Library: Univ. of Washington
Medical Center
____________________________________
Source: The Lancet, April 29, 2000 v355 i9214 p1486.
Title: Adjunctive non-pharmacological analgesia for invasive
medical procedures: a randomised trial.(Statistical Data Included) Author: Elvira V Lang, Eric G Benotsch, Lauri J Fick, Susan
Lutgendorf,
Michael L Berbaum, Kevin S Berbaum, Henrietta Logan and David Spiegel
Abstract: The use of behavioral methods in addition to drugs
during surgical procedures seems to be effective and safe. Hypnosis
had the most significant effects in relieving pain and reducing
anxiety. A total of 241 patients were divided into three groups.
During vascular or kidney surgery, they received standard care (79),
structured attention (80), or self-hypnotic relaxation (82), and
had intravenous control of analgesics. They rated pain and anxiety
every 15 minutes. Pain increased in the standard and attention groups
but remained flat with hypnosis. Anxiety decreased in all three
groups over time, and the standard care group used more analgesics.
Subjects: Hypnotism in surgery - Therapeutic use Analgesics
- Usage
Summary 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 [less than] 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 20.04 (standard), 20.07 (attention), and 20.11
(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.
Lancet 2000; 355: 1486-90
Introduction Minimally invasive, image-guided, percutaneous medical procedures
increasingly replace open surgery. Technical refinement minimises
tissue injury and largely obviates the need for general anaesthesia,
but patients may still experience distress, which can tax the coping
mechanisms of even well-functioning individuals.(1) Most physicians
rely on intravenous conscious sedation with narcotics and sedatives
to manage pain and anxiety.(2) These drugs, however, can induce
cardiovascular depression, hypoxia, apnoea, unconsciousness, and,
rarely, death, even in dosages usually well tolerated.(3,4) The
operator typically has to weigh the risks of medically induced oversedation
against the risks of uncontrolled discomfort and restlessness. An
approach that provides comfort while reducing or eliminating the
need for intravenous drugs is, therefore, highly desirable.
Biobehavioural "non-pharmacological" analgesia in the
form of imagery, relaxation training, and hypnosis has been used
successfully to treat procedure pain.(5-10) Clinical practice guidelines
for acute pain management, published by the US Public Health Service,
mention relaxation exercises and cognitive approaches, but do not
elaborate.(2) Behavioural methods still need testing in larger clinical
studies. To address this need, we designed a prospective randomised
trial comparing the standard approach of intravenous conscious sedation
alone with the adjunctive use of two behavioural non-pharmacological
interventions: structured attention and self-hypnotic relaxation.
We tested the hypothesis that adjunctive non pharmacological analgesia
would reduce patients' perceived pain and anxiety during interventional
radiological procedures, reduce the amount of intravenous conscious
sedation needed and make the procedure safer. Since operating teams
(and hospital administrators) are very sensitive to factors that
could prolong the patient's stay in the procedure room, we also
assessed how non-pharmacological analgesia adjuncts affect procedure
time.
Michael Bennett is a master practitioner
and trainer of NLP and Hypnotherapy, licensed and certified through
the Society of NLP. He operates a school for teaching these disciplines
to health professionals and persons interested in improving the
quality of their lives.
