Effects of Preparatory Coaching and Home Practice for Deep Inspiration Breath Hold on Cardiac Dose for Left Breast Radiation Therapy.

AIMS: Deep inspiration breath hold (DIBH) reduces cardiac radiation exposure by creating cardiac-chest wall separation in breast cancer radiotherapy. DIBH requires sustaining chest wall expansion for up to 40 s and involves complex co-ordination of thoraco-abdominal muscles, which may not be intuitive to patients. We investigated the effect of in-advance preparatory DIBH coaching and home practice on cardiac doses. MATERIALS AND METHODS: Successive patients from 1 February 2015 to 31 December 2016 with left-sided breast cancer who underwent tangential field radiotherapy utilising the DIBH technique were included. The study cohort consisted of patients treated by a physician who routinely provided DIBH coaching and home practice instructions at least 5 days before simulation. The control group included non-coached patients under another physician's care. Minimum, maximum and mean cardiac doses and V5, V10 and V30 from DIBH and free breathing simulation computed tomography scans were obtained from the planning system. DIBH and free breathing cardiac doses and volume exposures were compared between the coached and non-coached groups using the two-sample t-test, Fisher's exact test and the Mann-Whitney U-test. RESULTS: Twenty-seven coached and 42 non-coached patients were identified. The DIBH maximum cardiac dose was lower in coached patients at 13.1 Gy compared with 19.4 Gy without coaching (P = 0.004). The percentage cardiac volume exposure in DIBH was lower in coached patients; the DIBH V10 was 0.5% without coaching and 0.1% with coaching (P = 0.005). There was also a trend towards lower DIBH V5 in the coached group compared with the non-coached group (1.2% versus 1.9%, P = 0.071). No significant differences in patient cardiopulmonary comorbidity factors that might influence cardiac doses were found between the groups. CONCLUSIONS: Our results suggest that cardiac dose sparing can potentially be further improved with a 5 day regimen of preparatory DIBH coaching and in-advance home practice before simulation. These hypothesis-generating findings should be confirmed in a larger study.

Adjunctive non-pharmacological analgesia for invasive medical procedures: a randomised trial.

BACKGROUND: Non-pharmacological behavioural adjuncts have been suggested as efficient safe means in reducing discomfort and adverse effects during medical procedures. We tested this assumption for patients undergoing percutaneous vascular and renal procedures in a prospective, randomised, single-centre study. METHODS: 241 patients were randomised to receive intraoperatively standard care (n=79), structured attention (n=80), or self-hypnotic relaxation (n=82). All had access to patient-controlled intravenous analgesia with fentanyl and midazolam. Patients rated their pain and anxiety on 0-10 scales before, every 15 min during and after the procedures. FINDINGS: Pain increased linearly with procedure time in the standard group (slope 0.09 in pain score/15 min, p<0.0001), and the attention group (slope 0.04/15 min; p=0.0425), but remained flat in the hypnosis group. Anxiety decreased over time in all three groups with slopes of -0.04 (standard), -0.07 (attention), and -0.11 (hypnosis). Drug use in the standard group (1.9 units) was significantly higher than in the attention and hypnosis groups (0.8 and 0.9 units, respectively). One hypnosis patient became haemodynamically unstable compared with ten attention patients (p=0.0041), and 12 standard patients (p=0.0009). Procedure times were significantly shorter in the hypnosis group (61 min) than in the standard group (78 min, p=0.0016) with procedure duration of the attention group in between (67 min). INTERPRETATION: Structured attention and self-hypnotic relaxation proved beneficial during invasive medical procedures. Hypnosis had more pronounced effects on pain and anxiety reduction, and is superior, in that it also improves haemodynamic stability.

Imagery content during nonpharmacologic analgesia in the procedure suite: where your patients would rather be.

RATIONALE AND OBJECTIVES: Imagery as a hypnotic technique can produce analgesia and anxiolysis, but effective use may be restricted to select, highly hypnotizable individuals. This study assessed (a) whether patients not selected for hypnotizability can produce imagery during interventional radiologic procedures and (b) the type of imagery produced. A secondary goal of the study was to familiarize health care providers with a simple, time-efficient technique for imagery. MATERIALS AND METHODS: Fifty-six nonselected patients referred for interventional procedures were guided to a state of self-hypnotic relaxation by a health care provider according to a standardized protocol and script. Patient hypnotizability was assessed according to the Hypnotic Induction Profile test. RESULTS: Patients as a group had average distribution of hypnotizability. The induction script was started in all patients and completed in 53. All patients developed an imagery scenario. Chosen imagery was highly individual, but common trends were nature and travel, family and home, and personal skills. Being with loved ones was an important element of imagery for 14 patients. Thirty-two patients chose passive contemplation, and 24 were action oriented. CONCLUSION: Average patients who present for interventional radiologic procedures and are not preselected for hypnotizability can engage in imagery. Topics chosen are highly individual, thus making prerecorded tapes or provider-directed imagery unlikely to be equally successful.

Educating interventional radiology personnel in nonpharmacologic analgesia: effect on patients' pain perception.

RATIONALE AND OBJECTIVES: The purpose was to evaluate the effects on patients' pain perception of educating interventional radiology personnel in nonpharmacologic analgesia. MATERIALS AND METHODS: Ninety-six patients undergoing lower-extremity arteriography or percutaneous nephrostomy were asked to rate the pain they experienced during the procedure on a scale of 0 to 5 (0 = no pain, 1 = mild pain, 2 = moderate pain, 3 = severe pain, 4 = very severe pain, 5 = worst pain possible). Patients were studied at two baseline sessions (baseline 1, December 1993 to August 1994, n = 15; and baseline 2, September 1995 to January 1996, n = 11) and after the staff underwent one of two training sessions (posttraining 1, January 1995 to July 1995, n = 34; posttraining 2, January 1996 to April 1996, n = 36). Training targeted nurses and technologists and included rapport skills, correct use of language and suggestions, distraction, relaxation training, and self-hypnosis. Data were evaluated with analysis of variance for repeated measures. RESULTS: The mean pain scores reported after training were lower (1.48) and matched an "acceptable" pain score of 1.52 more closely than those reported under baseline conditions (2.54, P = .001). There was a tendency toward reduced use of intravenously administered agents for conscious sedation after training. There were no statistically significant differences in the pain scores between patients who underwent arteriography and patients who underwent nephrostomy overall (1.76 and 1.78, respectively), at baseline (2.58 and 2.43, respectively), and after staff training (1.49 and 1.42, respectively). CONCLUSION: Interventional radiology personnel trained in nonpharmacologic analgesia methods can help reduce patients' pain perception during interventional procedures.

Self-hypnotic relaxation during interventional radiological procedures: effects on pain perception and intravenous drug use.

The authors evaluated whether self-hypnotic relaxation can reduce the need for intravenous conscious sedation during interventional radiological procedures. Sixteen patients were randomized to a test group, and 14 patients were randomized to a control group. All had patient-controlled analgesia. Test patients additionally had self-hypnotic relaxation and underwent a Hypnotic Induction Profile test. Compared to controls, test patients used less drugs (0.28 vs. 2.01 drug units; p < .01) and reported less pain (median pain rating 2 vs. 5 on a 0-10 scale; p < .01). Significantly more control patients exhibited oxygen desaturation and/or needed interruptions of their procedures for hemodynamic instability. Benefit did not correlate with hypnotizability. Self-hypnotic relaxation can reduce drug use and improve procedural safety.

Anodyne imagery: an alternative to i.v. sedation in interventional radiology.

OBJECTIVE: Pain and anxiety are to be expected in patients undergoing interventional procedures, and they are usually treated by IV conscious sedation. Insufficient treatment of pain and anxiety can cause cardiovascular strain and restlessness, which may jeopardize the success of the procedure. On the other hand, pharmacologic oversedation can provoke respiratory and cardiovascular depression, thereby increasing the procedural risks and delaying the patient's recovery. We therefore evaluated a nonpharmacologic method, which we call anodyne imagery (anodyne: able to soothe or relieve pain; soothing the feelings; relaxing), as an alternative to the use of drugs in interventional radiology. SUBJECTS AND METHODS: Anodyne imagery technique consists of conditioned relaxation, induction of a trance state, and guided processing of the patient's internal imagery. An intrapatient comparison of drug use was made in five patients who had equivalent procedures with and without anodyne imagery and an intergroup comparison was made between a group of 16 other patients undergoing anodyne imagery and a group of 16 control patients matched for factors affecting use of drugs and recruited from 100 interventional cases analyzed for patterns of drug use. For statistical analysis, drug unit scores (weighting: 1 mg of midazolam = 1 unit and 50 micrograms of fentanyl = 1 unit) were compared within patients by paired t-test and between groups of patients by analysis of variance in two-sided tests, with p less than .05 considered to be significant. RESULTS: The 100 patients who did not have anodyne imagery received 0-6 mg of midazolam (median, 1.4 mg), 0-500 micrograms of fentanyl (median, 80 micrograms), and 0.5-9 drug units (median, 2.5). Drug administration was insignificantly affected by the physician conducting the procedure, the type of procedure, or the patient's age, but significantly increased with longer table times. Ten of the 21 patients undergoing anodyne imagery associated fear-provoking images with their interventional procedure that were generally intense, vivid, and dramatic. Intrapatient comparison showed significantly lower median drug use with anodyne imagery than without (0.1 vs 5.3 drug units, p = .01). Intergroup comparison also yielded significantly lower median drug use during procedures with anodyne imagery than without (0.2 vs 2.6 drug units, p = .0001). CONCLUSION: Patients having interventional radiologic procedures frequently experience intense and frightening imagery related to the procedure. Our initial experience with anodyne imagery suggests that this alternative method of analgesia can mitigate patients' anxiety and fears and reduce the amount of drugs used during interventional radiologic procedures, and thereby has the potential to improve procedural safety and increase the speed of recovery.