Update Course Rewind: Part 1 Non-Pectus Uses of Cryoanalgesia 2024

Globalcast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello Pediatric Surgery family. I'm Lizzie Lay from Cincinnati Children's Hospital Medical Center. In this video series, we'll be recapping the sessions and sharing the key highlights from our 12th annual update course in Pediatric Surgery, which was held in August 2024. This year, we introduced a new approach to classify practice-changing ideas at our update course. Presentations now fall into three categories: green circles for established practices, blue squares for promising newer practices, and black diamonds for early adopter practices only. Today, we are talking about cryoanalgesia uses outside of pectus repair with pediatric surgeon, Dr. Timothy Lotz, from Lurie Children's Hospital. This topic falls into the blue category as a newer approach. We're going to talk about some of the basics, some of the benefits in thoracotomy, and the novel uses especially if you start to use percutaneous applications of cryo. Cryoanalgesia is a minimally invasive procedure to alleviate pain during surgery. It temporarily blocks nerve conduction along peripheral nerve pathways. Freezing the affected nerve gives pain relief. You want to stay far enough posterior, but you also want to stay off of the sympathetic chain so as you can visualize this very clearly. You're getting axonal degeneration by the freeze, but at the same time the epineurium is staying intact. When you leave the fibrous outer neural structures intact, the axons can regenerate in four to six weeks. Let's look at our first poll question. What is your preferred pain control modality when doing a thoracotomy for pulmonary metastasis? The poll results from the combined live and virtual audience show that very few people do intercostal nerve cryoablation for pain control during a thoracotomy. I'm hoping I can convince you that cryo is a really good tool here. Epidurals are wonderful, but it is invasive procedure that takes time and you may or may not be leaving a fully. Epidurals usually only give pain relief for a few days, whereas cryoanalgesia can help with pain control all through the recovery period. We're doing a muscle-sparing thoracotomy and then an open direct application of the cryoprobe. We've done 300 ature cases and are seeing great results. Here are some tips and tricks for using the cryoprobe for thoracotomies. We're going one to two levels above and below the thoracotomy. You have to be a little bit careful about getting too low. Once you get to the T10 level or lower, you can start to get some pseudo hernias on the abdominal wall from affecting the motor branches there. 60 seconds is sufficient. We also do temporary intercostal nerve blocks to help for those first eight hours before it sets in. We're using the standard probe down to H3. We've done kids down to about 18 months. There's a cardiac probe that they use for some of their ablations. In smaller children, you have to be really careful in using a smaller probe. We get a retractor and hold the skin away because there's not a lot of chest wall musculature and you could get some skin freeze. With the newest probe that problem is totally eliminated because the shaft insulation only gets to room temperature. So you can touch the lung and you can touch the skin. The only thing that gets cold is the probe. The benefits is there's no epidural, there's no foley, they get up and moving right away. Their pulmonary toilet has been great. We did a comparison in our group and we saw a two to threefold reduction in narcotic use during the hospitalization. They were able to send these kids home without any narcotic prescriptions and another benefit was that you don't have to wait for a regional team. This was our data. We compared what their results were compared to all of the routine group, which was just IV pain bed only, but also compared to those that had regional block. In this study we had 23 thoracotomies who had cryo. When compared with the group that only used regional nerve blocks, the intercostal nerve cryoablation group used dramatically fewer oral morphine equivalents during their hospital stay. So 137 versus 533. We're using a lot less opioid. Other than our neonatal thoracotomies and we've gone to using this all the time. In summary, when performing thoracotomies, cryoanalgesia is a less invasive alternative to epidurals. It can reduce opioid use, decrease patient's pain scores, and expedite patient recovery. This concludes part one of our video on cryoanalgesia uses outside of pectus repair. To watch part two, click on the link below. Globalcast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.