Ahmed Turkistani MD,FCCMAssociate Professor & chairman of

AnesthesiaCollege of MedicineKing Saud University

  Ahmed Turkistani MD,FCCM Assoc. Professor of

Anesthesia  Magdy Elsayed FRCS Senior Registrar Department of Surgery  Khalid Mazen M.D Senior Registrar Department of Anesthesia   Saleh Al-Abri MBBcH Resident in Anesthesia King Khalid University Hospital

A. El-Dawlatly M.D. Professor Department of Anesthesia

Abdullah Al-Dohayan FRCS Head Department of Surgery

Mohamed Almajed FRCPC Assistant Professor

Essam Manaa M.D. Consultant Anesthetist 

Only few reports about pain relief following thoracoscopic sympathoctomy ( TS)

Pain after video assissted thoracoscopy ( VAST) considered to be moderste to sever ( naghiro et al , Ann Thorac Surg 2001 ) .

Due to conflicting results of techniques descibed for pain relief after VAST , we conducted this double blind randomized controlled trial

Aim of this study to establis a protocol for postoperative analgesia following TS

Thoracoscopic sympathectomy(TS) became standard procedure for treatment of Palmar hyperhidrosis .

Anesthesia for TS is challenging , our center published several articles on anesthetics mangement of TS ( eldawlatly et al Clin Autono Res,13:1/94-1/97), but post operative pain control still under investigation as in many other centres

After approval of hospital ethics committee and patients informed written consent , total of 40 patients were enrolled in the trial.

Patients ASA 1&2 with no major cardiorespiraroty diseases were in .

All patients premedicated with oral larazepam 2 mg 2hrs preop.

Standard intraoperative monitoring . Induction on anesthsia by sufentanil 0.1mcg/kg ,

propofol 3mg/kg followed by atracruim 0.5mg/kg

Single lumen tube intubation performed with maintaince of 50%oxygen+air and 1 MAC sevoflurane and increment of sufentanil and atracruim as required .

All procedures are done by same surgeon with technique of one lung collapsed ventilation .

At end of surgery silastic chest tube inserted and reversal is given .

4 groups were randomly allocated to reicive either :

1. Pethidine 1 mg /kg BW at end of surgery .2. Ketoprufen 100 mg I.M at end of

surgery . 3. Interpleural bupivacaine 0.5ml/kg4. Combination of I.M ketoprufen (100mg)

& interpleural bupivacaine (0.4ml/kg).

Post operative pain assessment using visaual analogue scale (VAS) .

Assessment was immediately at admission to recovery room , each 2 hours till 8 hours then at 12 hours and 24 hours .

Pain was assessed at rest , deep inspiration and coughing

Group IGroup llGroup IIIGroup IV

Age(yr)22.5 ± 3.126.6 ± 2.125.1 ± 430 ± 8

Weight(kg)67.8 ± 11.465.3 ± 11.668.8 ± 12.974.3 ± 7.7

Height(cm)171.8 ± 6.9165.9 ± 9.5167.6 ± 7.9166.8 ± 8.9

Sex(M:F)9 : 19 : 18 : 29 : 1

Duration of surgery (min)

22 ± 4.816 ± 6.524.2 ± 5.819.3 ± 7.9

Table 1. Patient’s characteristics & duration of surgery (mean±SD).

Group IGroup llGroup IIIGroup VITotal%

Cutting000512.5%

Coagulation945547.5%

Clipping165030%

Table 2. Types of surgery for all groups. Number of patients in each group.

Group IGroup llGroup IIIGroup IVP value

0 time2.8 ± 1.52.7 ± 3.22.9 ± 2.91.4 ± 1.20.456

2 hr3.2 ± 1.92.4 ± 1.63 ± 1.90.7± 0.90.006*

4 hr3.5 ± 1.82.7 ± 1.72.7± 1.81 ± 1.10.012*

6 hr3.2 ± 1.83 ± 1.83.1± 1.90.9 ± 1.4 0.014*

8 hr 1 ± 1.63.2 ± 2.33.4± 1.61 ± 1.60.003*

12 hr0.9 ± 1.22.6 ±1.93.1± 1.81 ± 1.50.007*

24 hr1.1 ± 1.41.8 ± 1.32.1± 1.50.1 ± 0.30.004*

Table 3. Visual analogue scale (VAS) at rest (mean±SD)

*P <0.05 significant

Group IGroup llGroup IIIGroup IV P value

0 time3.4 ± 1.53.3 ± 3.73.8 ± 32.4 ± 1.10.7

2 hr3.8 ± 1.22.8 ±1.84.2 ± 2.71.5 ±1.60.015*

4 hr4.1 ± 1.62.9 ±1.93.6 ± 1.80.9 ±1.40.0008*

6 hr4 ± 2.2 3.2 ±2.23.8 ± 1.31.1 ±1.70.006*

8 hr 2.4 ± 2.13.9 ±2.73.9 ± 1.41.1 ±1.70.009*

12 hr1.7± 1.62.9 ±2.33.7 ± 1.81.3 ±1.80.03*

24 hr1.8 ± 1.32 ± 1.62.7 ± 0.60.2 ±0.60.002*

Table 4. Visual analogue scale (VAS) at maximal inspiration (mean±SD).*P <0.05 significant

Group IGroup llGroup IIIGroup IVP value

0 time3.1± 1.33.7 ± 44 ± 3.43.1 ± 1.40.854

2 hr4 ±1.53 ± 24.5 ±2.91.9 ± 2.20.059

4 hr4.5 ±1.93.3 ± 2.53.7 ± 1.61.4 ± 1.80.009*

6 hr4.7 ±2.93.4 ± 2.53.9 ± 1.51.4 ± 2.30.023*

8 hr 2.7 ± 2.54.1 ± 3.14.1 ± 1.41.3 ± 2.20.036*

12 hr2.2 ± 1.82.6 ± 2.14 ±1.61.4 ± 2.40.045*

24 hr2 ± 1.31.9 ± 1.63.2 ± 1.50.4 ± 1.30.001*

Table 5. Visual analogue scale (VAS) at coughing (mean±SD).*P <0.05 significant

Supplemental requirement with morphine in first 24 hrs were as follows :

group 1 : 4 # 1.2 mg group 2 : 5# 0.8 mg group 3 : 4.5 # 0.76 mg group 4 : 1.2# 0.6 mg

VAST became standard procedure for many therapeutic and diagnostic indications .

It avoids many of the disadvantages of open thoracotomy i.e : decrease in postoperative pain ,postoperative lung dysfunction and postop M&M .

Although its considered as a minimally invasive procedure ,patients can experience moderate to severe pain .

PCA with systemic opioids have been used with limited analgesic effect and undesirable side effects(Mason et al BJA 2001;86:236-40

Many approaches for VAST postoperative pain management all with success :

1. Diclofenac and ketorolac were effective in treating post thoracoscopy pain ( perttungen et al BJA 1999;82:221-227)

2. *Paravertebral analgesia* ( Vogt et al BJA 2005 ;95:816-21)

3. Intrapleural analgesia ( Assalia et al Surg Endosc 2003 ; 17:921-2 )

4. Intercostal blockade provide effective pain relief and reduction in morphine requirement (Taylor et al J Cardiothorac Vasc Anesth 2004 ;18:317-21

Thoracic epidural analgesia ( TEA): Major study done by Yoshioka et al

published in Ann Thorac Cardiovasc Surg 12 (5) ,2006

they concluded : TEA is recommended until 1 POD after

VAST ,other kind of analgesics should be employed from 2 POD .

Current study showed that combination of interpleural local anesthsia and i.m ketoprufen provided the best analgescs quality following TS .

single shot or continuous techniques are also useful in providing postoperative analgesia following thoracic surgical procedures (Carabine et al., 1995).

Continuous paravertebral blocks provide superior postoperative analgesia when compared to single shot techniques (Catala et al., 1996).

G. Davies, P. S. Myles, and J. M. Graham comparison of the analgesic efficacy and

side-effects of paravertebral vs epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials Br. J. Anaesth. 2006 96: 418-426

PVB and epidural analgesia provide comparable pain relief after thoracic surgery, but PVB has a better side-effect

profile and is associated with a reduction in pulmonary complications. PVB can be recommended for major thoracic surgery

M. J. Liptay1 et al. 1Evanston Northwestern Healthcare, Evanston, IL, 2Indiana University, Indianapolis, IN,

CONCLUSIONS: Intraoperative paravertebral catheter insertion

provides comparable pain relief to the thoracic epidural catheter. Ease of insertion makes it an alternative to routine epidural insertion.