Anesthesia

THE SILVA METHOD AND NON TRAUMATIC

INDUCTION TO ANESTHESIA

Abstract This research was done to measure the effect of the Silva Method Relaxation techniques amongst patients programmed for surgery, evaluating the reduction in their consumption of chemical anesthesics and the elimination of pain.

SPECIALTIES HOSPITAL MEXICAN INSTITUTE OF SOCIAL SECURITY PUEBLA,

PUEBLA. MEXICO

1981

MIGUEL BAUTISTA M.D.

TRANSLATION: Martha C. Saldana

(Paper presented on the occasion of the XVI Latin American Congress on Anesthesiology held in Panama City from the 23rd. to the 27th. November, 1981.

INTRODUCTION

Whenever a person is about to be subjected to anesthesia, he is in a state of emotional stress. Maybe even a considerable number of anesthetists in the same circumstances, and aware of the risk they run, have shared that feeling of anxiety and fear. Despite of this, the anesthetist usually neglects to make an effort and alleviate his patient s tension or fear. In most cases, the reason for this is not that he doesn t want to do anything about it, but rather because he believes there is nothing he can actually do, or doesn t know how to go about in approaching someone who is emotionally upset. At times, the anesthetist tells his patient "Don t move" or "Stay calmed," using a tone of voice that is far from being comforting or relaxing. He neglects taking into consideration that ease of mind is not a state that can be urged upon anyone; on the contrary, it is the patient himself who, in this case, reaches it at his own pace, and the anesthetist s role is to help him in the process. Unfortunately, the latter is viewed as a waste of time, and priority is given to the number of anesthetized patients instead of devoting time and energy to serve our fellow men to the best of our capabilities. We know, for instance, that in spite of pre-anesthetic medication, the patient s fear of anesthesia and the lack of trust in the work of the anesthetist are overflowing to the point that he is too tense to let the sedative relax him deeply and perform the humanitarian function it was intended for. The result is that in cases when it is needed the most, the full effect of sedation is not there. Among the factors that contribute to this situation, the following can be cited: Inadequate dosage of sedative, usually insufficient; delay in the availability of operating rooms or in transferring the patient to the surgery area; inadequate attitude of the personnel in charge of transferring the patient; prolonged stay in the operating room before receiving anesthesia. In the latter case, the patient is exposed to using up the effect of the sedative and, therefore, listens to conversations between members of the personnel who may not be aware of the intimidating effect of their words; or be overwhelmed by the silence and loneliness that surrounds him while he awaits for someone to take care of him. When patients are too fearful or excited before actual induction to anesthesia, anesthetists are tempted to use a higher than recommended dosage in order to hasten the loss of consciousness. They overlook the fact that in this phase the patient s senses become more acute and magnify any noise -- whispers, footsteps, clashes ... -- assigning to it a special dimension before it is recorded in the subconscious. Patients tend to make bizarre associations with these sounds, making them even more apprehensive during this process which, on the other hand, may leave them with the impression of being afflicted along with sensations of falling and death. It mustn t be a surprise, then, that upon regaining consciousness these patients resume the struggle that took place in their minds while being anesthetized, and become even more excited after surgery because now their fears are accompanied with pain. The degree of anxiety a patient may fell is variable, since it depends on the person s temperament. But n any event, induction to anesthesia is a process that produces fear and, whether we like it or not, all inductions are traumatic.

PRELIMINARY INFORMATION

Although there are no electronic devices to measure fear, it is possible to measure its effects. Tsutuomo Oyama, MD., in his book Anesthesia and endocrine diseases states that “A significant number of patients appear to be anxious before surgical operations. Emotional stress is a powerful stimulant of cortical secretion in patients that are in the preoperative stage, as well as with odontological patients. This was observed by Frenkson and Gemsell, Price and collaborators, Shanon and Burnstein, in patients that were placed in hospitals to receive medical care. Nonetheless, Harmmond and collaborators, Virtue and collaborators, and Vandam and Moore have established that, on the contrary, the anxiety level in preoperative patients does not have a "significant effect on the adreno-cortical function." The effectiveness of pre-anesthetic medication as a sedative, including an adequate night sleep, is correlated with a diminution in the plasmatic levels of cortisol. These agents include pentobarbital (two milligrams [0.030 grain] for every kilogram [2.2046 pounds] of weight); Atarax, Vistaril, Diazepam (200 micrograms per kilogram of weight); and Nitracepam (200 micrograms per kilogram of weight). Nonetheless, meperidine taken one hour before anesthesia doesn t inhibit adreno-cortical stimulation resulting from preoperatory emotional stress. In general, it can be said that adequate sedation reduces unrestrained emotional manifestations produced by high levels of catecholamines, as well as their correlated effects on metabolism: Increase in body temperature, faster breathing, as well as coronary and peripherical circulation, etc. We know that when an individual is in a state of anxiety and fear his muscles contract, his jaw tightens to the point of producing a painful ache, and his whole body becomes

tense. We also know that voluntary relaxation of the muscular system induces mental and emotional relaxation, which in turn produces tranquillity. If this latter stage is reached (and it can even culminate with the person s falling asleep), the result is a sensation of inner peace.In 1932, I.H. Schultz (How to manage pain, J. W. Beck) introduced self-relaxation through concentration. Jacobson developed in 1938 a technique involving verbal instruction aimed at relaxing the voluntary muscles. These methods sought to build a barrier against two closely related factors: tension and anxiety. As it was found later on, anxiety and pain are interrelated, so when anxiety disappears, pain can be alleviated or, at least, reduced. According to Keneth Greenspan, MD., head of the stress-related disorders laboratory of the Presbyterian Medical Center in Columbia, there isn t one single method useful to all patients suffering from stress. He recommends a versatile approach encompassing methods such as psychotherapy, counseling, meditation and modification of behavior with techniques of biofeedback and relaxation.

Maxwell Maltz, plastic surgeon, says: "The greatest satisfaction that comes with relaxation is that it is contagious. Whoever is at peace with himself can spread to others the feelings of ease of mind, relaxation, and joy. As a matter of fact, relaxation is the first step to joy."

T. N.: No equivalent available. Freedman stated that the areas of the brain that intervene in the production of autonomous and neuro-endocrine responses are the activation reticular system, the limbic system, the hypothalamus and the cortex of the brain itself. The activation reticular system determines the level of anxiety by regulating the degree to which other neural systems activate, as well as by controlling the attention paid to afferent signals, and by transmitting inhibitors from the brain cortex. The limbic system adds an emotional charge, and the system composed by the hypothalamus and the endocrine and pituitary glands influences the production of cortisol, catecholamines, tiroxine, and related hormones.

For this reason, if we practice voluntary relaxation, we must also teach itin order to help the patient free himself from anxiety. This only takes a few minutes. How can this be done?

TECHNIQUE FOR NON-TRAUMATIC INDUCTION

The first thing that has to be done is to establish empathy with the other person. A way to do this is asking the patient about his previous experiences in this respect, and also about his feelings at the moment. Whether he admits to be afraid or not, our understanding of his emotions and sensations must be expressed at this moment. This opportunity should be used to explain to him that the way he feels is mainly the result of the stress that accompanies situations such as this one.

Using the relaxation techniques of the Silva Method, which I have personally applied with extraordinary results, we can induce the patient to a deep state of relaxation. This particular technique starts by asking the person to address his attention to different parts of his body in order to relax them. The process begins with the skull, and then with the forehead, eyelids, cheeks, neck and throat, shoulders, arms and hands, toraxic region, abdominal cavity, thighs, knees, calves, and feet. Upon reaching this part of the body, the induction continues verbally by telling the patient that this relaxation is now complete, that he now feels totally calm, and that therefore he will begin to feel drowsy. At this point, the pharmacological inductor is passed on to the patient, while our voice continues to induce in him a deep state of relaxation. In most cases, the patient will be asleep even before the relaxation of the body is over. Even under those circumstances we go on saying to him that "When you wake up your surgery will have finished, and you will be calmed, without pain or discomfort for three days (or two, or one, or twelve hours, according to what may be deemed necessary). With no pain or discomfort for three days; without pain or discomfort." Here we can also make suggestions in connection with dreams (hallucinations) produced by ketamine, by saying to him that if he dreams his dreams will be pleasant, and then repeat this several times. Since the bridge between consciousness and unconsciousness is usually very short, the inductor must be introduced very slowly in order to prolong the transition as much as possible and to increase the effect of the suggestions. The more the latter are repeated, the better they are engraved in the memory of the patient, even if he gives the impression of being asleep; for it is possible that his unconscious may still pick up the suggestions we are giving. Now we can follow the anesthesiologic procedure of our choice. If we have helped the patient to achieve total relaxation, then we shall verify that the dosage of the inductor (regardless of the type) will be less, as well as that of the relaxant required for intubation. Although it cannot be confirmed, the percentage of anesthetic will be lower; and post-surgery muscular relaxation will be achieved with half, or less, or the usual dosage. If we observe carefully this relaxation procedure, four essential steps are involved:

1. Muscular relaxation and calm.

2. Slow induction to chemical dream.

3. Reassurance to the subconscious regarding the perfect performance of the anesthesia and the actual surgery.

4. Certainty of waking up feeling calmed, with no harmful consequences.

COMMENTS REGARDING THIS TECHNIQUE

1. It is important to teach relaxation in connection with one specific part of the body.

2. Breathing should be introduced as reinforcement.

3. Relaxation must be carried out slowly, allowing enough time to avoid hurrying the patient onto the next step.

4. The complete attention of the patient can be achieved by saying to him “From this moment you will not pay attention to external noise. You will only listen to what I am saying.”

5. To guarantee the patient of our constant presence is to increase his trust in our work and to reinforce in him the feeling that he is safe in our hands.

6. Suggest to the subconscious ideas of peace of mind, calm, analgesia, etc.

CONCLUSIONS

1. 98 percent of the patients experiment fear and anxiety (even panic) before and during induction.

2. The voluntary relaxation method contributes to free the patient from these emotions, and makes induction calm, even eaceful.

3. This method doesn t substitute anything. It is a complement to:

a. Pre-anesthetic medication and sedation

b. Induction via medication

c. Regular anesthetic techniques applied according to the type of surgery, and the state of the patient.

4. Voluntary relaxation is a process easy to learn, practical, and fast since it takes from four to six minutes.

5. It is possible to make post-surgery suggestions: Calm awakening, absence of vomit and headaches (if they do not have an organic cause, of course), transforming terrifying hallucinations into pleasant experiences, etc.

6. Dosages for inductors, as well as relaxants are reduced significantly, although we ignore if the same happens with inhaled anesthetics.

7. Many more possibilities, since other anesthesiologists will certainly discover them in the future.

OBSERVATIONS AND STATISTICS RELATED TO NON TRAUMATIC INDUCTION TO ANESTHESIA THROUGH VOLUNTARY MUSCULAR RELAXATION USING THE SILVA METHOD. GENERAL ANESTHESIA WAS APPLIED TO 100 PATIENTS

66 Feminine subjects

34 Masculine subjects

PATIENTS ACCORDING TO AGE

Women Men

New born to 4 years 0 1

5 to 10 years 3 3

11 to 20 years 5 11

21 to 30 years 12 5

31 to 40 years 13 3

41 to 50 years 13 3

51 to 60 years 9 6

61 to 70 years 4 2

71 to 80 years 6 0

81 to 90 years 1

TOTAL 66 34 58

ECONOMIC LEVEL OF PATIENTS

Women Men

Low 28 13

Middle 31 17

High 7 4

TOTAL 66 34

PRE ANESTHESIC MEDICATION

Atropine/ Diazepam 92

Atropine/ Flunitrazepam 3

Atropine 1

Scopolamine/ Diazepam 1

Non medicated 3 (Average time of application for pre-anesthetic medication 1.33 Hrs.

PSYCHOLOGICAL STATE OF PATIENTS BEFORE ANESTHESIA

Tranquil 2

Apparently tranquil 15

Apprehensive 19

Fearful 45

Anxious 19

TOTAL 100

PERCENTAGE OF PATIENTS WHO COOPERATED WITH THE EXPERIMENTAL PROCEDURE

Positive 95 %

Negative 5 %

INDUCTIVE MEDICATION

Women Men 51

Thiopental 24 12

Propanidid 5 1

Ketamine 2 2

Inhaled 3 66 34

AVERAGE PERCENTAGE OF DOSAGE PER KILOGRAM OF BODY WEIGHT

Women Men 4.96 MGRS./KG

Thiopental 5.47 MGRS./KG6.06 MGRS./KG

Propanidid 6.27 MGRS./KG3.46 MGRS./KG

Ketamine 1.61 MGRS./KG

PERCENTAGE OF PATIENTS IN RELATION TO ANESTHETIC EMERSION

Tranquil 93 %

Excited 7 %

RATIO OF PAIN AMONGST PATIENTS 24 HOURS AFTER SURGERY

Negative 59

Tolerable 35

Intense

PSYCHOLOGICAL STATE OF PATIENTS 24 HOURS AFTER SURGERY

Tranquil 98 %

Excited 2 %

COMMENTS OF SOME OF THE PATIENTS 24 HOURS AFTER SURGERY

I had never relaxed. I felt inner peace.*

Relaxing gave me security and tranquillity.*

I felt fine, protected and well taken care of.*

Compared to previous experiences with anesthesia this was super - excellent.*

I felt nervous and fearful, but I became tranquil when they helped me relax.*

I felt more tranquil, it was a pleasant sensation. I used to have a bad impression of anesthesia.

SURGERIES DONE WITH 100 PATIENTS

Cholecystectomy 13

Resection of mammary fibromas 8

Esophageal dilations 4

Thyroidectomies 3

Hysterectomies 3

Laminectomies 2

Mitral valve implantation 2

Diverse 65

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