202 ANAESTHESIOLOGY, INTENSIVE CARE Zdrav Vestn | March – April 2021 | Volume 90 | https://doi.org/10.6016/ZdravVestn.3026 Department of Anaesthesiology and Surgical Intensive Care, Division of Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia Correspondence/ Korespondenca: Jasmina Markovič Božič, e: jasmina.markovic1@kclj.si Key words: perioperative hypnosis; perioperative stress; hypnosedation; multimodal perioperative treatment Ključne besede: perioperativna hipnoza; perioperativni stres; hipnosedacija; multimodalno perioperativno zdravljenje Received: 13. 1. 2020 Accepted: 4. 1. 2021 eng slo element en article-lang 10.6016/ZdravVestn.3026 doi 13.1.2020 date-received 4.1.2021 date-accepted Anaesthesiology, intensive care Anesteziologija, intenzivna nega discipline Professional article Strokovni članek article-type Perioperative use of medical hypnosis Perioperativna uporaba medicinske hipnoze article-title Perioperative use of medical hypnosis Perioperativna uporaba medicinske hipnoze alt-title perioperative hypnosis, perioperative stress, hypnosedation, multimodal perioperative treatment perioperativna hipnoza, perioperativni stres, sediranje s hipnozo, multimodalno perioperativno zdravljenje kwd-group The authors declare that there are no conflicts of interest present. Avtorji so izjavili, da ne obstajajo nobeni konkurenčni interesi. conflict year volume first month last month first page last page 2021 90 3 4 202 207 name surname aff email Jasmina Markovič Božič 1 jasmina.markovic1@kclj.si name surname aff Alenka Spindler Vesel 1 eng slo aff-id Department of Anaesthesiology and Surgical Intensive Care, Division of Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia Klinični oddelek za anesteziologijo in intenzivno terapijo operativnih strok, Kirurška klinika, Univerzitetni klinični center Ljubljana, Ljubljana, Slovenija 1 Perioperative use of medical hypnosis Perioperativna uporaba medicinske hipnoze Jasmina Markovič Božič, Alenka Spindler Vesel Abstract Emotional stress during medical procedures causes a direct negative experience as well as possi- ble negative consequences for patients. It can be reduced by pharmacological and non-pharma- cological interventions. Hypnosis is a non-pharmacological intervention which reduces periop- erative stress and pain. Hypnosedation is an anaesthetic technique that combines hypnosis with local and regional anaesthesia, procedural sedation and analgesia. It is associated with improved intraoperative comfort, reduced anxiety and pain, diminished intraoperative anxiolytics and an- algesics requirements, optimised surgical conditions and enhanced recovery. It is appropriated just for certain surgical procedures and selected patients. Multimodal strategies should include pharmacological and non-pharmacological approaches, where medical hypnosis is used as an adjunct in perioperative setting. Izvleček Perioperativni čustveni stres je za bolnika slaba izkušnja, ki ima negativne posledice. Zmanjšamo ga lahko s farmakološkimi ali nefarmakološkimi metodami. Medicinska hipnoza je nefarmakolo- ška metoda, ki zmanjša perioperativni stres in bolečino. Hipnosedacija je anestezijska tehnika, pri kateri se medicinska hipnoza uporablja kot dodatek k lokalni ali področni anesteziji ob se- daciji ali analgeziji. Izboljša udobje med posegom, zmanjša občutek tesnobe, bolečine, porabo anksiolitikov in analgetikov, izboljša pogoje za operacijo in skrajša čas okrevanja. Uporablja se le pri določenih kirurških posegih in pri izbranih bolnikih. Multimodalna strategija zdravljenja vklju- čuje tako farmakološke kot nefarmakološke pristope. Medicinska hipnoza se lahko uporablja kot sredstvo, ki učinkovito dopolnjuje perioperativno zdravljenje. Cite as/Citirajte kot: Markovič Božič J, Spindler Vesel A. Perioperative use of medical hypnosis. Zdrav Vestn. 2021;90(3–4):202–7. DOI: https://doi.org/10.6016/ZdravVestn.3026 Copyright (c) 2021 Slovenian Medical Journal. This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. Slovenian Medical Journal 1 Introduction The first documented use of medical hypnosis in surgery dates back to 1830 when Jules Cloquet and John Elliotson performed several surgical procedures under hypnosis and without the addition of anaesthetics (1,2). The introduction of chloroform, ether, and volatile anaes- thetics pushed medical hypnosis into the 203 PROFESSIONAL ARTICLE Perioperative use of medical hypnosis background, but it later began to be used again as a complementary method to gen- eral anaesthesia and sedation (3). Since 1992, it has been routinely used to supple- ment sedation and analgesia in procedures performed under local or regional anaes- thesia (hypnosedation) (4-9). Emotional stress during procedures contributes to an unsatisfactory experience for patients and can be associated with other negative con- sequences (pain, nausea, fatigue, inability to perform, poor wound healing) (10,11). Medical hypnosis is a nonpharmacological method that reduces perioperative stress and has no known side effects (10-12). It can be a complementary method for treat- ing perioperative stress as well as anxiety, pain, nausea, and fatigue. The beneficial effects reduce the inflammatory response, drug consumption and shorten recovery and hospital treatment times. Research suggests that medical hypnosis may also have a long-term effect on a more favour- able prognosis of cancer outcome (13,14). Therapeutic communication using med- ical hypnosis has also shown a beneficial mental impact on awake brain surgery pa- tients (14-17). The purpose of this article is to present how useful medical hypnosis can be in the perioperative period. 2 Neurobiology of hypnosis Medical hypnosis is a state of con- sciousness with focused attention, de- creased external awareness, and increased suggestibility (18). Scientific research con- firms that medical hypnosis is an effective way to relieve pain, anxiety, psychoso- matic diseases, dissociative disorders and behavioural disorders, and is useful in medicine, psychology and nursing care (4,9,10,18). Analysis of functional magnet- ic resonance imaging provides a better understanding of the effects of medical hypnosis on the brain. The functional connection of three brain networks was studied: the executive control network, which involves focused attention and working memory (ECN), the salience network, which involves working mem- ory, challenges, anxiety, emotions and will (SN), and the default mode network, which involves thinking and rest (DMN). The executive control network includes the bilateral dorsolateral prefrontal cortex (DLPFC) and its upper parietal part. It is involved in focused attention and work- ing memory (19). The main network com- bines the dorsal anterior cingulate cortex (dACC), the frontoinsular cortex and the subcortical area, e.g. the hypothalamus. It is activated in the face of challenges or anxiety (19). The default mode network consists of several structures: the posterior cingulated cortex (PCC) and other brain structures in the mid-sagittal line, such as the medial prefrontal cortex (mPFC). It is activated by thinking and rest and deacti- vated by task planning (19). In highly sug- gestible subjects, decreased default mode network activity during medical hypnosis has been reported. This suggests that hyp- nosis is a state of consciousness different from sleep (20). Increased suggestibility is associated with higher concentrations of dopamine metabolites (homovanillic acid) in cerebrospinal fluid (21). Recently, Jiang and colleagues demonstrated that medical hypnosis reduces dACC activity and increases the functional association between DLPFC and insula in the sa- lience network. It also reduces the con- nection between the executive control network and the default mode network (22). Medical hypnosis is characterized by the following changes in neural activ- ity: focused attention, enhanced physical and emotional control, and decreased self-awareness (Figure 1). 204 ANAESTHESIOLOGY, INTENSIVE CARE Zdrav Vestn | March – April 2021 | Volume 90 | https://doi.org/10.6016/ZdravVestn.3026 3 Perioperative use of hypnosis In a meta-analysis, Teflikow and col- leagues compared the effectiveness of perioperative hypnosis in three groups of adult patients: with standard care, with increased attention, or with medical hypnosis as a complementary method. Research has shown that medical hypno- sis reduce perioperative stress, pain, drug consumption, parameters of vital func- tions, postoperative recovery time, and duration of surgery (11). More frequent and prolonged therapy sessions with medical hypnosis before surgery does not take precedence over single and short- term therapy (11). Other studies have found that perioperative use of medical hypnosis or positive suggestions contrib- ute to faster wound healing, faster return of bowel function, and reduction of nau- sea (4,5,23). Moreover, medical hypnosis in children has also been shown to reduce Figure 1: Functional connection of three brain networks during hypnosis. Figure is summarized from Jiang H, et al (22). anxiety before and after surgery more ef- fectively than midazolam (24). Neuroradiological research has shown reduced activity of the extrinsic brain net- work involved in perceiving the environ- ment and sensations during medical hyp- nosis. Hypnosis regulates the perception of pain in interconnected brain networks involved in the transmission and sensa- tion of pain stimuli (8). Halsband and col- leagues have shown that in patients with dental phobia, medical hypnosis is effec- tive in reducing fear and the recollection of unpleasant memories (25). In major operations, surgery and an- aesthetic technique significantly affect the immune response. Cell-mediated immu- nity may increase the number of postop- erative complications such as infections, poor wound healing, decreased cognitive abilities, and cancer progression (26,27). In cancer patients, volatile and intrave- nous anaesthetics have a clinically relevant 205 PROFESSIONAL ARTICLE Perioperative use of medical hypnosis anti-inflammatory effect (28,29). In these patients, preoperative medical hypnosis effectively reduces emotional stress, nau- sea after surgery, pain, consumption of analgesics and their side effects, and the release of stress hormones. By reducing perioperative stress, the immune system is strengthened and tumour growth is slowed (2,9,13). Adverse effects of general anaesthesia and deep sedation may result in haemo- dynamic instability, respiratory arrest, prolonged mechanical respiration, slowed bowel function, delayed early mobilization of patients, increased cognitive impair- ment, and prolonged hospital treatment (9). This can be avoided using nonphar- macological approaches to treatment, such as the perioperative use of medical hypnosis, which is inexpensive and with- out side effects (4-8,13). It is performed 1–5 days before the operation, when the patient’s consent and trust are obtained. They are taught breathing techniques and how to visualize a safe and pleasant envi- ronment. The technique is based on reliv- ing pleasant life experiences. Patients are positively motivated as they are invited to play an active part in the treatment pro- cess (7,30). The act of recalling positive suggestions is used before anaesthesia, which then further reduces anxiety and stress response before surgery. As a com- plementary method, medical hypnosis can be used with local anaesthesia or sedation, which is known as hypnosedation. During the operation, the feeling of discomfort, anxiety and pain is reduced, consump- tion of anxiolytics and analgesics during the procedure is reduced, conditions for the operation are improved, and recovery is accelerated (8,10,30). Medical hypnosis brings added value to established anaes- thetic procedures but is only suitable for specific procedures and selected patients (7,13). It cannot be performed in deaf patients and patients with psychosis (7). A good hypnosedation performance requires close cooperation between the surgical and anaesthesia teams. The op- erating room needs to provide peace. The patient is conscious but has reduced ex- ternal consciousness, so he or she is dis- tanced from the procedure. The surgeon must work gently and precisely, and the anaesthesiologist must closely monitor the operation itself and the patient’s needs (7,30). Hypnosedation has become a routine technique in many branches of surgery, such as gynaecology, vascular surgery, plastic surgery, maxillofacial surgery, ophthalmology, oncology, orthopaedics, traumatology, dental surgery, and neuro- surgery (4-8,13-17). In Slovenia, the pioneer of medical hypnosis is prof. Marjan Pajntar, MD, PhD (31,32). In 1962, he began practis- ing medical hypnosis in obstetrics (33). The first operation with medical hyp- nosis alone was performed in 2016 at the University Medical Centre Ljubljana by prof. Uroš Ahčan, MD, PhD. Matej Serdinšek, MD, also a medical hypno- sis therapist, tested this method on him- self, having the hypnosis performed by the medical hypnosis therapist Mitja Perat, director of the Institute for Human Resource Development (34). 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