Rebound pain — the abrupt, severe pain that arrives as a single-injection nerve block wears off — undermines much of the benefit of regional anaesthesia, and prevention has been guided largely by habit. This network meta-analysis pooled 24 randomised trials, 2,130 patients and eight interventions.
Intravenous dexamethasone had the highest probability of reducing rebound pain incidence, with a surface under the cumulative ranking curve of 0.91, and was judged definitely superior to control. 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 control — a useful negative, since giving opioids in anticipation is a common reflex.
Certainty ranged from very low to moderate, and pain severity, patient satisfaction and sleep disturbance were reported too inconsistently to pool, which is a real gap given that rebound pain is defined partly by its effect on sleep. The practical conclusion is nonetheless clear and cheap: intravenous dexamethasone is already given routinely for nausea prophylaxis in many lists, so for a patient receiving a single-injection block this is often a matter of confirming it has been given rather than adding a drug.
- IV dexamethasone ranked first for preventing rebound pain (SUCRA 0.91)
- Perineural dexamethasone and dexmedetomidine best for delaying onset
- Pre-emptive opioids probably worse than control
- Certainty very low to moderate; severity and sleep data could not be pooled
The statistics, in plain English
A SUCRA value ranks how likely a treatment is to be best across the network, so 0.91 means dexamethasone came out near the top in almost every simulation. Ranking is not the same as effect size, though: a treatment can rank first while its advantage over second place is trivial. The phrase 'definitely superior to control' refers to the comparison against no prophylaxis, which is the firmer of the two claims here.
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