Intercostal Nerve Cryoanalgesia Versus Thoracic Epidural Analgesia in Lung Transplantation: A Retrospective Single-Center Study

Abstract

Introduction:The optimal pain management strategy after lung transplantation is unknown. This study compared analgesic outcomes of intercostal nerve blockade by cryoanalgesia (Cryo) versus thoracic epidural analgesia (TEA). Methods: Seventy-two patients who underwent bilateral lung transplantation via clamshell incision at our center from 2016 to 2018 were managed with TEA (N = 43) or Cryo (N = 29). We evaluated analgesic-specific complications, opioid use in oral morphine equivalents (OME), and pain scores (0-10) through postoperative day 7. Adjusted linear regression was used to assess for non-inferiority of Cryo to TEA. Results: The overall mean pain scores (Cryo 3.2 vs TEA 3.8, P = 0.21), maximum mean pain scores (Cryo 4.7 vs TEA 5.5, P = 0.16), and the total opioid use (Cryo 484 vs TEA 705 OME, P = 0.12) were similar in both groups, while the utilization of postoperative opioid-sparing analgesia, measured as use of lidocaine patches, was lower in the Cryo group (Cryo 21% vs TEA 84%, P \ 0.001). Analgesic outcomes remained similar between the cohorts after adjustment for pertinent patient and analgesic characteristics (P = 0.26), as well as after exclusion of Cryo patients requiring rescue TEA (P = 0.32). There were no Cryo complications, with four patients requiring subsequent TEA for pain control. Two TEA patients experienced hemodynamic instability following a test TEA bolus requiring code measures. Additionally, TEA placement was Erin Isaza and Jesse Santos contributed equally.

New Aspects of Lung Transplantation: A Narrative Overview Covering Important Aspects of Perioperative Management

“…Intercostal nerve block has been abandoned due to the high risk of local anesthetic toxicity, the short duration, and the difficulty of leaving a catheter in place for continuous infusion of local anesthetics. However, cryoablation of the intercostal nerve may be an attractive alternative to thoracic epidural analgesia [ 86 ]. Its prolonged analgesic effect, up to 3 to 9 months postoperatively, must be weighed against the risk of direct nerve injury (neuropathic pain and loss of intercostal muscle strength) [ 87 ].…”

Regional analgesia for lung transplantation

“…The findings indicated that ICN cryoablation was safe and provided equal analgesia compared with TEA. Therefore, they concluded that it might be a preferred option in this complex patient population as it can be used in all clinical scenarios and eliminate the risks and delays associated with TEA 52 …”

A Breath of Fresh Air - Lung Transplantation Has Come of Age

“…A more recent modality to prevent both short and long-term post thoracotomy pain, cryoanalgesia has been gaining traction in the transplant community. Cryoanalgesia involves mechanical freezing and killing of intercostal axons while leaving the nerve sheath intact [107]. This allows for several months of significant pain control as the nerve fibers slowly regenerate within the undamaged nerve sheath [107].…”

“…Cryoanalgesia involves mechanical freezing and killing of intercostal axons while leaving the nerve sheath intact [107]. This allows for several months of significant pain control as the nerve fibers slowly regenerate within the undamaged nerve sheath [107]. Data around cryoanalgesia has been mainly limited to a few studies in posterolateral thoracotomy [108,109].…”

“…Data around cryoanalgesia has been mainly limited to a few studies in posterolateral thoracotomy [108,109]. In a recent single center retrospective study of 72 patients undergoing bilateral lung transplantation via clamshell incision, Isaza and colleagues found cryoanalgesia to be a safe alternative to TEA with equivalent postoperative analgesic effects [107]. At our institution we are currently using cryo nerve blocks from levels 3-7 in the posterior intercostal spaces for post operative pain control as well as TEA preop when feasible.…”