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...happily accept bodily insults temperature challenges during outdoor recreational activities that, if experienced would be unacceptable. People willingly go up on ski lifts in subzero temperature, but shiver when their bedroom thermostat goes below 70[degrees] F. Even if a painful or frightening stimulus cannot be removed, a change in perception can nevertheless take the "hurt" out of the experience.
Some patients, confronted with pain and distress, resort to their own cognitive "non-pharmacological" means of coping, such as imagination of pleasant scenes, distraction, relaxation, self-hypnosis, or meditation (Anand 1961, Chaves 1974; Hilgard 1977; Quirk 1989a; Spanos 1981; Spanos 1984; Spanos 1979).
Reduction of anxiety decreases pain and symptoms (Barber 1959; Barber 1960; Hilgard 1969; Hill 1952; Hill 1952b; Martin 1991; Shor 1962). Hypnosis as a means of anxiety reduction has proven highly beneficial for patients undergoing MRI examinations (Friday 1990) and was shown to reduce drug use during coronary angioplasty (Weinstein 1991). In these studies, however, additional physicians/psychologists were needed for about 30 minutes, and this is impractical in most settings
Tapes promoting relaxation have been used to reduce (98) drug use during dental surgery (Corah 1979), gastrointestinal endoscopy (Wilson 1982), and femoral angiography (Mandle 1990). Tapes, however, have a 13% rejection rate (Feher 1989) and can result in the withholding of needed drugs in non-receptive patients. Also, presence of a "live therapist," who is a member of the treating team, is believed to be superior (Blankfield 1991). Selfhypnotic techniques including relaxation training and imagery, applied by members of an interventional radiology team, were highly effective in reducing pain and drug use during invasive procedures (Lang 1994; Lang 1996). In a prospective randomized study with patients undergoing invasive procedures, hemodynamic instability and procedure interruptions were significantly less frequent when patients had self-hypnotic relaxation (Lang 1996). Overall, self-hypnotic relaxation greatly increased procedural safety by reducing the occurrence of drug-related complications.
The Concept of Non-pharmacological Analgesia:
The Clinical Practice Guidelines for Acute Pain Management, published by the United States Department of Health and Human Services (Acute Pain Management Guideline Panel 1992), recognizes the limitations of intravenous conscious sedation and suggests that use of non-pharmacological analgesia methods be induced in the repertoire of acute pain management.
Because there are no guidelines for how these methods should be employed, we undertook to identify methods that regular staff members of a radiology department can apply in a safe fashion. These methods were elaborated during four training courses with different interventional radiology team members and encompass a spectrum of hypnotic techniques (Lang 1996b). We chose the designation non-pharmacological analgesia as a descriptive, generally acceptable term to allow for the individual adaptation of the techniques that are presented in the "Methodology" section of this chapter.
Economic Impact of Managing Pain and Anxiety Managing patients' anxiety and pain materially affects the health care budget. If a patient receives any amount of intravenous conscious sedation, stringent monitoring requirements and a full set of conscious sedation policies in accordance with the standard of care must be followed (Association of Operating Room Nurses 1992; Lang 1996; Steinbrich 1993). The patient's history must be taken, an anesthesia plan must be developed, and a dedicated observer who is not allowed to engage in any other activities must remain with the patient for the duration of the examination and afterward for at least 30 minutes after the last drug dose. The patient requires a responsible adult to accompany him or her home and is not permitted to drive, operate machinery, or conduct important legal business for the next 24 hours. Avoiding these inconveniences and costs to patient and hospital by use of non-pharmacological means is a highly economical alternative.
Based on data obtained from 34 consecutive patients treated in the Interventional Radiology Suite at the University of Iowa Hospital and Clinics, materials and observation requirements for intravenous conscious sedation added an average of $140 to every interventional radiology procedure. If it were possible * to reduce the need for intravenous conscious sedation to 25% of...
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