The edition · Anaesthesiology
Intravenous dexamethasone ranked best for preventing rebound pain after a single-shot nerve block
A network meta-analysis of 24 trials favoured IV dexamethasone, with perineural adjuncts mainly delaying the rebound. Protocolised blood pressure targets in noncardiac surgery showed no consistent benefit over usual care, and lower oxygen delivery on bypass was linked to higher mortality.
The edition in brief
A network meta-analysis of 24 randomised trials (2,130 adults) of drugs to prevent rebound pain after single-injection peripheral nerve blocks ranked intravenous dexamethasone highest for reducing its incidence; perineural dexamethasone and dexmedetomidine mainly delayed rebound and prolonged time to first rescue analgesia, and pre-emptive opioids were probably worse than control. Certainty ranged from very low to moderate. A Bayesian meta-analysis of 15 randomised trials in major noncardiac surgery found protocolised arterial pressure targets did not reduce mortality (OR 1.00) or myocardial injury compared with usual care; acute kidney injury estimates leaned towards benefit (OR 0.87, 95% CI 0.73–1.03) but were uncertain and fragile. A single-centre cohort of 4,358 cardiac surgery patients found each 10 mL/min/m² fall in indexed oxygen delivery on bypass was associated with 16% higher odds of 30-day death, and with acute kidney injury. A small caesarean trial (58 women) found quadratus lumborum block added to intrathecal morphine reduced early pain, though its primary recovery-score comparison was inconclusive. The pearl covers planning oral analgesia before a block wears off.
Protocolised intraoperative blood pressure targets showed no consistent benefit over usual care
Continue avoiding sustained hypotension, but do not expect a formal blood pressure target protocol alone to improve outcomes beyond good usual care.
Lower oxygen delivery on cardiopulmonary bypass was linked to higher 30-day mortality
Consider monitoring indexed oxygen delivery on bypass as a risk marker, while recognising no target has yet been tested in trials.
Quadratus lumborum block added to intrathecal morphine lowered early pain after caesarean
Keep intrathecal morphine as the standard after caesarean; consider a quadratus lumborum block as an alternative or add-on case by case.
Plan the oral analgesia before the block wears off
Start regular oral analgesia before a single-shot block is due to wear off, and tell patients when that will be.
IV dexamethasone was the most effective drug for preventing rebound pain after nerve blocks
Consider intravenous dexamethasone alongside single-shot peripheral nerve blocks to reduce rebound pain, checking glucose in patients with diabetes.
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