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Copyright © 2015 International Anesthesia Research SocietyDOI: 10.1213/ANE.0000000000000567

While regional anesthesia is a cornerstone of mod-ern anesthesiology, expectations and practice pat-terns surrounding the use of regional anesthesia

with or without accompanying sedation differ based on cultural factors, operating room management procedures, and individual preferences by patients, surgeons, and anesthesiologists. In response to the question “If I choose regional anesthesia, does that mean I am awake during the surgery?” the patient education section of the American Society of Regional Anesthesia website (http://www.asra.com/patient-info-regional-anesthesia-and-analgesia-for-surgery.php) states that “You may remain awake, or you may be given a sedative. You do not see or feel the actual surgery take place. (…). During minimal sedation, you will feel relaxed, and you may be awake. You can understand and answer questions and will be able to follow your physi-cian’s instructions. When receiving moderate sedation, you will feel drowsy and may even sleep through much of the procedure, but will be easily awakened when spoken to. You may or may not remember being in the operating room. During deep sedation, you will sleep through the procedure with little or no memory of the procedure room.”

In daily routine practice, the conversation between patient and anesthesiologist is often less detailed but sim-ple: “Do you want to be asleep during surgery?”

Perhaps rather than only asking this simple and easy to understand question, patients should also be made aware of findings suggesting adverse effects associated with routine use of sedation. For example, Brown et al.1 report in their trial in patients undergoing repair of hip fracture during spinal anesthesia, a significant reduction of postoperative delirium and a reduction of mortality in the light versus deep seda-tion group adding to a body of evidence that less sedation might be more effective, especially perhaps in patients with greater comorbidities.1 In addition, benzodiazepine-based sedation in intensive care unit (ICU) patients has been

linked to posttraumatic stress disorder and depression,2 the exact consequences one would have hoped to prevent using sedative medications.3,4 Disturbed memory forma-tion could be one suitable explanation, which would also be relevant for the situation in the operating room. Jones et al.5,6 hypothesized that depth and length of sedation could result in greater opportunities to form delusional memory in ICU patients and they showed that delusional memory is more strongly associated with the development of posttrau-matic stress disorder after the ICU stay rather than factual memory. While these findings in ICU patients may not be precisely applicable to those in the operating room, given the much briefer duration of drug use and the different environment, they do suggest that the choice of drug might play an important role favoring analgesic drugs over seda-tives if pain and discomfort (e.g., due to positioning during the procedure) are the main issues.

Egbert and Jackson7 recently revisited a classic article from 1963 demonstrating that patients receiving pentobar-bital alone became drowsy but not calm, whereas patients who had a preoperative visit were calm but not drowsy on arrival to the operating room and commented “Thus, the anesthesiologist–patient relationship (rapport) established during the preanesthetic visit had a beneficial anxiolytic effect. This study validated that the anesthesiologist was able to fulfill the intellectual and informational as well as the emotional needs of patients, the authors even suggest-ing that the greater therapeutic value was the emotional support.”8 While we have much better anxiolytic medica-tions compared to pentobarbital and preoperative anxiety might differ from anxiety during the procedure, the value of emotional support should not be dismissed.

This raises the question why sedation is used (sometimes excessively), when an otherwise adequate anesthetic (such as a spinal or epidural or for other procedures peripheral nerve blocks) is used and a conversation with the anesthesi-ologist might have a therapeutic effect?

In addition, nonpharmacological methods including medical hypnosis may be suitable alternatives to drug-based sedation regimens for sedation and anxiolysis. Several well-designed studies by Faymonville et al.9,10 used a 10-minute hypnotic induction session by a separate caregiver before the conventional administration of seda-tives and local anesthetic infiltration of the operative site for patients undergoing plastic surgical procedures, neck dissections, and thyroid surgery. In their prospective ran-domized clinical trials, patients in the treatment group had

Factors Determining the Need for Sedation During Successful Regional Anesthesia: When Is It Necessary?Sebastian Schulz-Stübner, MD, PhD

From the Deutsches Beratungszentrum für Hygiene (BZH GmbH), Freiburg, Germany.

Accepted for publication September 26, 2014.

Funding: None.

The author declares no conflicts of interest.

Reprints will not be available from the author.

Address correspondence to Sebastian Schulz-Stübner, MD, PhD, Deutsch-es Beratungszentrum für Hygiene (BZH GmbH), Schnewlinstr. 10, 79098 Freiburg, Germany. Address e-mail to schust@t-online.de.

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significantly lower pain scores, required less intraoperative opioid analgesics and sedatives, and had less postoperative nausea than those in the control group. Similarly, Lang et al.11 assessed the efficacy of structured attention or hypno-sis compared to standard care on pain, anxiety, and anal-gesic use during conscious sedation for minimally invasive interventional radiology procedures. The hypnosis group had less anxiety throughout the procedure, decreased pain, and required significantly less analgesic medication than the groups receiving standard care or structured attention. These results appear to be independent of patient age in adult populations.12 In 2007, Wobst13 provided an overview of the literature and concluded: “If hypnosis and autosug-gestion provides clinical benefit, they do so without the need for equipment or drugs. What other therapeutic mea-sure appears so devoid of increased cost and demonstrable adverse effects? Personal attention to the patient, emotional support, positive suggestions, and even hypnosis are read-ily available, safe, inexpensive, and attractive measures that might improve the care of our patients.”

In my personal experience when an adequate regional anesthetic is in place, hypnosis can be used without addi-tional drugs14,15 and even if no formal hypnosis or relax-ation technique is used, conversation with “small talk” or other nonpharmacological alternative techniques including listening to music or an audio book by earphones are suf-ficient to provide a comfortable atmosphere for the patient during a procedure. This approach is certainly not suitable for everyone and every procedure and the emotional state of the patient and the individual needs and wishes need to be assessed in the holding area, which can be difficult if time is limited. Nonsurgical pain associated with position-ing might also be a limiting factor. On the other hand, the effects of noxious odor (e.g., burning flesh from electrocau-tery) or sound (e.g., from sawing bone) can be incorporated and reframed and additional analgesic effects are demon-strated under formal hypnosis, not possible with small talk or distraction by ear phones or visual media. A combined approach of medication and a nonpharmacological inter-vention could also be meaningful. In cases of severe agita-tion (e.g., in emergency surgeries), a small amount of an anxiolytic sedative will open up an opportunity for “thera-peutic communication.” Cheong et al.16 demonstrated the prevention of ketamine-induced unpleasant dreams by pre-treatment with positive suggestions and not using negative suggestions is essential even during routine injection of a local anesthetic.17

In contrast to these studies, formal hypnotic induction is relatively contraindicated in the operating room without a specific psychotherapeutic setting in acutely intoxicated patients, patients with psychotic diseases, dementia, and in cases of a relevant language barrier. There is also a small per-centage of people who cannot be hypnotized at all and there is a wide range from low to high hypnotizability,18 with a normal distribution pattern among test populations.19 Hoeft et al.20 showed increased functional coupling between the dorsal anterior cingulate cortex and the dorsolateral pre-frontal cortex in high compared with low hypnotizable individuals in a functional magnetic resonance imaging study and Milling21 summarizes the evidence regarding hypnotizability and pain relief: “Although individuals in

the high suggestibility range show the strongest response to hypnotic analgesia, people of medium suggestibility, who represent approximately one third of the population, also have been found to obtain significant relief from hypnosis. The available evidence does not support the efficacy of hyp-notic pain interventions for people who fall in the low hyp-notic suggestibility range. However, some studies suggest that these individuals may benefit from imaginative anal-gesia suggestions, or suggestions for pain reduction that are delivered while the person is not in hypnosis.”

A brief way to assess the response to a suggestive tech-nique such as hypnosis is to ask the patient to stand in front of you and imagine wearing the shining metal armor of a knight. Now you touch the patients back and ask him to imagine a very strong magnet in his back while wear-ing that shining metal armor, which will protect him from all harm. You repeat the suggestions a few times and if the patient feels the heaviness of the metal armor and/or shows signs of imbalance due to the magnet pulling in the back you most likely have a medium to highly hypnotizable individuum.22

For the use of formal hypnosis and some other relax-ation techniques like guided imagery or progressive mus-cle relaxation, additional training of the anesthesia team is required. Currently, this is not a standard part of the train-ing curriculum and needs to be acquired in special training courses or workshops. Incorporation of some of these tech-niques into the residency program could be an important step to provide the current and future generations of anes-thesiologist trainees with additional low risk—potential high-yield tools.

Importantly, the perceived need to provide sedation lies more in the mind of the anesthesiologist and perhaps the surgeon who might fear an awake and responsive patient. An educational approach including all team members in the operating room (anesthesiologists, surgeons, nurses, and technicians) and leadership by example from the anesthesia team in cognizant use of words23 is therefore warranted.

While different cultural backgrounds might influence the decision to give words a trial, Pauker and Pauker’s statement in the American Society of Anesthesiologists Newsletter in their article “Communication, rapport and expectations: Improving postoperative outcome using words, hypnoidal language and trance” that “as we reframe our role and expand our tools as anesthesiologists, we won-der if we should re-examine who we think we are, what we call ourselves. The word “anesthesia” speaks to the lack of pain or sensation; we steer the ship of care away from pain. It might be interesting if instead we became more like stewards of patient comfort - “comfortologists,” if you will,”24 might indicate acceptance of alternative techniques to a propofol or dexmedetomidine infusion-based regimen even in the United States. Clearly more research is needed to identify patients at risk for development of complica-tions related to intraoperative sedation, to optimize alterna-tive psychological interventions like hypnosis, and to create algorithms for a tailored individual approach.

Given the potential risks of unnecessary sedation espe-cially in vulnerable patient populations including those older than 65 years of age or those with specific risks like morbid obesity or obstructive sleep apnea it might be time

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to discontinue asking “do you want to be asleep?” and use sedative drugs only if really indicated and not as a part of a routine standard operating procedure.

“Why don’t we have a nice chat about your favorite place in the world, while the surgeon is repairing your knee joint, so you can soon walk again…” could be a great invita-tion for a comfortable experience in the “surgical home.” E

DISCLOSURESName: Sebastian Schulz-Stübner, MD, PhD.Contribution: This author wrote the manuscript.Attestation: Sebastian Schulz-Stübner approved the final manuscript.This manuscript was handled by: Lawrence J. Saidman, MD.

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