2. Do You Want to Be Asleep?
March 2015 • Volume 120 • Number 3 www.anesthesia-analgesia.org 685
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 hypno-
sis compared to standard care on pain, anxiety, and anal-
gesic 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 autosug-
gestion provides clinical benefit, they do so without the
need for equipment or drugs. What other therapeutic mea-
sure appears so devoid of increased cost and demonstrable
adverse effects? Personal attention to the patient, emotional
support, positive suggestions, and even hypnosis are read-
ily 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 addi-
tional drugs14,15
and even if no formal hypnosis or relax-
ation technique is used, conversation with “small talk” or
other nonpharmacological alternative techniques including
listening to music or an audio book by earphones are suf-
ficient 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 position-
ing might also be a limiting factor. On the other hand, the
effects of noxious odor (e.g., burning flesh from electrocau-
tery) or sound (e.g., from sawing bone) can be incorporated
and reframed and additional analgesic effects are demon-
strated under formal hypnosis, not possible with small talk
or distraction by ear phones or visual media. A combined
approach of medication and a nonpharmacological inter-
vention could also be meaningful. In cases of severe agita-
tion (e.g., in emergency surgeries), a small amount of an
anxiolytic sedative will open up an opportunity for “thera-
peutic communication.” Cheong et al.16
demonstrated the
prevention of ketamine-induced unpleasant dreams by pre-
treatment 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 per-
centage 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 pre-
frontal 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 hyp-
notic pain interventions for people who fall in the low hyp-
notic suggestibility range. However, some studies suggest
that these individuals may benefit from imaginative anal-
gesia 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 tech-
nique 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 wear-
ing 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 relax-
ation techniques like guided imagery or progressive mus-
cle relaxation, additional training of the anesthesia team is
required. Currently, this is not a standard part of the train-
ing curriculum and needs to be acquired in special training
courses or workshops. Incorporation of some of these tech-
niques into the residency program could be an important
step to provide the current and future generations of anes-
thesiologist 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 won-
der 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 complica-
tions related to intraoperative sedation, to optimize alterna-
tive psychological interventions like hypnosis, and to create
algorithms for a tailored individual approach.
Given the potential risks of unnecessary sedation espe-
cially 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
3. E The Open Mind
686 www.anesthesia-analgesia.org anesthesia analgesia
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 invita-
tion for a comfortable experience in the “surgical home.” E
DISCLOSURES
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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