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

Abstract

Background: Inadequate 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).

Methods: We conducted a retrospective cohort study of LTRs from January 1, 2016 to December 31, 2021, before (precryo) and after (postcryo) initiation of an opioid-sparing protocol utilizing intraoperative intercostal nerve cryoablation. The precryo cohort included consecutive patients treated with opioids and selective use of epidural catheters. The postcryo cohort received intercostal nerve cryoablation at levels 3 to 7, scheduled acetaminophen, gabapentin, and tramadol. Additional opioids or epidural catheters were used for breakthrough pain.

Results: In total, 49 precryo and 40 postcryo patients were analyzed. Baseline demographics were similar aside from a shift to performing more bilateral lung transplants in the postcryo 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).

Conclusions: The 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.

Keywords: cryoablation; lung transplant; lung transplant surgery; opioid sparing; pain management.

Figure 1

Total MME prescribed during index hospitalization. Horizontal line represents the median and the ends of the box represent the interquartile range. X represents the mean. Whiskers represent the range. Medians compared using Mann-Whitney U test. MME, morphine milligram equivalent.

Figure 2

Total MME prescribed during index hospitalization by week. Epidural analgesia is not included in these calculations. Horizontal line represents the median and the ends of the box represent the interquartile range. X represents the mean. Whiskers represent the range. Medians compared using Mann-Whitney U test. MME, morphine milligram equivalent.

Figure 3

Total MME prescribed after discharge from index hospitalization. Horizontal line represents the median and the ends of the box represent the interquartile range. X represents the mean. Whiskers represent the range. Medians compared using Mann-Whitney U test. MME, morphine milligram equivalent.