Efficacy of therapeutic suggestions under general anesthesia: a systematic review and meta-analysis of randomized controlled trials

Touching the unconscious in the unconscious - hypnotic communication with unconscious patients

If hypnosis means contact to the unconscious to modulate psychological and physiological functions by means of suggestions, and if this is facilitated by attenuation of the critical mind, then the question arises as to whether suggestions also have an effect when waking consciousness is otherwise eliminated, namely by coma or anesthesia. A prerequisite would be perception, which actually is evidenced by reports of patients after traumatic brain injury, artificial coma, resuscitation or general anesthesia. Moreover, posttraumatic stress disorder (PTSD) frequently observed after these medical situations is hardly explainable without some sort of awareness under such conditions. Even advanced neurophysiological diagnostic cannot yet rule out consciousness or sensory processing. Especially reference to perception during unconsciousness is given by the results of a recent multicenter study on the effects of hypnotic communication with patients under controlled adequate deep general anesthesia. The observed reductions in incidence and severity of postoperative pain, opioid use, nausea and vomiting cannot be explained by the reaction of a few but only by a considerable proportion of patients. This leads to a strong plea for a more careful treatment of unconscious patients in the emergency room, operating theater or intensive care unit, for the abandonment of the restriction of therapeutic communication to awake patients, and for new aspects of communication and hypnosis research. Obviously, loss of consciousness does not protect against psychological injury, and continuation of communication is needed. But how and what to talk to unconscious patients? Generally addressing the unconscious mind with suggestions that generally exert their effects unconsciously, hypnotic communication appears to be the adequate language. Especially addressing meaningful topics, as derived from the basic psychological needs and known stressors, appears essential. With respect to negative effects by negative or missing communication or to the proposed protective and supporting effects of therapeutic communication with patients clinically rated as unconscious, the role of consciousness is secondary. For the effects of perceived signals and suggestions it does not matter whether consciousness is absent, or partial, or unrecognized present.

Intraoperative suggestions to prevent postoperative delirium in patients undergoing transaortic valvular replacement: a randomized placebo-controlled trial

BACKGROUND

Postoperative delirium (POD) is a serious complication following anaesthesia and surgery and significantly influences postoperative outcome especially in the elderly population. Intraoperative music and positive suggestions influence postoperative outcomes by attenuating analgesic demand and increasing patient satisfaction.

AIMS

Here, we examined the effect of intraoperative music and positive suggestions on the development of POD in aged patients undergoing transcatheter aortic valve replacement (TAVR) procedure under general anaesthesia.

METHODS

For this randomized placebo-controlled study, eligible patients without cognitive deficit, indicated by a MMSE < 10 points, were anesthetized using remifentanil and sevoflurane. Anaesthetic depth was guide with bispectral index. An audiotape with positive suggestions was applied from a MP3 player via headphones. POD, pain and PONV was assessed. CAM-ICU and Nu-DESC were done twice daily for the first 5 days.

RESULTS

Of 140 patients 118 patients could be analysed (57 male, 80.6 ± 5.1 years). POD was diagnosed in 16 patients (12.7%). POD was significantly more often observed in male (12, 21.1%) than in female (4, 6.6%, p = 0.02) and in patients with a low MMSE (23.6 ± 4.5 vs. 26.8 ± 2.8, p = 0.001). Anaesthetic depth did not influence the incidence of POD. Intraoperative music and suggestions did not affect the rate of POD, pain, analgesic requirement or PONV.

DISCUSSION

In patients undergoing TAVR male sex and low MMSE scoring are associated with an increase in POD.

CONCLUSIONS

Intraoperative music and positive suggestions do not influence the incidence of POD in this patient group.

STUDY REGISTRATION

DRKS: 00024444, start of registration: 4.02.202, final registration: 17.09.2021.

[What's new … Patients are listening-communication under general anesthesia]

There is ample evidence of awareness of at least some unconscious patients. A recent multicenter study found significant reductions after therapeutic communication during general anesthesia in postoperative pain and analgesic consumption, as well as in postoperative nausea and vomiting (PONV) and antiemetic requirements in high-risk patients. Thus, an intraoperatively presentet text represents a simple non-pharmacological method to reduce side effects of surgery and anesthesia. This also offers treatment in other unconscious patients. However, another finding seems worth noting: the results of the study cannot be explained by the known intraoperative awareness and response of individual patients. Therefore, there should be a fundamental change in the way patients are treated in the operating room and intensive care unit, and background noise and careless conversations should be eliminated. 56 years after David Cheek formulated "BE CAREFUL, THE PATIENT IS LISTENING should be engraved over the door of every operating room, every recovery room, every intensive care unit in every hospital." after his first observations of patient perceptions, perhaps it is now time to finally heed this call and to use communication with unconscious patients that goes beyond the most necessary announcement of interventions and is therapeutically effective through positive suggestions. When in doubt, assume that the patient is listening.

Effect of Music in Reducing Pain during Hemodialysis Access Cannulation: A Crossover Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

Pain during cannulation for vascular access is a considerable problem for patients with kidney disease who are undergoing hemodialysis. We examined whether listening to music can reduce cannulation pain in these patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a multicenter, single-blind, crossover, randomized trial of 121 patients who reported pain during cannulation for hemodialysis. We compared participants listening to "Sonata for Two Pianos in D Major, K.448" or white noise as control while undergoing the cannulation procedure. The cannulation operator was blinded to the intervention, and the hypothesized superiority of music over white noise was concealed during explanations to the participants. The primary end point was the visual analog scale score for cannulation pain independently evaluated by participants.

RESULTS

The primary analysis was on the basis of the modified intention-to-treat principle. The median baseline visual analog scale pain score was 24.7 mm (interquartile range, 16.5-42.3). Median change of the visual analog scale pain score from the "no sound" to the music period was -2.7 mm (interquartile range, -9.2 to 3.6), whereas it was -0.3 mm (interquartile range, -5.8 to 4.5) from "no sound" to white noise. The visual analog scale pain score decreased when listening to music compared with white noise. (Adjusted difference of visual analog scale pain score: -12%; 95% confidence interval, -21 to -2; P=0.02.) There were no significant differences in the secondary outcomes of anxiety, BP, or stress assessed by salivary amylase (adjusted difference of visual analog scale anxiety score -8%, 95% confidence interval, -18 to 4; P=0.17). No intervention-related adverse events were reported.

CONCLUSIONS

Listening to music reduced cannulation pain in patients on hemodialysis, although there was no significant effect on anxiety, BP, or stress markers.

Therapeutic Suggestions During General Anesthesia Reduce Postoperative Nausea and Vomiting in High-Risk Patients – A Post hoc Analysis of a Randomized Controlled Trial

Postoperative nausea and vomiting (PONV) are one of the most adverse events after general anesthesia, a distressing experience, and pose a risk to the patient. Despite advances in drug prophylaxis and PONV treatment, the incidence remains high and additional non-pharmacological treatments are needed. In this post hoc analysis of a recently published double-blind multicenter randomized controlled trial on the efficacy of intraoperative therapeutic suggestions on postoperative opioid dosage, we analyzed the effects of intraoperative therapeutic suggestions on PONV. We focus on patients with a high risk of PONV (Apfel risk score of 3–4) and distinguished early (first two postoperative hours) and delayed PONV (2–24 h). A total of 385 patients with a moderate or high risk for PONV were included. The incidence of early and delayed PONV was reduced (22.7–18.3 and 29.9–24.1%, respectively), without statistical significance, whereas in high-risk patients (n = 180) their incidence was nearly halved, 17.2 vs. 31.2% (p = 0.030) and 20.7 vs. 34.4% (p = 0.040), corresponding to a number needed to treat of 7 to avoid PONV. In addition, there was a significant reduction in PONV severity. In a multivariate logistic regression model, assignment to the control group (OR 2.2; 95% CI: 1.1–4.8) was identified as an independent predictor of the occurrence of early PONV. Our results indicate that intraoperative therapeutic suggestions can significantly reduce the incidence of PONV in high-risk patients. This encourages the expansion of therapeutic suggestions under general anesthesia, which are inexpensive and virtually free of side effects.

Clinical Trial Registration: German Clinical Trials Register, https://drks.de, registration number: DRKS00013800.

Use of hypnosis preoperatively for surgery of the spine: Pilot study

INTRODUCTION

Hypnosis is a technique requiring no drugs that acts during the three phases of surgery, reducing stress at the pre-surgical phase and the adminstration of anesthetic drugs during the intraoperative phase, as well as leading to improved management of postoperative pain and quality of life management.

MATERIAL ET METHOD

We carried out a retrospective study of 46 patients operated on for herniated disc or one or two-level laminectomy without arthrodesis. All patients benefited from a preoperative hypnosis session and completed a questionnaire about their possible concerns. The day after surgery, patients completed a second questionnaire on their postoperative experience following hypnosis.

RESULTATS

Our results indicate that this technique had a positive impact on the management of preoperative stress (80% of patients) and on postoperative quality of life (48% of patients). Pain measured by decreased from 4.8/10 preoperatively to 0.9/10 postoperatively.

CONCLUSION

Our results are consistent with previous findings in the literature as to the positive contribution of this technique in the management of preoperative stress and patient quality of life. Further studies are however required involving considerably larger cohorts and more extensive surgeries to confirm the effect of this technique on management of anesthesia and pain in spine surgery.

Effect of therapeutic suggestions during general anaesthesia on postoperative pain and opioid use: multicentre randomised controlled trial

OBJECTIVE

To investigate the effect of therapeutic suggestions played to patients through earphones during surgery on postoperative pain and opioid use.

DESIGN

Blinded randomised controlled study.

SETTING

Five tertiary care hospitals in Germany.

PARTICIPANTS

385 of 400 patients consecutively recruited from January to December 2018 who were to undergo surgery for 1-3 hours under general anaesthesia. In the per protocol analysis 191 patients were included in the intervention group and 194 patients in the control group.

INTERVENTION

The intervention comprised an audiotape of background music and positive suggestions based on hypnotherapeutic principles, which was played repeatedly for 20 minutes followed by 10 minutes of silence to patients through earphones during general anaesthesia. Patients in the control group were assigned to a blank tape.

MAIN OUTCOME MEASURES

The main outcome was dose of opioid administered by patient controlled analgesia or nurse controlled analgesia within the first postoperative 24 hours, based on regular evaluation of pain intensity on a numerical rating scale (range 0-10, with higher scores representing more severe pain).

RESULTS

Compared with the control group, the intervention group required a significantly (P=0.002) lower opioid dose within 24 hours after surgery, with a median of 4.0 mg (interquartile range 0-8) morphine equivalents versus 5.3 (2-12), and an effect size (Cohen's d) of 0.36 (95% confidence interval 0.16 to 0.56). The number of patients who needed opioids postoperatively was significantly (P=0.001) reduced in the intervention group: 121 of 191 (63%, 95% confidence interval 45% to 70%) patients in the intervention group versus 155 of 194 (80%, 74% to 85%) in the control group. The number needed to treat to avoid postoperative opioids was 6. Pain scores were consistently and significantly lower in the intervention group within 24 hours after surgery, with an average reduction of 25%. No adverse events were reported.

CONCLUSIONS

Therapeutic suggestions played through earphones during general anaesthesia could provide a safe, feasible, inexpensive, and non-drug technique to reduce postoperative pain and opioid use, with the potential for more general use. Based on the finding of intraoperative perception by a considerable number of patients, surgeons and anaesthetists should be careful about background noise and conversations during surgery.

TRIAL REGISTRATION

German Clinical Trial Register DRKS00013800.

Integrating complementary medicine in the perioperative period: a simple, opioid-sparing addition to your multimodal analgesia strategy?

The current US opioid health-related crisis underscores the importance for perioperative physicians to optimize various approaches to pain management. Multimodal techniques and enhanced recovery after surgery (ERAS) protocols are frequently cited as the most effective strategies for improving the experience of pain and reducing opioid exposure. Complementary medicine (CM) techniques, while frequently shown to be effective at reducing opioid and other pharmacologic agent use, are rarely discussed as part of these multimodal strategies. In general, CM therapies are low-cost with minimal associated risk, making them an ideal choice for incorporation into ERAS and other opioid-sparing protocols. In this Daring Discourse, we discuss the benefits and challenges of incorporating CM therapy into anesthetic practice. We hope that anesthesiologists can become more familiar with the current evidence regarding perioperative CM therapy, and begin incorporating these therapies as part of their comprehensive multimodal approach to perioperative pain management.

Nocebo Effects and Negative Suggestions in Daily Clinical Practice - Forms, Impact and Approaches to Avoid Them

Medical situations are hot spots in the life of a patient with potentially long lasting effects arising from the use of either negative expressions or encouraging statements, or the lack of empathy or a positive physician-patient relationship. Health care personnel should be aware of and evaluate what patients are exposed to, hear and see. Knowing more about the effects of nocebos and negative suggestions, combined with increased attention to these matters, provides the basis for better recognition of detrimental influences in their own clinical environment and to be able to avoid, stop or neutralize them. After anamnesis patients should not be left with a focus on a negative past, but shifted to positive experiences prior to their illness, or to positive expectations in the future following surgery and rehabilitation. For example, after examining an injured leg the doctor should not turn to the computer for documentation unless he has shifted the patient's focus on the other, unimpaired leg. "Is that painful too? No? Good! Can you feel that? Yes? Perfect! Can you bend that knee, move these toes? Great! That's good." This example draws attention to the fact that negative effects (discussed in the following) substantially are dependent on the focus of the patient and thus can be affected by focus shift and distraction. Patients, their symptoms and their healing are negatively affected by the omission of placebo effects, by nocebo effects and by negative suggestions.

Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper

Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care have prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components and self-care/self-efficacy strategies. Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability. The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short- and long-term therapeutic and economic impact of comprehensive care practices.