Anestesia total intravenosa libre de opioides guiada por qCON y qNOX en paciente obesa / Total Intravenous anesthesia in patients with intestinal occlusive syndrome

Introducción: En los últimos años la anestesia libre de opioides ha constituido una alternativa más a las técnicas tradicionales de anestesia general. Con la exclusión de este grupo de fármacos se evitan los múltiples efectos adversos y complicaciones asociados al mismo. A pesar de que la anestesia libre de opioides tiene sus indicaciones y que ha demostrado sus beneficios en cierto grupo de pacientes, existen aún controversias en relación con su utilidad en el paciente obeso. Características como la obesidad hacen que los modelos multimodales empleados para programar la anestesia libre de opioides sean cada vez más complejos. Objetivos: Describir un caso clínico realizado con la técnica de anestesia libre de opioides que constituye la primera experiencia en Ecuador. Presentación del caso: Se presenta el caso de una paciente obesa intervenida de colecistectomía laparoscópica mediante infusión de propofol, ketamina, lidocaína, sulfato de magnesio, y dexmedetomidina. La titulación de estos fármacos se realizó mediante cálculo de concentraciones plasmáticas a través de modelos farmacocinéticos y guiada por monitorización de profundidad anestésica y analgésica, con lo cual se logró optimizar el consumo de fármacos, disminuir las complicaciones y una evolución clínica favorable. Hasta donde se conoce a nivel local y de país (Ecuador) es la primera experiencia que se reporta con esta técnica. Conclusiones: La anestesia libre de opioides puede resultar una elección en el paciente obeso ya que asegura una adecuada recuperación sin efectos adversos asociados(AU)

Introduction: In recent years, opioid-free anesthesia has become another alternative in front of traditional general anesthesia techniques. The exclusion of this group of drugs avoids the numerous adverse effects and complications associated with its usage. Although opioid-free anesthesia has its indications and has showed its benefits in a certain group of patients, there is still controversy regarding its usefulness in the obese patient. Characteristics such as obesity make the multimodal models used to program opioid-free anesthesia increasingly complex. Objectives: To describe a clinical case involving the opioid-free anesthesia technique, which is the first experience in Ecuador. Case presentation: The case is presented of a female obese patient who underwent laparoscopic cholecystectomy by infusion of propofol, ketamine, lidocaine, magnesium sulfate and dexmedetomidine. Titration of these drugs was carried out by calculating plasma concentrations through pharmacokinetic models and guided by monitoring of anesthetic and analgesic depth, thus optimizing drug consumption, reducing complications and achieving a favorable clinical evolution. As far as known locally and in the country (Ecuador), this is the first reported experience with this technique. Conclusions: Opioid-free anesthesia may be a choice in the obese patient, since it ensures adequate recovery without associated adverse effects(AU)

Hypnosis for cingulate-mediated analgesia and disease treatment.

Hypnosis is a technique that induces changes in perceptual experience through response to specific suggestions. By means of functional neuroimaging, a large body of clinical and experimental studies has shown that hypnotic processes modify internal (self-awareness) as well as external (environmental awareness) brain networks. Objective quantifications of this kind permit the characterization of cerebral changes after hypnotic induction and its uses in the clinical setting. Hypnosedation is one such application, as it combines hypnosis with local anesthesia in patients undergoing surgery. The power of this technique lies in the avoidance of general anesthesia and its potential complications that emerge during and after surgery. Hypnosedation is associated with improved intraoperative comfort and reduced perioperative anxiety and pain. It ensures a faster recovery of the patient and diminishes the intraoperative requirements for sedative or analgesic drugs. Mechanisms underlying the modulation of pain perception under hypnotic conditions involve cortical and subcortical areas, mainly the anterior cingulate and prefrontal cortices as well as the basal ganglia and thalami. In that respect, hypnosis-induced analgesia is an effective and highly cost-effective alternative to sedation during surgery and symptom management.

Impact of Perioperative Hypnosedation on Postmastectomy Chronic Pain: Preliminary Results.

Objectives: The main aim of this prospective nonrandomized study was to evaluate if mastectomy performed with perioperative hypnosedation led to a lower incidence of chronic pain compared with mastectomy under general anesthesia. Methods: Forty-two breast cancer patients who underwent mastectomy either under GA (GA group, n = 21) or HYP (HYP group, n = 21) associated with local and/or regional anesthesia were included. The type of adjuvant therapy as well as the number of reconstructive surgical procedures were well balanced between the 2 groups. The average age of the patients and the type of axillary surgery were also equivalent. Incidence of postmastectomy chronic pain, lymphedema, and shoulder range of motion (ROM) were evaluated after a mean 4-year follow-up. Results: The study shows a statistically significant lower incidence of postmastectomy chronic pain in HYP group (1/21, 1 patient out of 21 experiencing pain) compared with GA group (9/21) with 9 patients out of 21 experiencing pain (P = .008). ROM for shoulder was also less frequently affected in the hypnosedation group, as only 1 patient had decreased ROM, instead of 7 in the other group (P = .04). Conclusions: Our study is the first to hint at the potential benefits of hypnosedation on postmastectomy chronic pain. Despite the limitations of this study (nonrandomized, small sample), preliminary results merit further study of hypnosedation.

The Effect of Hypnosis on Intraoperative Hemorrhage and Postoperative Pain in Rhinoplasty.

This prospective, randomized study investigated the effects of preoperative hypnosis on hemorrhage and pain in open septorhinoplasty (SRP). Twenty-two patients undergoing SRP under general anesthesia were included and equally divided into two groups. Patients in the hypnosis group (HG) received a total of three sessions of hypnotic induction. The first two sessions occurred 3 days and 1 day prior to surgery, respectively, and the last session was in the hospital the day of surgery. The other 11 patients constituted the control group (CG). Compared with the CG, the HG's intraoperative use of total remifentanil and the visual analog scale scores at the 2nd and 3rd postoperative hours were significantly lower (p < .05). Hypnosis did not affect the quality of the surgical field. However, preoperative use of hypnosis decreased intraoperative remifentanil requirements and postoperative pain.

Optogenetics and Chemogenetics.

Optogenetics and chemogenetics provide the ability to modulate neurons in a type- and region-specific manner. These powerful techniques are useful to test hypotheses regarding the neural circuit mechanisms of general anesthetic end points such as hypnosis and analgesia. With both techniques, a genetic strategy is used to target expression of light-sensitive ion channels (opsins) or designer receptors exclusively activated by designer drugs in specific neurons. Optogenetics provides precise temporal control of neuronal firing with light pulses, whereas chemogenetics provides the ability to modulate neuronal firing for several hours with the single administration of a designer drug. This chapter provides an overview of neuronal targeting and experimental strategies and highlights the important advantages and disadvantages of each technique.

Influence of Depth of Hypnosis on Pupillary Reactivity to a Standardized Tetanic Stimulus in Patients Under Propofol-Remifentanil Target-Controlled Infusion: A Crossover Randomized Pilot Study.

BACKGROUND: Pupillometry allows the measurement of pupillary diameter variations in response to nociceptive stimuli. This technique has been used to monitor the balance between analgesia and nociception. Under general anesthesia, the amplitude of pupillary dilation is related to the amount of administered opioids. The objective of this study was to determine whether at a constant infusion rate of opioids, the pupillary response was influenced by depth of hypnosis assessed by the bispectral index (BIS). METHODS: Twelve patients (14-20 years) anesthetized for orthopedic surgery were included. Under propofol-remifentanil target-controlled infusion, remifentanil effect site target concentration was fixed at 1 ng/mL. Two measures of pupillary reflex dilation were performed on each patient in a randomized order: one at BIS 55 and one at BIS 25. These levels of BIS were obtained by adjusting propofol target concentration and maintained for 10 minutes before each measure. For each measure, we applied a standardized tetanic stimulation on the patient's forearm (60 mA, 100 Hz, 5 seconds). All measures were performed before the beginning of surgery. RESULTS: Pupillary dilation was significantly greater at BIS 55 than at BIS 25: 32.1% ± 5.3% vs 10.4% ± 2.5% (mean difference estimate [95% confidence interval]: 21.8% [12.9-30.6], P < .001), without carryover effect (P = .30) nor period effect (P = .52). Hemodynamic parameters and BIS were not modified by the stimulation. CONCLUSIONS: In patients receiving a constant infusion of remifentanil at a target concentration of 1 ng/mL, pupillary dilation after a standardized tetanic stimulation was influenced by depth of hypnosis assessed by the BIS.

Hypnosis and Axillary Compartment Block for Breast Cancer Surgery: A Case Report.

Hypnosis has been proven to be a powerful tool in the management of anxiety and pain. It allows for an increase of pain threshold, which can reach the level of surgical analgesia. Recently injection of local anesthetics around the serratus muscle has been presented as an alternative to paravertebral block for cancer breast surgery. We report the successful use of hypnosis in combination with an axillary compartment block for lumpectomy and axillary lymph node dissection.

Impact of a preoperative conversational hypnotic session on propofol consumption using closed-loop anesthetic induction guided by the bispectral index: A randomized controlled trial.

OBJECTIVE: The automated administration of propofol in a closed loop could be used to objectively evaluate the nonpharmacological anesthetic action of hypnotherapy. The objective of this study was to evaluate the impact of a conversational hypnosis session on the consumption of propofol for anesthetic induction. DESIGN: A randomized, usual care-controlled, single-center, patient-blind trial. SETTING: Tertiary care center in France from November 2012 to December 2013. PARTICIPANTS: Adult patients scheduled for a surgical procedure under general anesthesia. INTERVENTIONS: Before surgery, patients were randomized with a computer-generated random list for a preoperative conversational hypnosis session or for usual care. The conversational hypnosis session was conducted and individualized by the therapist with an academic degree in hypnosis in a quiet environment. Anesthetic induction was automatically performed by propofol without opioids and was assisted by the bispectral index in a closed loop. OUTCOME: Primary endpoint was the propofol dose required for anesthesia induction, defined as a Bispectral index less than 60 for at least 30 seconds. RESULTS: The study included 48 patients in the hypnosis group and 49 patients in the control group. No difference in propofol consumption to obtain anesthesia induction was observed between the groups (total dose: 138.6 [67.5] and 130 [47.9] mg, P = .47; adjusted dose: 2.15 [1.09] and 1.95 [0.66] mg/kg, P = .28, for the hypnosis and control groups, respectively). Hetero-evaluation of arm movement during propofol injection (no reaction: 98% and 74%; P = .004, in the hypnosis and control groups, respectively) and face reaction at venous access placement (no reaction 59% and 30%; P = .017, in the hypnosis and control groups, respectively) were lower in the hypnosis group. No adverse event was reported. CONCLUSIONS: No difference in propofol consumption was observed in this study designed to evaluate the effect of a hypnotic conversational session on anesthesia induction using an automated tool for propofol administration.

Hypnopraxia, a new hypnotic technique for hypnoanesthesia.

Various hypnotic techniques are used in anesthesia, either on their own or as adjuncts. A new hypnotic technique, hypnopraxia, was tested in 5 patients undergoing various procedures (4 colonoscopies, 1 inguinal hernia repair, and 1 transobturator tape procedure). The patients were accompanied throughout the procedure by an anesthetist trained in hypnoanesthesia and hypnopraxia. Initially developed for use in hypnotherapy, the accompaniment with hypnopraxia relied on the closeness of the link between the anesthetist and the patient. This was constantly built in the present moment, here and now, by giving back to the patient what the anesthetist observed of the manifestations of the patient's unconscious mind (the patient's speech and choice of words, facial microexpressions, involuntary bodily movements, and emotions). The anesthetist's verbal accompaniment was therefore determined by the patient. No other anesthetic technique was needed during the colonoscopies. For the 2 surgical procedures, some sufentanil was given and local anesthetic was applied by the surgeon. All 5 patients were well satisfied after the procedure. They were especially pleased at having been able to go through their procedure without needing any drug anesthesia, and at being in charge throughout. This preliminary experience with hypnopraxia would tend to show that this technique could be useful in the anesthetic setting. More experience is obviously required with hypnopraxia in anesthesia so as to improve the technique further, and to determine its implications, if any, for the patients and for the procedures. Furthermore, it will be of the greatest interest to determine, before carrying out any procedure with hypnoanesthesia, which patient will benefit most from which hypnotic technique.

An Evaluation of the Effect of Hypnosis on Postoperative Analgesia following Laparoscopic Cholecystectomy.

Little attention has been paid to the effectiveness of hypnosis in improving the results of surgery in Iran. One hundred and twenty patients scheduled for laparoscopic cholecystectomy were randomly divided into either control (standard care) or experimental (hypnosis) groups. Prior to surgery and again after surgery, abdominal pain, nausea, and vomiting were assessed. The results suggest that hypnosis could effectively reduce pain after laparoscopic cholecystectomy and significantly reduce hospitalization time.

Hypnosis for Acute Procedural Pain: A Critical Review.

Clinical evidence for the effectiveness of hypnosis in the treatment of acute procedural pain was critically evaluated based on reports from randomized controlled clinical trials (RCTs). Results from the 29 RCTs meeting inclusion criteria suggest that hypnosis decreases pain compared to standard care and attention control groups and that it is at least as effective as comparable adjunct psychological or behavioral therapies. In addition, applying hypnosis in multiple sessions prior to the day of the procedure produced the highest percentage of significant results. Hypnosis was most effective in minor surgical procedures. However, interpretations are limited by considerable risk of bias. Further studies using minimally effective control conditions and systematic control of intervention dose and timing are required to strengthen conclusions.

The association of hypno-anesthesia and conventional anesthesia in a patient with multiple allergies at risk of anaphylactic shock.

A male patient needed surgery for the ablation of 4 impacted maxillary molars that prevented chewing and had contributed to progressively worsening trigeminal neuralgia. Two previous anesthetic procedures led to episodes of severe anaphylactic shock with the need for a prolonged stay in the ICU. Hypnotic anesthesia was therefore selected as a safer option for this patient. After 4 preparative sessions, on the day of surgery, the hypnotist provided an induction followed by suggestions for mouth and face anesthesia. Intubation occurred following the introduction of remifentanil and sevoflurane. The surgery lasted about 90 minutes and proceeded uneventfully. This case report describes how conventional and hypnotic anesthesia may work synergistically and may be particularly advantageous in case of drug allergy.

[Evaluation of hypnosis in pain management during photodynamic therapy: a pilot study]. / Évaluation de l'hypnose à visée antalgique dans la photothérapie dynamique : étude pilote.

BACKGROUND: Pain is the main adverse effect of photodynamic therapy (PDT) and few effective analgesic methods are currently available. Our aim was to evaluate the efficacy of hypnoanalgesia with the use of PDT. PATIENTS AND METHODS: Between August 2011 and February 2013, a hypnoanalgesia session was proposed to patients requiring PTD for the treatment of (pre)carcinomatous lesions. At the end of the hypnosis session, patients evaluated their pain on a numeric pain scale (NPS) of 0 to 10. RESULTS: Twelve patients of average age 74.6 years were included. The indication for PDT was actinic keratosis (AK) in 9 patients, 1 Bowen's disease of the penis, 1 mammary Paget's disease and 1 bowenoid papulosis of the penis. Hypnoanalgesia was effective in 8 patients with a mean pain evaluation score of 2.9/10 on the NPS. Six of these 8 patients had previously undergone treatment by PDT without hypnosis and with an average pain score of 8.3/10. DISCUSSION: Hypnoanalgesia appears to be of value for pain management with PTD. This method is simple, inexpensive and devoid of side effects, and it is active on both pain and anxiety. To improve the use of hypnoanalgesia in PDT, it would be necessary to have better knowledge of the predictive factors for pain in PDT, to determine how to best select patients "sensitive" to hypnosis, and to encourage the training of nurses and doctors in this method.

Posthypnotic use of olfactory stimulus for pain management.

Chronic pain due to disease or injury persists even after interventions to alleviate these conditions. Opiates are not always effective for the patient and have undesirable side effects. Hypnosis has been shown to be an effective treatment and may be enhanced by the use of olfactory stimulation as a posthypnotic cue. The article details 2 case reports that demonstrate the possible benefits of olfactory stimulus as an adjunct to hypnosis for pain relief.

[The first labor analgesia with drug was performed in late Meiji Period (1868-1912). Hypnosis also attracted attention as a method of labor analgesia in mid-Meiji Period].

Ether or chloroform, was in use for ambulatory surgery after 1861 in Japan. An inhalational anesthetic, especially chloroform, was administered for cesarean section in early Meiji Period (from 1868) up to 1897. According to an article in 1903, chloroform was recommended as a strategy for internal cephalic version. However, it is uncertain whether inhalational anesthetic had been utilized for vaginal deliveries before 1903. There is evidence that hypnosis had attracted attention as a method of labor analgesia around that time.

Aplicabilidade da hipnose na ecocardiografia transesofágica / Applicability of hypnosis in transesophageal echocardiography

Objetivo: Comparar eficácia da hipnose frente ao midazolam e ao controle (sem sedação), quando utilizada como técnica sedativa antes do ecocardiograma transesofágico (ETE). Método: Estudo prospectivo em 60 pacientes que realizaram ETE no Pronto Socorro Cardiológico de Pernambuco, entre os meses de fevereiro de 2009 e dezembro de 2009. Os pacientes foram alocados em um de três grupos: sedação com midazolam intravenoso, sedação com hipnose ou controle. Os três grupos receberam lidocaína spray na garganta. Após o exame, os pacientes e médicos operadores responderam a um questionário de pesquisa. A análise estatística foi realizada com o programa Bioestat 5.0. Teste utilizado foi o de Kruskal-Wallis. O teste de Dunn foi utilizado a posteriori. Resultados: O grupo da sedação hipnótica apresentou diferença significativa frente ao grupo controle, quanto ao menor grau de lembrança do procedimento (H= 20,87; gl= 2; p < 0.01) e menor grau de desconforto (H= 7,65; gl= 2; p < 0,05) pelo paciente. O grupo hipnose apresentou maior grau de facilidade para o médico operador frente aos grupos de sedação com midazolam e controle (H= 12,34; gl= 2; p < 0,01). Não houve diferença significativa entre os grupos quanto ao grau de dor ou náusea. Conclusão: A hipnose, como técnica de preparo para o ETE, em pacientes susceptíveis, mostrou-se superior em relação às técnicas tradicionais, quando analisados o grau de lembrança ou do desconforto pelo paciente e, principalmente, o grau de facilidade na execução do procedimento pelo médico.

Objective: To compare the eff ectiveness of hypnosis outside the midazolam and control (without sedation), when used as a sedative before the transesophageal echocardiography (TEE). Method: A prospective study of 60 patients who underwent TEE in “Pronto-socorro Cardiológico de Pernambuco” between February/2009 and December/2009, after approval by the Ethics in Research. Patients were assigned into one of three groups: sedation with midazolam intravenous, sedation with hypnosis or control. All three groups received lidocaine spray in the throat. After examination, patients and physicians operators answered a questionnaire. Statistical analysis was performed by the program Bioestat 5.0 using initially the Kruskal-Wallis test and Dunn a posteriori. Results: Th e group of hypnotic sedation showed signifi cant diff erence against the control group on the lower level of memory of the procedure (H = 20.87, df = 2; p < 0.01) and less discomfort (H = 7.65, df = 2, p < 0.05) by the patient. Th e hypnosis group had a greater degree of ease for the doctor performing the examination front groups of sedation with midazolam and control group (H = 12.34, df = 2, p < 0.01). Th ere was no signifi cant diff erence between groups regarding the degree of pain or nausea. Conclusion: As a preparation technique on TEE, hypnosis was shown to be superior when which applied in relation to traditional techniques when analyzed the degree of remembrance or discomfort by the patient and especially the degree of ease in execution of the procedure by the doctor.

Use of preoperative hypnosis to reduce postoperative pain and anesthesia-related side effects.

The purpose of this pilot project was to test the feasibility of hypnosis as a preoperative intervention. The unique features of this study were: (a) use of a standardized nurse-delivered hypnosis protocol, (b) intervention administration immediately prior to surgery in the preoperative holding area, and (c) provision of hypnosis to breast cancer surgery patients receiving general anesthesia. A mixed-method design was used. Data collected from the intervention group and historical control group included demographics, symptom assessments, medication administration, and surgical, anesthesia, and recovery minutes. A semi-structured interview was conducted with the intervention group. A reduction in anxiety, worry, nervousness, sadness, irritability, and distress was found from baseline to postintervention while pain and nausea increased. The results support further exploration of the use of nurse-led preoperative hypnosis.