Does Rebound Pain after Peripheral Nerve Block for Orthopedic Surgery Impact Postoperative Analgesia and Opioid Consumption? A Narrative Review

Regional anesthesia has been considered a great tool for maximizing post-operative pain control while minimizing opioid consumption. Post-operative rebound pain, characterized by hyperalgesia after the peripheral nerve block, can however diminish or negate the overall benefit of this modality due to a counter-productive increase in opioid consumption once the block wears off. We reviewed published literature describing pathophysiology and occurrence of rebound pain after peripheral nerve blocks in patients undergoing orthopedic procedures. A search of relevant keywords was performed using PubMed, EMBASE, and Web of Science. Twenty-eight articles (n = 28) were included in our review. Perioperative considerations for peripheral nerve blocks and other alternatives used for postoperative pain management in patients undergoing orthopedic surgeries were discussed. Multimodal strategies including preemptive analgesia before the block wears off, intra-articular or intravenous anti-inflammatory medications, and use of adjuvants in nerve block solutions may reduce the burden of rebound pain. Additionally, patient education regarding the possibility of rebound pain is paramount to ensure appropriate use of prescribed pre-emptive analgesics and establish appropriate expectations of minimized opioid requirements. Understanding the impact of rebound pain and strategies to prevent it is integral to effective utilization of regional anesthesia to reduce negative consequences associated with long-term opioid consumption.

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Continuous Peripheral Nerve Blocks

Acute Pain Medicine ◽

10.1093/med/9780190856649.003.0053 ◽

2019 ◽

pp. 555-567

Keyword(s):

Peripheral Nerve ◽

Regional Anesthesia ◽

Nerve Block ◽

Peripheral Nerve Block ◽

Nerve Blocks ◽

Peripheral Nerve Blocks

This chapter reviews the use of peripheral nerve block catheters in regional anesthesia.

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Continuous Peripheral Nerve Blocks

Military Advanced Regional Anesthesia and Analgesia Handbook ◽

10.1093/med/9780197521403.003.0028 ◽

2020 ◽

pp. 216-230

Keyword(s):

Peripheral Nerve ◽

Regional Anesthesia ◽

Nerve Block ◽

Peripheral Nerve Block ◽

Nerve Blocks ◽

Peripheral Nerve Blocks

This chapter reviews the use of peripheral nerve block catheters in regional anesthesia.

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Continuous Versus Single-Injection Peripheral Nerve Blocks: A Prospective Cohort Study Comparing Procedural Time and Estimated Personnel Cost

The Open Anesthesiology Journal ◽

10.2174/1874321801509010001 ◽

2015 ◽

Vol 9 (1) ◽

pp. 1-5 ◽

Cited By ~ 3

Author(s):

Brendan Carvalho ◽

Romy D. Yun ◽

Edward R. Mariano

Keyword(s):

Peripheral Nerve ◽

Regional Anesthesia ◽

Nerve Block ◽

Single Injection ◽

Clinical Care ◽

Personnel Cost ◽

Additional Time ◽

Nerve Blocks ◽

Peripheral Nerve Blocks ◽

Physician Time

Background and Objectives: Continuous peripheral nerve blocks (CPNB) provide many additional benefits compared to single-injection peripheral nerve blocks (SPNB). However, the time and costs associated with CPNB provision have not been previously considered. The objective of this study was to compare the time required and estimated personnel costs associated with CPNB and SPNB. Methods: This IRB-exempt observational study involved provision of preoperative regional anesthesia procedures in a “block room” model by a dedicated team during routine clinical care. The primary outcome, the time to perform ultrasound-guided popliteal-sciatic blocks, was recorded prospectively. This time measurement was broken down into individual tasks: time to place monitors, prepare the equipment, scan and identify the target, perform the block, and clean up post-procedure. For peripheral nerve block catheters, time to insert, locate, and secure the catheter was also recorded. Cost estimates for physician time were determined using published national mean hourly wages. Results: Time measurements were recorded for 24 nerve block procedures (12 CPNB and 12 SPNB). The median (IQR; range) total time (seconds) taken to perform blocks was 1132 (1083-1290; 1060-1623) for CPNB versus 505 (409-589; 368-635) for SPNB (Table 1; p<0.001). The median (IQR) cost attributed to physician time during block performance was $35.20 ($33.66-$40.11) and $15.69 ($12.73-$18.32) for CPNB and SPNB, respectively. Conclusion: CPNB requires approximately 10 more minutes per procedure to perform when compared to SPNB. This additional time should be considered along with potential patient benefits and available resources when developing a regional anesthesia and acute pain medicine service.

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The Use of Long Acting Opioids to Prevent Rebound Pain Following Peripheral Nerve Blocks for Outpatient Foot and Ankle Surgery

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00248 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0024

Author(s):

Leah Herzog ◽

Sylvia H. Wilson ◽

Christopher E. Gross

Keyword(s):

Peripheral Nerve ◽

Nerve Block ◽

Peripheral Nerve Block ◽

Pain Medication ◽

Nerve Blocks ◽

Peripheral Nerve Blocks ◽

Pain Scores ◽

Ankle Surgery ◽

Patient Reported ◽

Long Acting

Category: Ankle; Bunion Introduction/Purpose: Peripheral nerve blocks have become an integral part of orthopedic surgery to assist with postoperative pain. However, 40% of patients who undergo a peripheral nerve block will experience rebound pain, which in turn, long-acting narcotics may be able to block. Unfortunately, this rebound pain can cancel out the potential benefits of decreased opioid medication use. Therefore, this study seeks to compare the difference in patient reported pain scores in those patients whom received long-acting opioid pain medication and those who did not. Methods: This is a retrospective review of patient-reported pain scores for 96 patients who underwent a peripheral nerve block for outpatient foot and ankle surgery. 48 patients either received three days of long-acting opioids or did not. Each patient was asked to fill out and return a pain diary as well as fill out a pain catastrophizing survey (PCS) at their postoperative appointment. The pain diary discussed their Visual Analogue Scale pain scores, amount of pain medication, and time they took the medicine. This data was then collected and compared via paired student t-tests for evaluation of significance. Results: Pain diaries were completed by 69 patients (72%). There were no significant differences between those comorbidities, types of procedures, age, or BMI between the groups. Mean postoperative pain scores did not differ between patients that did and did not receive postoperative extended release opioid medications (p = 0.226). Mean opioid consumption did not differ between groups (p = 0.945). There were no correlations between daily reported pain scores or the postoperative day with the highest pain score for those who received long acting opioid pain medication versus those who did not (r=0.336, p=0.550). Conclusion: Rebound pain is a difficult potential side effect of peripheral nerve blocks that currently does not have a preventative measure. This study was an attempted effort to help eliminate rebound pain, but there did not appear to be a significant benefit to adding long-acting opioid pain medication in addition to the peripheral nerve block and short-acting pain medication

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Lack of July effect in the utilization of neuraxial and peripheral nerve block in US teaching hospitals: a retrospective analysis

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2020-101318 ◽

2020 ◽

Vol 45 (5) ◽

pp. 357-361

Author(s):

Sang Jo Kim ◽

Lauren Wilson ◽

Jiabin Liu ◽

David H Kim ◽

Megan Fiasconaro ◽

...

Keyword(s):

Peripheral Nerve ◽

Nerve Block ◽

Peripheral Nerve Block ◽

Neuraxial Anesthesia ◽

House Staff ◽

Teaching Hospitals ◽

Nerve Blocks ◽

Peripheral Nerve Blocks ◽

Opioid Prescribing ◽

July Effect

BackgroundGiven the steep learning curve for neuraxial and peripheral nerve blocks, utilization of general anesthesia may increase as new house staff begin their residency programs. We sought to determine whether “July effect” affects the utilization of neuraxial anesthesia, peripheral nerve blocks, and opioid prescribing for lower extremity total joint arthroplasties (TJA) in July compared with June in teaching and non-teaching hospitals.MethodsNeuraxial anesthesia, peripheral nerve block use, and opioid prescribing trends were assessed using the Premier database (2006–2016). Analyses were conducted separately for teaching and non-teaching hospitals. Differences in proportions were evaluated via χ2 test, while differences in opioid prescribing were analyzed via Wilcoxon rank-sum tests.ResultsA total of 1 723 256 TJA procedures were identified. The overall proportion of neuraxial anesthesia use in teaching hospitals was 14.4% in both June and July (p=0.940). No significant changes in neuraxial use were seen in non-teaching hospitals (24.5% vs 24.9%; p=0.052). Peripheral nerve block utilization rates did not differ in both teaching (15.4% vs 15.3%; p=0.714) and non-teaching hospitals (10.7% vs 10.5%; p=0.323). Overall median opioid prescribing at teaching hospitals changed modestly from 262.5 oral morphine equivalents (OME) in June to 260 in July (p=0.026) while median opioid prescribing remained at a constant value of 255 OME at non-teaching hospitals (p=0.893).ConclusionUtilization of neuraxial and regional anesthesia techniques was not affected during the initial transition period of new house staff in US teaching institutions. It is feasible that enough resources are available in the system to accommodate periods of turnover and maintain levels of regional anesthetic care including additional attending anesthesiologist oversight.

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Continuous Peripheral Nerve Blocks at Home for Treatment of Recurrent Complex Regional Pain Syndrome I in Children

Anesthesiology ◽

10.1097/00000542-200502000-00022 ◽

2005 ◽

Vol 102 (2) ◽

pp. 387-391 ◽

Cited By ~ 107

Author(s):

Christophe Dadure ◽

Frederic Motais ◽

Christine Ricard ◽

Olivier Raux ◽

Rachel Troncin ◽

...

Keyword(s):

Peripheral Nerve ◽

Complex Regional Pain Syndrome ◽

Nerve Block ◽

Peripheral Nerve Block ◽

Pain Syndrome ◽

Nerve Blocks ◽

Rescue Analgesia ◽

Peripheral Nerve Blocks ◽

Children And Parents ◽

Bier Block

Background Recurrent complex regional pain syndrome I is not rare in the pediatric population. The authors conducted this study to evaluate the efficacy of continuous peripheral nerve blocks with elastomeric disposable pumps associated with initial Bier blocks for the treatment of recurrent complex regional pain syndrome I in children. Methods After parental informed consent, 13 children who did not respond to conventional complex regional pain syndrome treatment were included (mean age, 13 yr; range, 9-16 yr). After general anesthesia, peripheral nerve block was performed using 0.5 ml/kg lidocaine, 1%, with epinephrine and 0.5% ropivacaine injected in the peripheral nerve block catheter. Then, a 20-min Bier block was performed using a tourniquet and 0.2 ml/kg lidocaine, 1%; 3 ml/kg hydroxyethyl starch 130/06; and 5 mg/kg buflomedil injected intravenously. A solution of 0.1 ml . kg . h continuous ropivacaine, 0.2%, was infused through the catheter using an elastomeric pump for 96 h. Need for rescue analgesia, occurrence of side effects, and status of motor and sensory block were recorded at hours 1, 6, 12, 24, 48, 72, and 96. Children and parents completed a satisfaction assessment. All of the children had follow-up visits after 2 months. Results Postoperative analgesia was excellent. The median pain score was 0 for each period studied. Motor blockade was minimal before 12 h (median, 1) and absent thereafter. One child needed rescue analgesia. All children were able to walk easily after the initial 24-h period (walking score, > 4). Children and parents were all satisfied. Children returned home under parental surveillance beginning in the 24th hour. Neither peripheral nerve block nor Bier block caused side effects. After 2 months, none of the children exhibited any clinical symptom of recurrent complex regional pain syndrome. Conclusion Ambulatory continuous peripheral nerve block associated with an initial Bier block seems to be a significant and novel contribution to treat recurrent pediatric complex regional pain syndrome I. It allows complete pain relief, early mobilization, and rapid return home, representing a psychological advantage for these children.

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Regional Anesthesia For Postdural Puncture Headache (PDPH): A New Solution For An Old Problem? A Systemic Review.

10.21203/rs.3.rs-103755/v1 ◽

2020 ◽

Author(s):

Luca Gregorio Giaccari ◽

Francesco Coppolino ◽

Caterina Aurilio ◽

Valentina Esposito ◽

Maria Caterina Pace ◽

...

Keyword(s):

Peripheral Nerve ◽

Regional Anesthesia ◽

Nerve Block ◽

Conservative Management ◽

Systemic Review ◽

Postdural Puncture Headache ◽

Nerve Blocks ◽

Peripheral Nerve Blocks ◽

Occipital Nerve ◽

Occipital Nerve Block

Abstract Background: Postdural puncture headache (PDPH) is one of the earliest recognized complications of regional anesthesia. It is a common complication after inadvertent dural puncture. When conservative management is ineffective, the Epidural Blood Patch (EBP) is the “gold standard” for the treatment of PDPH. Due to the potential complications of EBP, several alternatives have been promoted as peripheral nerve blocks.A systematic review of the use of regional anesthesia for PDPH is needed to identify an alternative method of pain management.Objectives: To systematically review literature to establish the efficacy and applicability of regional anesthesia used in the treatment of PDPH in the hospital setting.Methods: Embase, MEDLINE, Google Scholar and Cochrane Central Trials Register were systematically searched in May 2020 for studies examining regional anesthesia for PDPH. The methodological quality of the studies and their results were appraised using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist and specific measurement properties criteria, respectively.Results: Nineteen studies evaluating peripheral nerve blocks for PDPH were included for a total of 221 patients. Sphenopalatine ganglion block (SPGB), greater occipital nerve block (GONB) and lesser occipital nerve block (LONB) were performed. All participants reported NRS lower than 4 after peripheral nerve blocks at 1, 24 and 48 hours. Only patients who experienced PDPH after diagnostic lumbar puncture reported NRS ≥ 4 after 48 hours. No adverse event was reported after the execution of nerve blocks, except an occasionally discomfort related to the insertion of cotton-tip applicators intranasally for SPGB. 17% of patients underwent a second or more peripheral nerve block due to uncontrolled pain. In 30 participants, EBP was required; none of cases followed spinal anesthesia.Conclusion: Peripheral nerve blocks can be considered as analgesic options in the management of PDPH, as not all cases require EBP for successful treatment. Treatment of PDPH with peripheral nerve blocks seems to be a minimal invasive, easy and effective method, which can offer to patients when conservative management is ineffective.

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Peripheral Nerve Blocks for the Lower Extremity

10.2310/fm.15074 ◽

2017 ◽

Author(s):

Candace Shavit ◽

Monica W. Harbell

Keyword(s):

Lower Extremity ◽

Peripheral Nerve ◽

Regional Anesthesia ◽

Nerve Block ◽

Femoral Nerve Block ◽

Femoral Nerve ◽

Improve Patient Care ◽

Nerve Blocks ◽

Peripheral Nerve Blocks ◽

Peripheral Nerve Catheter

Lower extremity peripheral nerve blocks (PNBs) are often used for surgical anesthesia and postoperative pain management. The use of PNB provides improved analgesia, reduced opioid consumption, and improved patient satisfaction and can facilitate earlier rehabilitation and discharge. As the number of lower extremity total joint arthroplasties is projected to increase significantly, the role of peripheral nerve blocks can be expected to grow in similar fashion. With the growing number of procedures and the increasing focus on patient experience and expeditious hospital discharge, PNBs are increasingly recognized as a powerful tool to improve patient care and facilitate recovery after lower extremity surgery. We provide a basic review of regional anesthesia for lower extremity surgical procedures. The widespread availability of ultrasonography has improved the performance and efficacy of PNBs; thus, we focus on ultrasonography-guided procedures. In this review, we discuss pertinent lower extremity anatomy and sonoanatomy, indications, patient outcome measures, techniques, and complications of the most commonly used blocks. This review contains 35 figures, 11 tables, 5 videos, and 103 references. Key words: adductor canal block, analgesia, ankle block, clinical applications of peripheral nerve blocks, complications of peripheral nerve blocks, continuous peripheral nerve catheter, early ambulation, fascia iliaca compartment block, femoral nerve block, lower extremity nerve blocks, lower extremity regional anesthesia, lumbar plexus block, obturator nerve block, peripheral nerve block, peripheral nerve catheter, popliteal block, psoas compartment block, regional anesthesia, regional anesthesia techniques, saphenous nerve block, sciatic nerve block, ultrasonography guided

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Peripheral Nerve Blocks for the Lower Extremity

10.2310/pm.15074 ◽

2017 ◽

Author(s):

Candace Shavit ◽

Monica W. Harbell

Keyword(s):

Lower Extremity ◽

Peripheral Nerve ◽

Regional Anesthesia ◽

Nerve Block ◽

Femoral Nerve Block ◽

Femoral Nerve ◽

Improve Patient Care ◽

Nerve Blocks ◽

Peripheral Nerve Blocks ◽

Peripheral Nerve Catheter

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The Effects of Perioperative Peripheral Nerve Blocks on Peri- and Postoperative Opioid Use and Pain Management

The American Surgeon ◽

10.1177/00031348211023395 ◽

2021 ◽

pp. 000313482110233

Author(s):

Taylor W. Cardwell ◽

Vanessa Zabala ◽

Jocelyn Mineo ◽

Christopher N. Ochner

Keyword(s):

Pain Management ◽

Peripheral Nerve ◽

Nerve Block ◽

Opioid Consumption ◽

Opioid Use ◽

Nerve Blocks ◽

Peripheral Nerve Blocks ◽

Pain Scores ◽

Patient Reported ◽

Postoperative Physical Therapy

Introduction The amount of peri- and post-operative use of opioids for pain management, and the duration in which they are used following surgery, are positively associated with the likelihood of subsequent opioid use and addiction. Aware of this issue, many clinicians are seeking ways to reduce opioid use while maintaining adequate pain management. Recent evidence suggests that peripheral nerve block utilization may present a viable mechanism by which clinicians can accomplish this goal. Methods Ovid MEDLINE and Pubmed databases were searched to identify relevant articles. Using the advanced search option, the key terms “opioid,” “morphine,” “nerve block,” “peripheral anesthesia,” “pain management,” “preoperative,”, “intraoperative,” and “postoperative” were used and combined with the Boolean terms “AND” and “OR.” This review examines the extant literature surrounding the use of peripheral nerve blocks in relation to patient-reported pain scores, intraoperative opioids, postoperative opioids, patient-controlled analgesic with opioids, and opioid consumption once the patient has left the hospital. Further, the effect peripheral nerve blocks have on postoperative physical therapy, surgery related complications, and overall patient satisfaction are briefly discussed. Results The use of perioperative peripheral nerve blocks decreases opioid consumption not only in the postoperative period, but also intraoperatively as well. The most significant decrease in opioid consumption is seen in the first 24-72 hours postoperatively. Patient reported pain scores were also lower in patients who received peripheral nerve blocks. Discussion Despite relatively robust efficacy data, utilization of peripheral nerve blocks is not ubiquitous; the potential reasons for which are also discussed. Lastly, clinical recommendations based on the available data are provided.

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