Kleiboeker Hanna L, Hall David J, Lowery Erin M, Hayney Mary S, Maloney James D, DeCamp Malcolm M, McCarthy Daniel P
Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, Wisconsin.
Division of Cardiothoracic Surgery, Department of Surgery, Madison, Wisconsin.
JHLT Open. 2024 Mar 21;4:100084. doi: 10.1016/j.jhlto.2024.100084. eCollection 2024 May.
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).
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.
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%, < 0.0001). Total opioid usage during the index hospitalization decreased by 24% (1110 vs 841 morphine milligram equivalents [MME], = 0.027), and 28% in the bilateral LTR subgroup analysis (1168 vs 846 MME, = 0.007). Epidural use declined from 61% to 3% ( < 0.0001). Median opioids prescribed at discharge decreased by 66% (450 vs 154 MME, < 0.0001).
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.
肺移植术后疼痛控制不佳会增加围手术期并发症。基于标准阿片类药物的治疗方案存在不良反应，而减少阿片类药物使用的硬膜外导管因禁忌证和技术挑战而受到限制。我们报告了使用肋间神经冷冻消融术来加强围手术期疼痛控制，作为肺移植受者（LTR）阿片类药物节约方案的一部分。
我们对2016年1月1日至2021年12月31日期间的LTR进行了一项回顾性队列研究，分为采用术中肋间神经冷冻消融术的阿片类药物节约方案启动前（冷冻前）和启动后（冷冻后）两个阶段。冷冻前队列包括连续接受阿片类药物治疗并选择性使用硬膜外导管的患者。冷冻后队列在第3至7肋间水平接受肋间神经冷冻消融术，并按计划使用对乙酰氨基酚、加巴喷丁和曲马多。额外的阿片类药物或硬膜外导管用于治疗突破性疼痛。
总共分析了49例冷冻前患者和40例冷冻后患者。除了冷冻后队列中双侧肺移植手术比例有所增加外（57%对95%，<0.0001），基线人口统计学特征相似。指数住院期间的阿片类药物总使用量减少了24%（1110对841吗啡毫克当量[MME]，P = 0.027），在双侧LTR亚组分析中减少了28%（1168对846 MME，P = 0.007）。硬膜外导管的使用从61%降至3%（<0.0001）。出院时开具的阿片类药物中位数减少了66%（450对154 MME，<0.0001）。
实施包括肋间神经冷冻消融术的围手术期疼痛管理方案与指数住院期间及出院时硬膜外导管使用和阿片类药物使用的显著减少相关。需要进一步研究以了解其对结局的影响。
