Intercostal Nerve Cryoablation as Part of an Opioid-Sparing Protocol Reduces Narcotic and Epidural Use After Lung Transplant

Abstract

<h3>Purpose</h3> Inadequate pain control increases perioperative complications yet narcotic-based analgesia is associated with serious side effects. Epidural catheters can reduce narcotic use but contraindications and technical challenges are common. We report on the use of intercostal nerve cryoablation as part of an opioid-sparing perioperative pain control protocol. <h3>Methods</h3> We reviewed adult lung transplants from 10/2017-8/2021 to compare practices before (pre-cryo) and after (post-cryo) the protocol. The pre-cryo cohort included consecutive patients treated with narcotics and selective use of epidural catheters. The post-cryo cohort received cryoablation at levels 3-7, scheduled acetaminophen, gabapentin, and tramadol. Stronger narcotics or epidurals were used for breakthrough pain. Patients were excluded for intubation >48 hours, reintubation, or <8 week follow-up. Morphine milligram equivalents (MME) were collected and analyzed at several time points. Outpatient use was estimated by prescriptions written within 8 weeks of transplant. <h3>Results</h3> A total of 34 pre-cryo and 30 post-cryo patients were analyzed. Baseline demographics were similar aside from a significantly older post-cryo cohort (61 vs 56 years, p=0.043). Total inpatient and outpatient narcotic use decreased by 32% (figure). In addition, epidural use declined from 53% to 3% (p<0.001). These decreases occurred even though the post-cryo cohort included significantly more bilateral lung transplants (93% vs 56%, p=0.001). Post-cryo patients were prescribed significantly less narcotics at discharge (p<0.001) but received similar post-discharge outpatient prescriptions. <h3>Conclusion</h3> The implementation of a perioperative pain protocol that includes intercostal nerve cryoablation was associated with a significant reduction in epidural utilization and total opioid consumption in the first 8 weeks post-transplant. Further research is needed to delineate the impact on clinical outcomes.