Cryotherapy Reduces Pain, Narcotic Use After Surgery

Miriam E. Tucker
October 11, 2013

WASHINGTON, DC — Cryotherapy involving the simplest of pain remedies can ease symptoms after major abdominal surgery, according to a new randomized controlled trial.

“Ice packs can reduce postoperative pain and narcotic use. They are an easy, benign, and cost-effective addition to postoperative pain management,” said Ammara Abbasi, MD, a general surgery resident and research fellow at Beth Israel Deaconess Medical Center and Harvard Medical School in Boston.

Dr. Abbasi presented the study results here at the American College of Surgeons 2013 Annual Clinical Congress.

“This study is quite interesting,” said study discussant Brian Zuckerbraun, MD, from the University of Pittsburgh Medical Center. “It is a simple idea. Icing or cryotherapy is widely used for postoperative inflammation and pain management in orthopedics. The elegance of the idea lies in the low cost, the ease of implementation, and the presumed high safety profile,” he told Medscape Medical News.

In this prospective trial, postoperative pain was assessed in patients who had undergone open abdominal operations with midline incisions. A group of 27 patients was treated with morphine plus cryotherapy, and 28 patients, who served as the control group, were treated with morphine alone.

In the cryotherapy group, ice packs were place on the dressing immediately after surgery and were maintained for at least 24 hours, with refills and removal as needed.

Pain was assessed twice a day with a 10-point visual analog pain scale, and total morphine equivalents were calculated. Nurses and patients also completed questionnaires after 3 days.

Each ice pack had a cloth covering, which served to prevent direct skin contact. Patients could also regulate how cool they felt by putting a towel around the ice pack. “We typically limited ice pack use by advising patients to have it off for at least 30 minutes per hour,” Dr. Abbasi told Medscape Medical News.

The cryotherapy group used the ice packs for a mean of 2.75 days. None asked for it to be removed prior to 24 hours.

Pain scores and morphine use didn’t differ between the 2 groups in the postanesthesia care unit. However, pain scores assessed the morning after surgery were significantly lower in the cryotherapy group than in the control group (3.12 vs. 4.86), as were scores assessed that afternoon (2.13 vs 4.76).

On the third postoperative afternoon, the difference in pain scores was significant, with a combined day 1 and day 3 P value of <.005, Dr. Abbasi reported. There was significantly less narcotic use on postoperative day 1 in the cryotherapy group than in the control group (13.5 vs 17.4 morphine equivalents; P = .008). The length of hospital stay did not differ significantly between the cryotherapy and control groups (6.5 vs. 5.7 days). Differences in pulmonary complication rates were also insignificant (6 vs 4), as were differences in wound complication rates (3 vs 1). "Some downsides were that the ice pack leaked, but this was minimal and easily cleaned," Dr. Abbasi told Medscape Medical News. "Also, for obvious reasons, the patients felt cold, but this was resolved with warm blankets. There was no documented hypothermia in any of our patients." Of the 21 cryotherapy patients who completed the survey, 17 (81%) said they had postoperative pain relief and 16 (76%) said they would request an ice pack for additional surgery. Of the 10 nurses surveyed, 8 reported that their patients experienced moderate to significant pain relief, and 6 said they would request an ice pack for themselves if they were to have abdominal surgery. How Nice Is Ice? In the past, surgeons might have been concerned that ice would interfere with wound healing, promote surgical-site infection, or dampen a dry surgical dressing. However, Dr. Abbasi pointed out that most surgical dressings today are covered with water-resistant Tegaderm. "Our study showed that there was no increased risk of wound complications among patients," she said. Another reason ice might not have been considered in the past for midline incisions has to do with the use of epidurals. Because they numb the abdomen, ice would presumably have little benefit. This isn't the case, she explained. "An epidural can have various levels of effectiveness, based on position and setting. It also has a reasonable failure rate and is often discontinued on postoperative day 2 or 3. Many of our abdominal patients stay in-house longer than that, and would benefit from local therapy to their abdominal wound." "This study was relatively small and the results are modest," Dr. Zuckerbraun told Medscape Medical News. "However, the data do demonstrate a statistically significant reduction in the use of opioid pain medications at several time points." "I do not believe this will replace opioid medications, but it could be part of a multimodality approach to pain that may decrease opioid use," he noted. Dr. Zuckerbraun said he "would like to see a larger study with a more complete dataset. This would include information regarding nonopioid pain medications, and have secondary clinical end points such as duration of postoperative ileus and patient mobility. Additional data on wound inflammation or markers of systemic inflammation would also be interesting." Skin burns are a potential concern, he said, but they can be avoided with the intermittent use of ice and by preventing direct contact between the ice and skin. "As with any study, one should always be skeptical, but data can change this," Dr. Zuckerbraun told Medscape Medical News. "I would be willing to implement this therapy, and look forward to more data and studies involving cryotherapy." Dr. Abbasi and Dr. Zuckerbraun have disclosed no relevant financial relationships. American College of Surgeons (ACS) 2013 Annual Clinical Congress. Presented October 8, 2013.

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