Hypnosis for cataract surgery in an American Society of Anesthesiologists physical status IV patient.
A 73-year-old morbidly obese female patient (weight 125 kg, height 156 cm) was scheduled for cataract surgery of her right eye. Her past medical history included right facial nerve palsy, a transient ischaemic attack, stable angina, hypertension, sleep apnoea treated with non-invasive assisted ventilation at night, chronic obstructive pulmonary disease, gastro-oesophageal reflux, colitis, insulin-dependent diabetes, hypo-thyroidism and hyperuricaemia. She had had six pregnancies, all without any complication. She had undergone several relatively minor operations under general anaesthesia prior to 1994. Since then she had received right pupil surgery under local anaesthesia and three colonoscopies without anaesthesia. Her medications included home oxygen 14 hours a day, levothyroxine, allopurinol, tramadol, paracetamol, fruosemide, ramipril, clopidogrel, insulin, loflazepate (a benzodiazepine), pantoprazole, loperamide and molsidomine (a coronary vasodilator). Her health status was stable in the week prior to surgery, with no further optimisation possible.
The anaesthesia technique was discussed a week before surgery and it was decided to perform the operation under topical local anaesthesia. In order to keep her protected from cardiovascular events, clopidogrel was to be continued before, during and the day after surgery. This implied that regional eye blocks could not be performed because of the risk of haemorrhage. Therefore, the only option remained to apply anaesthetic eye drops (tetracaine with and without 2% ophthalmic lignocaine) combined with a mydriatic and cycloplegic collyrium Mydriasert[R] (tropicamide and phenylephrine). However, as this is often insufficient to prevent the patient from moving during the surgery, surgeons often request light sedation. In addition, because of her serious medical background, the patient was very anxious and requested sedation during surgery. However, due to her multiple high risks, an alternative to pharmacological sedation was sought.
During the pre-anaesthetic interview the day before surgery, the patient said that she had experienced hypnosis in 1971 which, in her opinion, helped to alleviate the neurological symptoms of her previous transient ischaemic attack. Consequently, she responded very positively to the proposal of utilising perioperative hypnosis and was willing to participate. Pre-hypnotic testing for suggestibility using suggestions for a 'heavy arm' (imagining holding a bucket of water in her left hand while the eyes are closed) was instantly positive and her left arm went down immediately after suggestion.
On the day of surgery she was premedicated with hydroxyzine 100 mg, cimetidine 400 mg and she also received her regular morning doses of molsidomine, clopidogrel, levothyroxine and ramipril. In the operating theatre the patient was fully alert, cooperative and conscious without any signs of drowsiness. Standard monitoring was applied and intravenous access obtained. In case of perioperative problems, appropriate equipment and drugs were on stand-by for emergency endotracheal intubation. Hypnotic induction was achieved with the heavy eyelid technique as described by the modified Elman technique (14-16), putting the patient into trance within 30 seconds. Continuous suggestions of her holidays in her favourite spa resort with words like "warm bubbling water bath", "body relaxation" and "watching the blue sky outside the window" as described by the patient herself the day before surgery, were used to maintain the trance state. This was an application of the "utilisation" principle, so named by Erickson, of incorporating content and language from the patient's own repertoire into hypnotic techniques (8). She later reported that she was not aware of being in the operating room, but experienced profound relaxation in a jacuzzi while enjoying the view of the garden of the spa hotel in the sunshine. Soon after hypnotic induction the patient received one gram of intravenous paracetamol. During hypnosis, respiration was deep and regular at about 12 per minute, oxygen saturation remained stable between 95 and 98% with three litres per minute of oxygen via a nasal cannula. Perioperative blood pressure was between 125/60 mmHg and 150/70 mmHg with a steady heart rate at around 70 beats per minute. During surgery, her blood glucose level was 5.3 mmol/l. Her limbs remained floppy and relaxed. Surgery lasted 35 minutes and was uneventful. The surgeon described operating conditions as optimal. Arousal of the hypnotic trance was slow despite suggestions for returning to full awareness. Therefore, it was suggested to the patient to take the train from the spa resort back to her home town where she would undergo eye surgery; this was effective in bringing her out of trance. Once fully aware, she took a few minutes to realise that her cataract operation had been completed and did not complain of any unpleasant symptoms. The postoperative and posthypnotic recovery was uneventful and the patient expressed great satisfaction with her perioperative experience.
Hypnotisability appears not to be related to the placebo effect (17) and brain-imaging studies confirm the involvement of the anterior cingulate cortex, the thalamus and the ponto-mesencephalic brainstem in the production of hypnotic states (10,12). Considerable variability exists in individuals' responses to nociceptive stimuli (18) as well as the responses to hypnotic intervention (19). A distinction is often made between high and low hypnotisability in patients (19,20) and it has been stated that although between 60 and 85% of patients are readily hypnotisable, only around 15% of patients can achieve the depth of hypnosis needed for surgery without anaesthesia (2). However, in non-surgical settings, initial low response can be increased with practice and a small number of cases known to the writers indicate that this may also be achievable in surgical settings. Success of the hypnosis also relies on the patient being highly focused, often on a visualised safe and comfortable place (2). Our patient chose her favourite spa resort. The fact that the patient had already experienced hypnosis successfully in her past also made a rapid and successful response more likely.
Remifentanil could have been used as an alternative to hypnotic sedation and is rapidly metabolised by serum esterases within three to five minutes and reversible with naloxone. However, considering the presence of chronic respiratory failure requiring home oxygen and stable angina, the choice of remifentanil would have implied some risks of perioperative respiratory depression with intermittent falls of oxygen saturation. Consequently, adjusting the plasma concentration of remifentanil to correct oxygen saturation could have offset the objectives of sedation, namely a calm patient during surgery with a stable blood pressure, as sedation depends on a constant blood level of remifentanil. Alternatively, short-acting benzodiazepines such as midazolam, which can be reversed by flumazenil, offer good sedation levels. However, pharmacokinetic difficulties with midazolam are similar to remifentanil. Even with midazolam, it can be complicated in high-risk patients to maintain a constant sedation level while preventing respiratory depression. In the case of significant desaturation, excessive sedation with midazolam can be reversed with flumazenil, but with the drawback that the patient is insufficiently sedated and becomes restless and anxious during surgery. This dilemma is especially true for patients with chronic obstructive pulmonary disease and morbid obesity with a background of coronary insufficiency.
In contrast to pharmacological sedation, the gag reflex is still fully preserved under hypnosis, which is an important advantage especially in the light of a past medical history with gastro-oesophageal reflux.
Arguments in favour of perioperative hypnosis are supported by a small-scale study concluding that during interventional radiological procedures, significantly more patients with intravenous conscious sedation exhibited oxygen desaturation and/or needed interruptions of their procedures for haemodynamic instability compared to patients with self-hypnotic relaxation (1). Another study also shows that hypnosedation is more cost-effective than anaesthesia saving an average of 47% per case, due to fewer complications from general anaesthesia, shorter procedure times and lower cost of materials (21).
In summary, perioperative hypnosis proved to be a satisfactory option for sedation in this high-risk patient and should be actively considered for similar, easily suggestible patients who are undergoing minor surgery.
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(20.) Weitzenhoffer A, Hilgard J. Stanford scales of hypnotic susceptibility, form C. Palo Alto, CA: Consulting Psychologists Press 1962.
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G. KISS *, J. BUTLER ([dagger])
Department of Anaesthesia and Surgical Intensive Care, University Hospital of Brest, Brest, France
* M.D., Consultant.
[[dagger]] M.B.S.H., C.H., B.A., B.Sc., D.H., Dip. A.T., Head, Hypnotherapy Training Institute of Britain, London, United Kingdom.
Address for correspondence: Dr G. Kiss, Department of Anaesthesia, CHU La Cavale Blanche, Bd Tanguy Prigent, F-29200 Brest, France.
Accepted for publication on June 26, 2011.
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|Author:||Kiss, G.; Butler, J.|
|Publication:||Anaesthesia and Intensive Care|
|Article Type:||Case study|
|Date:||Nov 1, 2011|
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