Intercostal nerve cryoablation as part of an opioid-sparing protocol reduces opioid and epidural use after lung transplant

Abstract

IntroductionInadequate pain control after lung transplantation increases perioperative complications. Standard opioid-based regimens are associated with adverse effects and epidural catheters that reduce opioid use are limited by contraindications and technical challenges. We report the use of intercostal nerve cryoablation to enhance perioperative pain control as part of an opioid-sparing protocol for lung transplant recipients (LTR). MethodsWe conducted a retrospective cohort study of LTRs from 1/1/2016-12/31/2021, before (pre-cryo) and after (post-cryo) initiation of an opioid-sparing protocol utilizing intraoperative intercostal nerve cryoablation. The pre-cryo cohort included consecutive patients treated with opioids and selective use of epidural catheters. The post-cryo cohort received intercostal nerve cryoablation at levels 3-7, scheduled acetaminophen, gabapentin, and tramadol. Additional opioids or epidural catheters were used for breakthrough pain. ResultsIn total, 49 pre-cryo and 40 post-cryo patients were analyzed. Baseline demographics were similar aside from a shift to performing more bilateral lung transplants in the post-cryo cohort (57% vs 95%, p<0.0001). Total opioid usage during the index hospitalization decreased by 24% (1110 vs 841 morphine milligram equivalents [MME], p=0.027), and 28% in the bilateral LTR subgroup analysis (1168 vs 846 MME, p=0.007). Epidural use declined from 61% to 3% (p<0.0001). Median opioids prescribed at discharge decreased by 66% (450 vs 154 MME, p<0.0001). ConclusionsThe implementation of a perioperative pain management protocol that included intercostal nerve cryoablation was associated with a significant reduction in epidural utilization and opioid use during index hospitalization and upon discharge. Further research is needed to understand the impact on outcomes.