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• W3192481857 abstract "Hello, is there anybody in there? Just nod if you can hear me, is there anyone home? – Waters R, Gilmour D. Comfortably Numb. Pink Floyd; The Wall, 1979. Perhaps the title in the famous Pink Floyd song could be applied to the female patient from whom a thigh tumour was removed solely under hypnotic focused analgesia, as described by Facco et al. in their case report in this month's issue of Anaesthesia 1. However, this title could also aptly describe the attitude of many modern anaesthetists towards accommodating unconventional therapies that could be really useful adjuncts in their theatre, labour ward and pain clinics. Unless ideas fall within our limits of understanding, we often have no time or inclination to question, learn about, or use them. Hypnosis and acupuncture are two ‘weird’ phenomena that have been described in the anaesthetic literature for over 150 years, yet there is still reluctance to accept them in some quarters. As anaesthetists, we have no problem employing a technique whose mechanism of action we do not fully understand at a cellular level since its endpoint (loss of consciousness) is clear. Many clinicians reject hypnosis and acupuncture since their mechanism of action is also a mystery but in addition, their endpoint is hard to define. Facco et al. describe a scientific and pragmatic approach to hypnosis that seems so straightforward that some of us might even harbour thoughts of disbelief as to its validity and credibility. The authors have provided good evidence of a measurable endpoint; however, those of us who are not ‘numb’ will want to know more and see more cases ‘live’. There is no increased incidence of anaphylactic reactions to general anaesthetics in patients with the ‘multiple chemical sensitivity’ described in this report 2, and most of us would probably opt for a straightforward general anaesthetic in such a case. However, substitute this patient for one with severe ischaemic heart disease or perhaps muscular dystrophy, and the hypnosis option might seem of more interest. Many experimental studies describe an increased pain threshold under hypnosis 3, 4. An excellent review in Anesthesia and Analgesia in 2007 by Wobst 5 covers the history, basic science and clinical evidence for the use of the power of suggestion. It makes for uncomfortable but almost compulsory reading for sceptics. Imaging studies of the brain support specific alterations in metabolic activity in the limbic system such as the insula and anterior cingulate gyrus, comparable with those observed in acupuncture. However, the prefrontal cortices may still hold the key to sensory gating. The first recorded painless operation using hypnosis was a mastectomy performed by Jules Cloquet in 1829 6. Esdaile, who worked with William James Simpson in Edinburgh, described over 300 cases of operations carried out solely under hypnosis in 1846 7. The British Medical Association's Psychology Subcommittee Report in 1955 recommended that trainee anaesthetists and obstetricians be instructed in the use of hypnotherapy based on the evidence it had assessed to that date 8. Since the late 1950s, interest in hypnosis amongst surgeons and anaesthetists has dramatically declined, presumably due to the increasing safety of anaesthetic drugs, machines and monitors, and the perceived variation in patient sensitivity. This journal, to its credit, has long retained a spark of interest in hypnosis, with several case reports and studies published 9-11. Of note, Mason in 1955 carried out a major plastic breast procedure under hypnosis and tested the susceptibility of the patient by previously hypnotising her for removal of two impacted wisdom teeth 9. Perhaps such case reports are what prompted Facco et al. 1 to carry out a pre-operative pain threshold test using a dental pulp stimulator. This scientific assessment of the level of analgesia achievable under hypnosis is commendable before proceeding to surgery. Similarly to hypnosis, acupuncture research has had to surmount many obstacles in the face of an objective and mechanistic scientific world. It is now known that some subjects will respond to acupuncture stimulation with a variety of needling techniques, both on recognised acupuncture meridians and seemingly more randomly chosen ‘clinical’ points. Some people with chronic conditions respond dramatically to acupuncture above and beyond that expected by any placebo response 12. Rather than searching for the perfect sham therapy, researchers into acupuncture are now embarking on comparisons with conventional therapy. This pragmatic approach to acupuncture and hypnosis research is surely one worth pursuing. How many anaesthetists in the UK inform their patients of the excellent evidence for acupuncture's efficacy in preventing or treating postoperative nausea and vomiting 13? What would be the readers' response if a patient requested information about hypnosis for their operation? We have so little time to trawl the past 150 years of literature, and rely on review articles 5, meta-analyses 14 and case series 15 to inform us. And they do. Hypnosis does seem to work as an effective adjunct for surgical patients. Meurisse and his team from Liege, Belgium, have an impressive experience in the technique of hypnosedation in over 1000 patients, dating back to 1992 15. Hypnosedation is a combination of hypnosis and conscious intravenous sedation and might be a more acceptable option to anaesthetists. The beauty of their method of bilateral neck exploration for primary parathyroidism under hypnosedation is that hypnosis (immobility, subjective wellbeing and increased pain thresholds) was induced in 10 minutes and needed no pre-operative testing other than the patients' agreement to continue. In their series of 31 patients having bilateral neck exploration, the anaesthetist creates a calm environment so that the patient is able to place him/herself in a hypnotic state by focusing on a single positive memory 15. The results were so impressive that the authors proposed this technique as a new standard of care for that procedure. So where do we go from here? Should each anaesthetic directorate or region have a lead for ‘weird phenomena’? A clinician who is interested, is trained, can train and can be called in to hypnotise specific cases? Same-day admission has led to the almost complete extinction of anxiolytic premedication and patients are frequently met only minutes before their operation. We are left with a short time to establish a trusting rapport with our patients. We are in a most privileged position and without even realising it, have probably been hypnotising patients for years pre-operatively or at induction, with the use of carefully chosen linguistic programming 16. The use of a monotonous voice and repetition of calm phrases, plus a respectful quietness in the anaesthetic room, as used in Meurisse's series, should be encouraged. There can be no place for negativity during these important interactions. Perhaps anaesthetic training should focus more on these areas and introduce specific communication skills to improve the patient experience and outcome 17. Not all patients will reach a level of analgesia under hypnosis like Facco et al.'s patient, to undergo surgery. Developing the infrastructure to test this pre-operatively will be a challenge, but with pre-operative assessment units present in most hospitals, it should be achievable. Hypnosedation may be a more acceptable and pragmatic approach. Further research into the role and efficacy of hypnosis as a peri-operative adjunct or a sole technique providing analgesia should always be encouraged; however, there is already enough published evidence to suggest that it has a place in modern anaesthesia now. Time should not be wasted searching for the perfect convincing randomised controlled trial. Educational meetings should invite those with experience to speak and enlighten others. Workshops on hypnotic techniques, like those for the airway and nerve blocks, could be developed. Now is the time for those with an interest in hypnosis to come forward and be supported. The rest of us need to be less numb. No external funding and no competing interests declared." @default.
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