Keywords
regional anesthesia
peripheral nerve block
adjuvants
morphine
opioids
combat trauma
VAS
OMEDD
How to Cite
Abstract
Introduction. Rebound pain (RP) is one of the adverse consequences of regional anesthesia. It is defined as a transient yet intense increase in postoperative pain that occurs following the resolution of a peripheral nerve block. In military patients with combat-related limb injuries, this phenomenon has particular clinical significance, as it is associated with high levels of anxiety, an increased risk of post-traumatic stress disorder, and neuropathic pain. High doses of opioids are known to induce opioid-induced hyperalgesia (OIH), which may further exacerbate RP.
Aim. To determine the relationship between opioid dosage and the incidence of rebound pain in military patients undergoing limb surgery.
Materials and methods. The study included 148 male servicemen aged 22-58 years with firearm- and blast-related extremity injuries. Patients were divided into four groups: (1) intramuscular morphine (n = 36); (2) single-shot peripheral nerve block (PNB) with bupivacaine (n = 41); (3) prolonged catheter-based PNB with continuous bupivacaine infusion (n = 28); and (4) combined treatment with intramuscular morphine and catheter-based PNB using bupivacaine with dexamethasone as an adjuvant (n = 43). Pain intensity was assessed using the Visual Analogue Scale (VAS) at 6 and 12 hours postoperatively, and opioid consumption was converted to the Oral Morphine Equivalent Daily Dose (OMEDD).
Results. The highest opioid doses (mean OMEDD ≈120 mg/day) and the highest incidence of RP (up to 40%) were observed in group 1. In contrast, patients treated with catheter-based PNB combined with adjuvants required minimal opioid doses (0-20 mg/day), and cases of RP were almost absent. The combined strategy (group 4) proved to be the most effective, providing both prevention of RP and a significant reduction in opioid consumption.
Conclusions. High doses of morphine were associated with an increased risk of rebound pain. The use of prolonged catheter-based PNB, particularly when combined with adjuvants and minimal opioid doses, provided optimal postoperative pain control in military patients undergoing limb surgery.
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