Factors associated with a reduction in the preventive effect of intravenous dexamethasone on rebound pain after axillary brachial plexus block.

Abstract

BACKGROUND Rebound pain after regional anaesthesia remains a significant clinical problem. Intravenous dexamethasone is commonly used as an adjuvant to prevent rebound pain although its effectiveness varies among patients. We aimed to identify phenotypic and biological factors influencing glucocorticoid sensitivity contributing to dexamethasone resistance in the prevention of rebound pain. METHODS Patients undergoing ambulatory upper limb surgery with an axillary brachial plexus block were enrolled prospectively to receive dexamethasone (0.1 mg kg-1 i.v.) before surgery. Preoperative factors analysed encompassed clinical aspects (central sensitivity, anxiety, and pain scores) and biological parameters (salivary cortisol, annexin-A1, and blood inflammatory markers). Postoperative outcomes comprised rebound pain incidence (numerical rating scale >7 within the first 24 h) and persistent pain at 3 months. RESULTS Of the 104 patients included, 36 (34.6%) developed rebound pain. Preoperative nocturnal awakening pain (odds ratio [OR]=3.09, P=0.03), severe anxiety (OR=3.54, P=0.01), high catastrophising score (OR=4.14, P=0.01), and low salivary cortisol levels (<1147 pg ml-1) (OR=3.33, P=0.02) were associated with an increased risk of rebound pain. Persistent pain at 3 months (27%) was associated with the presence of postoperative rebound pain (P=0.04). CONCLUSIONS Preoperative nocturnal pain, severe anxiety, high catastrophising, and low salivary cortisol levels are factors that might reduce the efficacy of dexamethasone in preventing rebound pain. These findings support the development of personalised preventive strategies. CLINICAL TRIAL REGISTRATION NCT05763433.