Rebound pain as a single-injection peripheral nerve block regresses is common, distressing and often blamed on the surgery rather than the block. This network meta-analysis pooled 24 randomised trials, 2,130 patients and eight prophylactic strategies to rank them.
Intravenous dexamethasone had the highest probability of reducing the incidence of rebound pain (surface under the cumulative ranking curve 0.91) and was judged definitely superior to control — the standout for prevention. Perineural dexamethasone and perineural dexmedetomidine ranked highest for delaying the onset of rebound pain and prolonging time to first rescue analgesia. Pre-emptive opioids were probably inferior to doing nothing. Certainty ranged from very low to moderate.
The usable message is simple: give intravenous dexamethasone to prevent rebound pain, and use a perineural adjunct (dexamethasone or dexmedetomidine) where the aim is to stretch out the block. Pre-emptive opioids are not the answer. Fold this into the block plan rather than treating rebound pain reactively on the ward.
- IV dexamethasone ranked first for preventing rebound-pain incidence (SUCRA 0.91)
- Perineural dexamethasone or dexmedetomidine best for delaying onset and prolonging analgesia
- Pre-emptive opioids probably worse than control — drop them for this purpose
- Plan prophylaxis at the time of the block, not as ward rescue
The statistics, in plain English
A SUCRA of 0.91 means that across the network, IV dexamethasone was near the top of the ranking almost every time the analysis was run — strong relative evidence, though ranking does not quantify how large the benefit is. Certainty from very low to moderate means the order of options is more trustworthy than the precise effect sizes behind it.
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