajectories for the first 48 postoperative hours using four different strategies for acute pain management. Generally speaking, pain intensity is much lower in the immediate and early postoperative period in patients who receive a single-injection peripheral nerve block (PNB) or continuous peripheral nerve block (cPNB). Patients who do not receive a single-injection PNB may initially experience more pain, but this gradually decreases with administration of systemic analgesics and normal wound healing. As the effect of a single-injection PNB wears off, there can be an abrupt increase in pain intensity or ‘rebound pain’ (yellow arrow). The magnitude and timing of this increase will vary depending on patient, surgery, and block-related factors. The magnitude of this rise can be attenuated if the PNB is complemented with optimal multimodal analgesia (MMA) initiated before its effect wears off. Compared to other strategies, effective cPNB plus MMA will also attenuate rebound pain and lower pain scores for as long as cPNB is continued. VAS: visual analogue scale for pain.