I know what you're thinking, and no, hypnosedation doesn't involve swinging a pocket watch while telling patients you're getting sleepy very, very sleepy before surgery. Hypnosedation combines hypnosis with the incremental doses of local anesthetics to keep patients calm and comfortable during surgery without the use of inhalational gases or short-acting sedatives.

The concept is neither new (Scottish neurosurgeon James Braid coined the term "hypnosis" in the 1840s to describe the state of deep relaxation he put his patients in) nor experimental (the National Comprehensive Cancer Network lists hypnosis in its pain management guidelines). It's also not yet mainstream, however, so let's explore the anesthesia alternative that's no cheap parlor trick.

A team of collaborators from the breast surgery, integrative medicine and anesthesia departments here at MD Anderson Cancer Center implemented a hypnosedation program for patients undergoing segmental mastectomies with sentinel node biopsy and intraoperative lymph node mapping.

Candidates for hypnosedation are assessed on a case-by-case basis, but patients who respond positively to the idea and are open to trying it generally have the right temperament and attitude to be successfully hypnotized. Patients who agree to be hypnotized meet with a hypnotherapist before scheduled procedures to practice entering a hypnotic state and learn about what to expect during the process.

On the day of surgery, after the patient is positioned on the OR table, the surgical team works quietly and often with the lights dimmed to create a relaxed environment. The hypnotherapist sits close to the patient's ear and uses a soothing voice to lead them through guided imagery hypnosis. Patients are asked to recall places where they felt at ease (the beach or a relative's house) and to focus on specific details (the scratch of sand on their feet or the smell of grandmom's cookies baking in the oven). They breathe deeply, feeling each breath at it enters and leaves their body. It generally takes only a few minutes for the hypnotherapist to hypnotize the patient.

The feedback from patients who have been hypnotized during surgery has been overwhelmingly positive.

During surgery, the hypnotherapist maintains the patient in a conscious, but disassociated state. You likely experience this sensation during your morning commute. Thoughts enter and leave your consciousness as you drive the familiar route and when you arrive at work, you likely don't remember maneuvering the car during every second of the trip. You were conscious, but not fully aware of what was going on around you.

Special in-services are needed for members of the surgical team, who must be taught about the enhanced coordination these cases demand. The team works alongside and communicates constantly with the hypnotherapist, who remains by the patient's side for the entire procedure. Anesthesia providers, in particular, work closely with the hypnotherapist and the surgical team to titrate local anesthetics — appropriate dosages of local are calculated before procedures begin and on hand in the room, ready for administration — at the surgical site based on the patient's level of hypnosis.

Patients could undergo hypnosedation to eliminate the common side effects associated with general anesthesia, avoid intubation so as to not exacerbate severe TMJ disorders or sidestep worries about the link between inhalational gases and post-op cognitive dysfunction. Hypnotized patients require no benzodiazepines, volatile anesthetics or propofol for cases that would otherwise require the administration of all 3 medications. Plus, the OR is an appropriate setting to attempt hypnosedation for patients who express interest in the technique because you can easily transition to administering general anesthesia if patients don't respond appropriately.

We've used electroencephalogram monitoring to measure brain activity in hypnotized patients and noticed increased activity in the occipital cortex, which is associated with vision, and decreased activity in some of the somatosensory pathways, which are associated with pain sensations. Those fascinating results, which we published in the May 2019 issue of the journal Breast (osmag.net/b9QAuY), provide evidence of hypnosedation's effectiveness and show it's a method worthy of further investigation.

After surgery, recovering patients are wide awake and ready for faster discharges. Anecdotally, we've noticed a reduction in the amount of intraoperative and post-operative opioids we administer, perhaps in part because of the targeted and incremental injections of local anesthetics. The association between hypnosedation and reduced opioid use demands further study before we can claim a definitive link.

Will hypnosedation ever replace general anesthesia as the primary means of sedating patients for surgery? Absolutely not. But the approach is feasible for some minor surgeries, preferred by some patients and might be the best option for individuals with comorbidities that increase the risk of using general anesthetics.

The feedback from patients who have been hypnotized during surgery has been overwhelmingly positive and some surgeons have even approached our multidisciplinary team unprompted to let us know some of their patients with severe pulmonary or cardiac issues have agreed to receive the alternative form of sedation. With patients and surgeons becoming more receptive to the idea, hypnosedation is developing into a practice worth pursuing. OSM