[Use of hypnosis in chronic pain : a setting in motion]. / Utilisation de l'hypnose lors de douleurs chroniques : une mise en mouvement.

The biopsychosocial complexity of chronic pain requires a multimodal approach of which hypnosis is one. Its effectiveness is increasingly proven by studies using functional neuroimaging, as well as clinical studies in various etiologies of chronic pain. The goal of hypnosis is to restore the patient to an active role where, during the sessions, he will discover his creative capacities allowing him to temporarily modify or even significantly reduce painful sensations. Regular practice of self-hypnosis amplifies and anchors these changes. Gradually, hypnosis allows patients to regain both physical and mental mobility.

La complexité biopsychosociale des douleurs chroniques impose une approche multimodale dont l'hypnose fait partie. Son efficacité est de plus en plus prouvée par des études utilisant la neuro-imagerie fonctionnelle, ainsi que des études cliniques dans diverses étiologies de douleurs chroniques. Le but de l'hypnose est de redonner au patient un rôle actif où, au cours des séances, il découvrira ses capacités créatrices lui permettant de modifier, voire de nettement réduire temporairement les sensations douloureuses. La pratique régulière de l'autohypnose amplifie et ancre ces modifications. Progressivement, l'hypnose permet aux patients de retrouver une mobilité tant physique que psychique.

Influence of CYP2D6 activity on pre-emptive analgesia by the N-methyl-D-aspartate antagonist dextromethorphan in a randomized controlled trial of acute pain.

BACKGROUND: There is some evidence that dextromethorphan (DM) is effective as a pre-emptive analgesic agent.  DM is mainly metabolized to dextrorphan (DOR) by CYP2D6 whose activity can be inhibited by pharmacologic intervention. OBJECTIVES: To investigate the efficacy of DM as a pre-emptive analgesic agent and describe the population pharmacokinetics in the presence of normal and poor CYP2D6 metabolism in acute post-operative pain. STUDY DESIGN: Double blind, randomized, placebo-controlled trial SETTING: Post-surgical analgesic consumption after knee ligament surgery, a setting of acute pain. METHODS: Forty patients were randomized to a single oral dose of 50 mg quinidine or placebo, administered 12 hours before 50 mg DM. Patients were genotyped for the major CYP2D6 and ABCB1 variants and phenotyped for CYP2D6 using urine DM/DOR metabolic ratios and blood samples for population pharmacokinetic modeling. RESULTS: Quinidine was effective in inhibiting CYP2D6 activity, with 2-fold reduction of DM to DOR biotransformation clearance, prolonged DM half-life, and increased DM systemic availability. Patients in the quinidine group required significantly less often NSAIDs than patients in the placebo group (35.3% vs. 75.0%, P = 0.022). The odds ratio for NSAID consumption in the placebo vs. quinidine group was 5.5 (95% confidence interval (CI) 1.3 - 22.7) at 48 hours after surgery. LIMITATIONS: While this study shows an impact of DM on pre-emptive analgesia and is mechanistically interesting, the findings need to be confirmed in larger trials. CONCLUSION: CYP2D6 inhibition by quinidine influenced the pre-emptive analgesic effectiveness of DM confirming that CYP2D6 phenotypic switch increases the neuromodulatory effect of oral dextromethorphan.

Incidence and impact of distracting events during induction of general anaesthesia for urgent surgical cases.

BACKGROUND AND OBJECTIVE: Distractions and interruptions during clinical activities can decrease performance and increase the risk of error. The incidence and impact of distracting events on anaesthetic teams during the critical phases of general anaesthesia are unknown. The purpose of this study was to quantify and analyse the frequency, the source and the impact of these events during the period of induction of general anaesthesia. METHODS: Twenty-nine anaesthetic team members participated in the study. Anaesthetic teams were videotaped during the induction period of a general anaesthesia. All videotapes were reviewed by two investigators using a scoring system in order to categorize the distracting events according to their origin, source, nature, duration, impact on patient and consequences on team activities. A total of 37 videotapes of general anaesthesia inductions for urgent surgical cases were analysed. RESULTS: The results show that the sources of distracting events are multiple and diverse. Distracting events occurred frequently (median five per video) and at least one event was present for 39.5% of the total observed period. They had a significant impact on the activity of the team members during 21.8% of the total observed period and had a negative impact on patient management in one-fifth of the cases. CONCLUSION: During the induction phase of general anaesthesia, distracting events are frequent and affect significantly the task at hand. Future research should design and implement preventive strategies to minimize the occurrence of unnecessary distracting events during this critical phase of anaesthesia when calm and vigilance should prevail.

The brain under self-control: modulation of inhibitory and monitoring cortical networks during hypnotic paralysis.

Brain mechanisms of hypnosis are poorly known. Cognitive accounts proposed that executive attentional systems may cause selective inhibition or disconnection of some mental operations. To assess motor and inhibitory brain circuits during hypnotic paralysis, we designed a go-no-go task while volunteers underwent functional magnetic resonance imaging (fMRI) in three conditions: normal state, hypnotic left-hand paralysis, and feigned paralysis. Preparatory activation arose in right motor cortex despite left hypnotic paralysis, indicating preserved motor intentions, but with concomitant increases in precuneus regions that normally mediate imagery and self-awareness. Precuneus also showed enhanced functional connectivity with right motor cortex. Right frontal areas subserving inhibition were activated by no-go trials in normal state and by feigned paralysis, but irrespective of motor blockade or execution during hypnosis. These results suggest that hypnosis may enhance self-monitoring processes to allow internal representations generated by the suggestion to guide behavior but does not act through direct motor inhibition.

Near-death experience in a boy undergoing uneventful elective surgery under general anesthesia.

Near-death experience (NDE) is a complex subjective experience, which may include affective elements such as a sense of peacefulness, paranormal components such as a sensation of floating out of the body, and a perception of being in a dark tunnel and seeing a brilliant light. It is usually reported to occur in association with a wide range of life-threatening situations, as for instance, cardiopulmonary resuscitation. We report on an episode of NDE that occurred in a 12-year-old boy who underwent a general anesthesia for an elective uncomplicated surgery. To our knowledge, this is the first case of NDE in a child that has been reported in this context.

Investigation of implicit memory during isoflurane anesthesia for elective surgery using the process dissociation procedure.

BACKGROUND: This prospective study evaluated memory function during general anesthesia for elective surgery and its relation to depth of hypnotic state. The authors also compared memory function in anesthetized and nonanesthetized subjects. METHODS: Words were played for 70 min via headphones to 48 patients (aged 18-70 yr) after induction of general anesthesia for elective surgery. Patients were unpremedicated, and the anesthetic regimen was free. The Bispectral Index (BIS) was recorded throughout the study. Within 36 h after the word presentation, memory was assessed using an auditory word stem completion test with inclusion and exclusion instructions. Memory performance and the contribution of explicit and implicit memory were calculated using the process dissociation procedure. The authors applied the same memory task to a control group of nonanesthetized subjects. RESULTS: Forty-seven patients received isoflurane, and one patient received propofol for anesthesia. The mean (+/- SD) BIS was 49 +/- 9. There was evidence of memory for words presented during light (BIS 61-80) and adequate anesthesia (BIS 41-60) but not during deep anesthesia (BIS 21-40). The process dissociation procedure showed a significant implicit memory contribution but not reliable explicit memory contribution (mean explicit memory scores 0.05 +/- 0.14, 0.04 +/- 0.09, and 0.05 +/- 0.14; mean automatic influence scores 0.14 +/- 0.12, 0.17 +/- 0.17, and 0.18 +/- 0.21 at BIS 21-40, 41-60, and 61-80, respectively). Compared with anesthetized patients, the memory performance of nonanesthetized subjects was better, with a higher contribution by explicit memory and a comparable contribution by implicit memory. CONCLUSION: During general anesthesia for elective surgery, implicit memory persists even in adequate hypnotic states, to a comparable degree as in nonanesthetized subjects.