SLR - July 2023 - Rebecca Mina DPM
Title: The Effects of Intravenous Dexamethasone on Rebound Pain After Nerve Block in Patients with Ankle Fracture: A Randomized Control TrialReference: Gao M, Li Y, Yu J, Li W, Qin S, Zhang Y, Zhu L, Hou Z, Wang Q. The Effects of Intravenous Dexamethasone on Rebound Pain After Nerve Block in Patients with Ankle Fracture: A Randomized Controlled Trial. J Pain Res. 2023 Mar 31;16:1127-1136. doi: 10.2147/JPR.S399660. PMID: 37025954; PMCID: PMC10072140.
Level of Evidence: II
Scientific Literature Review
Reviewed By: Rebecca Mina DPM
Residency Program: Inspira Medical Center, Vineland NJ
Podiatric Relevance: Patients with ankle fractures may find relief with single-injection nerve blocks preoperatively. However, this pain relief is somewhat ephemeral, and patients may experience rebound pain postoperatively. This article evaluates the effect of the addition of intravenous dexamethasone and assesses whether or not patients have prolonged perioperative pain relief with its administration in combination with adductor/popliteal blocks for patients with ankle fractures due to dexamethasone’s systemic anti-inflammatory and analgesic effects.
Methods: This is a randomized, double-blind study which included 130 adults who underwent open reduction and internal fixation for bi- or tri- malleolar fractures in one hospital in China. The patients were separated equally into two groups, the first group was given normal saline in addition to the peripheral nerve block, and the second group was given 10mL of intravenous dexamethasone in addition to the peripheral nerve block. All nerve blocks were performed using ropivacaine, all were performed by the same physician. All patients were given a patient-controlled intravenous analgesia (PCIA) pump postoperatively in order to receive a bolus if in severe pain. Results were assessed as pain rebound, defining well-controlled pain as a pain score of < 3 and severe pain as a pain score of >7. Patients also rated their postoperative pain levels at 6, 12, 18, 24, and 48 hours after operation. Other factors such as use of the analgesia pump and quality of sleep postoperatively were also evaluated.
Results:
The group that received dexamethasone in addition to peripheral nerve blocked had significantly lower percentage of rebound pain (15% vs 44% in the control group). Duration of rebound pain was about 3 hours in both groups. Duration of nerve blocks were on average 8 hours longer in the group that received the dexamethasone IV. Patients pressed the analgesia pump more frequently in the control group, and the time to first analgesic request was 17 hours in the control group vs 26 hours in the group that received the dexamethasone. Though there were comparable rates of patient satisfaction on the first postoperative night, there were significantly higher sleep scores on the night of the surgery for the group which received the dexamethasone.
Conclusions: This study concluded that there is longer duration of the nerve block when dexamethasone is added, and the incidence of rebound pain was found to be reduced by 29% with the addition of dexamethasone. The most notable limitation of this study is that the patients applied the PCIA devices themselves postoperatively, without physician assistance. Perhaps future studies may evaluate the use of different multimodal pain management using oral medications rather than PCIA device. Nonetheless, surgeons have different regimes for postoperative pain management and must consider opioid consumption in the perioperative period- this study supports the addition of dexamethasone to prolong pain relief and potentially avoid the overuse of opioids.