Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.
Issue link: http://outpatientsurgery.uberflip.com/i/1347514
painful procedures such as total shoulders and total knees. He also regularly uses the treatment for rib fractures and occasionally for other sensory nerve neu- ropathies where rapid onset is desired or potential dysesthesia could be an issue. In terms of technique, Dr. Wilton prefers to use a 90mm stim needle under ultrasound guidance whenever possible. He identifies the target nerve via ultrasound and preps and numbs the skin around the planned insertion site. "A pilot hole is created with an 18-gauge needle before the stim needle is inserted and advanced to the target nerve, almost always under ultrasound guidance," explains Dr. Wilton. He then uses the stim needle to guide the cryo probe to the nerve. Dr. Rigdon estimates he performs approximately 10 cryo procedures per month. "We use it for diag- nostic and therapeutic inventions, before total knee replacements and to help increase patients' partici- pation in physical and occupational therapies." Like Dr. Wilton, the most common cryo proce- dures Dr. Rigdon performs are done via in-plane ultrasound guidance to confirm the terminal needle placement. The procedure produces a lesion in the peripheral nerve tissue by applying cold therapy to the selected site, and blocks the pain signal that the site would send to the brain. Patients are contacted soon after the procedure to ensure there are no unexpected issues. "We always follow up with patients by phone within 72 hours of their treat- ments," says Dr. Rigdon. A promising future Dr. Ilfeld is quick to point out that cryo has a highly variable duration. "Pain relief sometimes lasts multi- ple weeks, and sometimes is lasts multiple months," he says. "There have been cases that have lasted nine months." That variability in the consistency of duration is a limitation, notes Dr. Ilfeld. Still, he sees a lot of potential in cryo and expects use of the treatment to increase significant- ly in outpatient surgical facilities moving forward, especially with the advent of minimally invasive delivery methods. Before that can happen, however, he says more data is needed to prove the effective- ness of this form of analgesia in the surgical setting. "Historically, cryo has been mainly used to treat chronic pain, so now we're looking to see how this technique can be applied to acute pain," says Dr. Ilfeld. "We currently don't have the randomized tri- als to provide us the information needed to opti- mize postoperative cryoanalgesia for our patients." That data might not yet be available, but diligent investigators like Dr. Ilfeld are doing their part to ensure reliable and valid research is published in the near future. In fact, Dr. Ilfeld is leading a number of randomized trials to examine the potential benefits of cryo in treating acute pain. (You can download one of his papers at outpatientsurgery.net/forms.) What he's discovered thus far has been quite promis- ing. For instance, in a recent editorial published in the British Journal of Anaesthesia, Dr. Ilfeld says current evidence suggests that ultrasound-guided percutaneous cryo holds enormous potential for making a dramatic leap forward in providing long- term analgesia far surpassing typical continuous peripheral nerve blocks, with minimal risk and a lower patient burden. Providers who already use cryo regularly, such as Dr. Wilton, expect its usage to ramp up in the future. "There is an increase in interest for alterna- tive targets, including the hip, shoulder, intercostal space, greater occipital nerve and many other sen- sory nerve neuropathies," he says. Like all emerging interventions, the most compelling reason for adoption is improved patient care. "I believe all facilities have a responsibility to explore interventions based on nonopioid-based pain management," says Dr. Wilton. Based on the already available evidence, cryo is certainly worth exploring. OSM M A R C H 2 0 2 1 • O U T P A T I E N T S U R G E R Y . N E T • 9 I believe all facilities have a responsibility to explore interventions based on nonopioid-based pain management. — Jon Wilton, DNAP, CRNA