Rebound pain prevention after peripheral nerve block: A network meta-analysis comparing intravenous, perineural dexamethasone, and control

Abstract

Study objective: Peripheral nerve blocks (PNBs) are widely used for postoperative analgesia, but rebound pain following block resolution poses a significant clinical challenge. Dexamethasone, administered either intravenously (IV) or perineurally, has shown promise in reducing rebound pain incidence, but the optimal route remains unclear. This network meta-analysis (NMA) aims to compare the effectiveness of different routes of dexamethasone administration, including IV, perineural, and control, in reducing the incidence of rebound pain following PNBs.

Design: Network meta-analysis.

Setting: Operating room, postoperative recovery area and ward.

Patients: Seven randomized controlled trials involving 561 patients undergoing peripheral nerve block for postoperative pain management.

Interventions: Intravenous and perineural dexamethasone compared to control for preventing rebound pain.

Measurements: The primary outcome was the incidence of rebound pain. Secondary outcomes included median time to first analgesic request, rebound pain resolution time, difference in pain scores before and after PNB resolution, and nausea/vomiting.

Main results: Both IV and perineural dexamethasone significantly reduced the incidence of rebound pain following peripheral nerve blocks compared to the control group. IV dexamethasone ranked first based on P-score (OR, 0.13; 95 % CI, 0.07-0.23; P-score, 0.92). Secondary outcomes, including time to the first analgesic request, pain score difference, and nausea/vomiting, also favored both IV and perineural dexamethasone over the control group.

Conclusion: Both IV and perineural dexamethasone are preferred over no dexamethasone for preventing rebound pain after PNBs, with IV dexamethasone being the more effective route. Despite limitations, these findings provide valuable insights for clinical decision-making in postoperative pain management.

Systematic review registration: PROSPERO CRD42024530943.

Keywords: Anesthesia adjuvant; Dexamethasone; Network meta-analysis; Peripheral nerve block; Rebound pain; Regional anesthesia.