While regional anesthesia is a cornerstone of modern anesthesiology, expectations and practice patterns surrounding the use of regional anesthesia with or without accompanying sedation differ based on cultural factors, operating room management procedures, and individual preferences by patients, surgeons, and anesthesiologists. In response to the question “If I choose regional anesthesia, does that mean I am awake during the surgery?” the patient education section of the American Society of Regional Anesthesia website (http://www.asra.com/patient-info-regional-anesthesia-and-analgesia-for-surgery.php) states that “You may remain awake, or you may be given a sedative. You do not see or feel the actual surgery take place. (…). During minimal sedation, you will feel relaxed, and you may be awake. You can understand and answer questions and will be able to follow your physician’s instructions. When receiving moderate sedation, you will feel drowsy and may even sleep through much of the procedure, but will be easily awakened when spoken to. You may or may not remember being in the operating room. During deep sedation, you will sleep through the procedure with little or no memory of the procedure room.”
In daily routine practice, the conversation between patient and anesthesiologist is often less detailed but simple: “Do you want to be asleep during surgery?”
Perhaps rather than only asking this simple and easy to understand question, patients should also be made aware of findings suggesting adverse effects associated with routine use of sedation. For example, Brown et al.1 report in their trial in patients undergoing repair of hip fracture during spinal anesthesia, a significant reduction of postoperative delirium and a reduction of mortality in the light versus deep sedation group adding to a body of evidence that less sedation might be more effective, especially perhaps in patients with greater comorbidities.1 In addition, benzodiazepine-based sedation in intensive care unit (ICU) patients has been linked to posttraumatic stress disorder and depression,2 the exact consequences one would have hoped to prevent using sedative medications.3,4 Disturbed memory formation could be one suitable explanation, which would also be relevant for the situation in the operating room. Jones et al.5,6 hypothesized that depth and length of sedation could result in greater opportunities to form delusional memory in ICU patients and they showed that delusional memory is more strongly associated with the development of posttraumatic stress disorder after the ICU stay rather than factual memory. While these findings in ICU patients may not be precisely applicable to those in the operating room, given the much briefer duration of drug use and the different environment, they do suggest that the choice of drug might play an important role favoring analgesic drugs over sedatives if pain and discomfort (e.g., due to positioning during the procedure) are the main issues.
Egbert and Jackson7 recently revisited a classic article from 1963 demonstrating that patients receiving pentobarbital alone became drowsy but not calm, whereas patients who had a preoperative visit were calm but not drowsy on arrival to the operating room and commented “Thus, the anesthesiologist–patient relationship (rapport) established during the preanesthetic visit had a beneficial anxiolytic effect. This study validated that the anesthesiologist was able to fulfill the intellectual and informational as well as the emotional needs of patients, the authors even suggesting that the greater therapeutic value was the emotional support.”8 While we have much better anxiolytic medications compared to pentobarbital and preoperative anxiety might differ from anxiety during the procedure, the value of emotional support should not be dismissed.
This raises the question why sedation is used (sometimes excessively), when an otherwise adequate anesthetic (such as a spinal or epidural or for other procedures peripheral nerve blocks) is used and a conversation with the anesthesiologist might have a therapeutic effect?
In addition, nonpharmacological methods including medical hypnosis may be suitable alternatives to drug-based sedation regimens for sedation and anxiolysis. Several well-designed studies by Faymonville et al.9,10 used a 10-minute hypnotic induction session by a separate caregiver before the conventional administration of sedatives and local anesthetic infiltration of the operative site for patients undergoing plastic surgical procedures, neck dissections, and thyroid surgery. In their prospective randomized clinical trials, patients in the treatment group had significantly lower pain scores, required less intraoperative opioid analgesics and sedatives, and had less postoperative nausea than those in the control group. Similarly, Lang et al.11 assessed the efficacy of structured attention or hypnosis compared to standard care on pain, anxiety, and analgesic use during conscious sedation for minimally invasive interventional radiology procedures. The hypnosis group had less anxiety throughout the procedure, decreased pain, and required significantly less analgesic medication than the groups receiving standard care or structured attention. These results appear to be independent of patient age in adult populations.12 In 2007, Wobst13 provided an overview of the literature and concluded: “If hypnosis and autosuggestion provides clinical benefit, they do so without the need for equipment or drugs. What other therapeutic measure appears so devoid of increased cost and demonstrable adverse effects? Personal attention to the patient, emotional support, positive suggestions, and even hypnosis are readily available, safe, inexpensive, and attractive measures that might improve the care of our patients.”
In my personal experience when an adequate regional anesthetic is in place, hypnosis can be used without additional drugs14,15 and even if no formal hypnosis or relaxation technique is used, conversation with “small talk” or other nonpharmacological alternative techniques including listening to music or an audio book by earphones are sufficient to provide a comfortable atmosphere for the patient during a procedure. This approach is certainly not suitable for everyone and every procedure and the emotional state of the patient and the individual needs and wishes need to be assessed in the holding area, which can be difficult if time is limited. Nonsurgical pain associated with positioning might also be a limiting factor. On the other hand, the effects of noxious odor (e.g., burning flesh from electrocautery) or sound (e.g., from sawing bone) can be incorporated and reframed and additional analgesic effects are demonstrated under formal hypnosis, not possible with small talk or distraction by ear phones or visual media. A combined approach of medication and a nonpharmacological intervention could also be meaningful. In cases of severe agitation (e.g., in emergency surgeries), a small amount of an anxiolytic sedative will open up an opportunity for “therapeutic communication.” Cheong et al.16 demonstrated the prevention of ketamine-induced unpleasant dreams by pretreatment with positive suggestions and not using negative suggestions is essential even during routine injection of a local anesthetic.17
In contrast to these studies, formal hypnotic induction is relatively contraindicated in the operating room without a specific psychotherapeutic setting in acutely intoxicated patients, patients with psychotic diseases, dementia, and in cases of a relevant language barrier. There is also a small percentage of people who cannot be hypnotized at all and there is a wide range from low to high hypnotizability,18 with a normal distribution pattern among test populations.19 Hoeft et al.20 showed increased functional coupling between the dorsal anterior cingulate cortex and the dorsolateral prefrontal cortex in high compared with low hypnotizable individuals in a functional magnetic resonance imaging study and Milling21 summarizes the evidence regarding hypnotizability and pain relief: “Although individuals in the high suggestibility range show the strongest response to hypnotic analgesia, people of medium suggestibility, who represent approximately one third of the population, also have been found to obtain significant relief from hypnosis. The available evidence does not support the efficacy of hypnotic pain interventions for people who fall in the low hypnotic suggestibility range. However, some studies suggest that these individuals may benefit from imaginative analgesia suggestions, or suggestions for pain reduction that are delivered while the person is not in hypnosis.”
A brief way to assess the response to a suggestive technique such as hypnosis is to ask the patient to stand in front of you and imagine wearing the shining metal armor of a knight. Now you touch the patients back and ask him to imagine a very strong magnet in his back while wearing that shining metal armor, which will protect him from all harm. You repeat the suggestions a few times and if the patient feels the heaviness of the metal armor and/or shows signs of imbalance due to the magnet pulling in the back you most likely have a medium to highly hypnotizable individuum.22
For the use of formal hypnosis and some other relaxation techniques like guided imagery or progressive muscle relaxation, additional training of the anesthesia team is required. Currently, this is not a standard part of the training curriculum and needs to be acquired in special training courses or workshops. Incorporation of some of these techniques into the residency program could be an important step to provide the current and future generations of anesthesiologist trainees with additional low risk—potential high-yield tools.
Importantly, the perceived need to provide sedation lies more in the mind of the anesthesiologist and perhaps the surgeon who might fear an awake and responsive patient. An educational approach including all team members in the operating room (anesthesiologists, surgeons, nurses, and technicians) and leadership by example from the anesthesia team in cognizant use of words23 is therefore warranted.
While different cultural backgrounds might influence the decision to give words a trial, Pauker and Pauker’s statement in the American Society of Anesthesiologists Newsletter in their article “Communication, rapport and expectations: Improving postoperative outcome using words, hypnoidal language and trance” that “as we reframe our role and expand our tools as anesthesiologists, we wonder if we should re-examine who we think we are, what we call ourselves. The word “anesthesia” speaks to the lack of pain or sensation; we steer the ship of care away from pain. It might be interesting if instead we became more like stewards of patient comfort - “comfortologists,” if you will,”24 might indicate acceptance of alternative techniques to a propofol or dexmedetomidine infusion-based regimen even in the United States. Clearly more research is needed to identify patients at risk for development of complications related to intraoperative sedation, to optimize alternative psychological interventions like hypnosis, and to create algorithms for a tailored individual approach.
Given the potential risks of unnecessary sedation especially in vulnerable patient populations including those older than 65 years of age or those with specific risks like morbid obesity or obstructive sleep apnea it might be time to discontinue asking “do you want to be asleep?” and use sedative drugs only if really indicated and not as a part of a routine standard operating procedure.
“Why don’t we have a nice chat about your favorite place in the world, while the surgeon is repairing your knee joint, so you can soon walk again…” could be a great invitation for a comfortable experience in the “surgical home.”
Name: Sebastian Schulz-Stübner, MD, PhD.
Contribution: This author wrote the manuscript.
Attestation: Sebastian Schulz-Stübner approved the final manuscript.
This manuscript was handled by: Lawrence J. Saidman, MD.
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