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.

Rebound pain: distinct pain phenomenon or nonentity?

“…14 Alternatively, it may represent a form of exaggerated hyperalgesia uniquely associated with local anaesthetic use. 7 Current evidence supports the former concept. 7 Regardless of the mechanism, it is a fact that many patients who receive regional anaesthesia, either as the sole anaesthetic technique or combined with general anaesthesia or sedation, experience intense pain upon resolution of sensory block.…”

“…2,5 Regional anaesthesia offers many advantages in the ambulatory setting: high-quality perioperative analgesia, reduced opioid requirements, reduced postoperative nausea and vomiting, shorter duration of hospital stay, lower hospital readmission rates, lower rates of nosocomial infection, lower morbidity and mortality, and high levels of patient satisfaction. 3,4,6,7 There is evidence that regional anaesthesia may have a role in reducing the risk of progression from acute to chronic pain. 7,8 It is also believed that regional anaesthesia has immunomodulating effects that may reduce recurrence of some cancers, 7,9 although this remains a controversial issue.…”

“…3,4,6,7 There is evidence that regional anaesthesia may have a role in reducing the risk of progression from acute to chronic pain. 7,8 It is also believed that regional anaesthesia has immunomodulating effects that may reduce recurrence of some cancers, 7,9 although this remains a controversial issue.…”

“…13 It has been observed to occur after both peripheral nerve block and neuraxial anaesthesia. 4 It has been variously defined, 7 but as yet, there is no firm consensus on a formal definition. Indeed, it is not a concept that has garnered universal acceptance as a distinct pain phenomenon.…”

“…7 Regardless of the mechanism, it is a fact that many patients who receive regional anaesthesia, either as the sole anaesthetic technique or combined with general anaesthesia or sedation, experience intense pain upon resolution of sensory block. 4,6,7,15,16 On balance, it seems reasonable to assign a term to describe this pain phenomenon, if for no other reasons than to prioritise investigation that could lead to development of more effective postoperative analgesia strategies, and to open up a dialogue in the literature. Across the board, it turns out we are not very good at providing effective postoperative analgesia.…”