2. Ahmed Turkistani MD,FCCM Associate Professor & chairman of Anesthesia College of Medicine King Saud University

3.   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

4.  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

5.  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

6.  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

7.  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.

8.  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/kg 4. Combination of I.M ketoprufen (100mg) & interpleural bupivacaine (0.4ml/kg).

9.  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

10. 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 : 1 8 : 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).

11. Group IGroup llGroup IIIGroup VITotal % Cutting000512.5 % Coagulation945547.5% Clipping165030% Table 2. Types of surgery for all groups. Number of patients in each group.

12. 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 ± 1.40.014* 8 hr1 ± 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

13. Group IGroup llGroup IIIGroup IVP 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 ± 2.23.2 ±2.23.8 ± 1.31.1 ±1.70.006* 8 hr2.4 ± 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

14. 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 hr2.7 ± 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

15.  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

16.  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

17.  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

19.  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.

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

24.  single shot or continuous techniques are also useful in providing postoperative analgesia following thoracic surgical procedures (Carabine et al., 1995).Carabine et al., 1995  Continuous paravertebral blocks provide superior postoperative analgesia when compared to single shot techniques (Catala et al., 1996).Catala et al., 1996

25.  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

26.  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

27.  M. J. Liptay 1 et al. 1 Evanston Northwestern Healthcare, Evanston, IL, 2 Indiana 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.