This document summarizes factors that determine the need for sedation during regional anesthesia. It discusses how sedation is routinely used during regional anesthesia but may not always be necessary and can have adverse effects, especially in older or higher risk patients. It suggests that alternatives to sedation like hypnosis, music, or conversation may provide adequate comfort for many patients during procedures when regional anesthesia is used. More research is still needed but moving away from routinely asking "do you want to be asleep?" and only using sedation when truly indicated could help reduce risks.

1. 684 www.anesthesia-analgesia.org March 2015 • Volume 120 • Number 3
Copyright © 2015 International Anesthesia Research Society
DOI: 10.1213/ANE.0000000000000567
W
hile 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.
The Open MindE

2. Do You Want to Be Asleep?
March 2015 • Volume 120 • Number 3 www.anesthesia-analgesia.org 685
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

3. E The Open Mind
686 www.anesthesia-analgesia.org anesthesia analgesia
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
DISCLOSURES
Name: 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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