International Journal of Clinical and Experimental

Hypnosis

ISSN: 0020-7144 (Print) 1744-5183 (Online) Journal homepage: http://www.tandfonline.com/loi/nhyp20

Effects of Positive Suggestions on the Need for Red

Blood Cell Transfusion in Orthopedic Surgery

Csenge Szeverényi, Zoltán Csernátony, Ágnes Balogh, Tünde Simon & Katalin
Varga

To cite this article: Csenge Szeverényi, Zoltán Csernátony, Ágnes Balogh, Tünde Simon &
Katalin Varga (2016) Effects of Positive Suggestions on the Need for Red Blood Cell Transfusion
in Orthopedic Surgery, International Journal of Clinical and Experimental Hypnosis, 64:4,
404-418, DOI: 10.1080/00207144.2016.1209041

To link to this article: http://dx.doi.org/10.1080/00207144.2016.1209041

Published online: 02 Sep 2016.

Submit your article to this journal

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=nhyp20

Download by: [Flinders University of South Australia] Date: 04 September 2016, At: 11:40
Intl. Journal of Clinical and Experimental Hypnosis, 64(4): 404–418, 2016
Copyright © International Journal of Clinical and Experimental Hypnosis
ISSN: 0020-7144 print / 1744-5183 online
DOI: 10.1080/00207144.2016.1209041

EFFECTS OF POSITIVE SUGGESTIONS ON

THE NEED FOR RED BLOOD CELL
TRANSFUSION IN ORTHOPEDIC SURGERY
Csenge Szeverényi and Zoltán Csernátony

University of Debrecen, Clinical Center, Hungary

Ágnes Balogh

Independent Statistician, Brussels, Belgium

Tünde Simon

University of Debrecen, Clinical Center, Hungary

Katalin Varga

Eötvös Loránd University, Budapest, Hungary

Abstract: This study examined whether positive suggestions applied

without a hypnotic induction in the perioperative period reduces the
need for red blood cell transfusions in patients who underwent total
hip or knee arthroplasties with spinal anesthesia. No hypnotic assess-
ment was performed. Ninety-five patients were randomly assigned
to the suggestion group (n = 45) and to the control group (n = 50).
Patients in the suggestion group received verbal suggestions before
and audiotaped suggestions during the surgery for reducing blood
loss, anxiety, postoperative pain, and fast recovery. Our study showed
that using positive suggestions in the perioperative period signifi-
cantly decreases the necessity for transfusion.

The use of hypnosis in the medical field is becoming more and

more accepted worldwide. During a formal hypnotic procedure with
an induction, the patient is likely to shift to a modified mental state
that increases his or her acceptance of suggestions. Giving suggestions
in this context can be used for different goals under medical circum-
stances (e.g., anesthesia, to decrease pain, vomiting, and/or the need
for medications). Several studies were published in which patients

Manuscript submitted May 10, 2014; final revision accepted November 9, 2015.
Address correspondence to Csenge Szeverényi, MD, Nagyerdei krt. 98, Debercen
H-4032, Hungary. E-mail: szcsenge@med.unideb.hu

404
 POSITIVE SUGGESTIONS’ EFFECT ON TRANSFUSION NEED 405

were hypnotized before or during a surgical intervention and the effec-

tiveness of suggestions received in hypnosis were analyzed (Ashton
et al., 1997; Enqvist, von Konow, & Bystedt, 1995; Ghoneim, Block,
Sarasin, Davis, & Marchman, 2000; Hart, 1980; Kiss & Butler, 2011;
Lang et al., 2000; Mauer, Burnett, Ouellette, Ironson, & Dandes, 1999;
Montgomery et al., 2007; O’Shea, Dodd, Panayiotou, & Palmer, 2011;
Rapkin, Straubing, & Holroyd, 1991). According to the meta-analysis
of Montgomery, David, Winkel, Silverstein, and Bovbjerg (2002), 89%
of surgical patients benefited from adjunctive hypnosis interventions
relative to patients in control conditions.
As is well known, suggestions also may be effective out of hypno-
sis (Meyer & Lynn, 2011), and they can be used to improve patients’
recovery (Bejenke, 1996; Cheek, 1969; Ewin, 2011; Kekecs, Jakubovics,
Varga, & Gombos, 2014; Varga, 2011, 2013). The application of posi-
tive suggestions following the protocol of Varga, Diószeghy, and Fritúz
(2007) and Szilágyi, Diószeghy, Benczur, and Varga (2007) decreased the
length of time patients were on a ventilator in an intensive care unit.
This finding was successfully replicated recently (Szilágyi, Diószeghy,
Fritúz, Gál, & Varga, 2014), along with a reduced drug intake (Schlanger,
Fritúz, & Varga, 2013). The authors emphasized the importance of
keeping patients informed, and they focused the patient’s attention
on the signs of gradual recovery while applying suggestions to relax
the patient. Several studies confirmed that taped positive suggestions
played during surgery can decrease postoperative vomiting, length
of hospitalization, and time of the return of gastrointestinal motility
(Cowan, Buffington, Cowan, & Hathaway, 2001; Disbrow, Bennett, &
Owings, 1993; Eberhart, Döring, Holzrichter, Roscher, & Seeling, 1998;
Kekecs & Varga, 2013; Nilsson, Rawal, Uneståhl, Zetterberg, & Unosson,
2001).

Special Characteristics of Knee and Hip Surgeries

Among orthopedic surgeries, hip and knee arthroplasties are the
most common great joint surgeries. The extent of blood loss during
these operations can be so severe that red blood cell transfusion
becomes necessary. It is well known that, although red blood cell
transfusion is increasingly safe, it is still not without risk. It may have
immunological and nonimmunological and immediate and late onset
adverse effects (Miskovits, 2008). Studies suggested that perioperative
red blood cell transfusion significantly increases the rate of complica-
tions (Abbas, Murtaza, Umer, Rashid, & Qadir, 2012), and it influences
the length of stay in the hospital (Jonas, Smith, Blair, Dacombe, &
Weale, 2012).
406 CSENGE SZEVERÉNYI ET AL.

Aim of this Study

Based on the above, it is obvious that decreasing the red blood
cell transfusion rate during and in the days after these surgeries has
prominent relevance to the patient’s health and postoperative recov-
ery. Furthermore, decreasing the red blood cell transfusion rate is
relevant for health care institutions as well: Preparation and admin-
istration of transfusions burdens the medical staff, the preparation of
blood products has high costs, and sometimes the institution even
faces the problem of scarce blood stock. There are several methods to
reduce blood loss—and, therefore, potentially the need for red blood
cell transfusions—during a surgical intervention. One possibility is that
the anesthesiologist maintains a controlled hypotension, but even a
transitory elevation of blood pressure can lead to increased bleeding.
Blood loss during surgery can be decreased by medication as well, such
as tranexamic acid (Charoencholvanich & Siriwattanasakul, 2011; de
Jonge, 2012; Yang, Chen, & Wu, 2012). However, the use of this prod-
uct at orthopedic surgeries to reduce blood loss was not authorized in
Hungary at the time of the study.
Until now, only a few trials have dealt with the effectiveness of sug-
gestions during the perioperative period aiming to decrease blood loss,
and all of these suggestions were given under hypnosis. Hart (1980)
examined the amount of blood loss and the need for blood transfusion
in open heart surgeries; Rapkin et al. (1991) examined head and neck
cancer surgeries; Enqvist et al. (1995) examined maxillofacial surgeries;
and Ross (1982) examined dental surgeries. In their studies, they used
suggestions of relaxation, quick recovery, and visual imagery to facil-
itate hemostasis and successful postsurgical recovery. Based on their
results, the amount of blood loss was reduced by the given sugges-
tions, and they also showed that the decrease in blood loss was higher
in those patients with higher hypnotizability scores (Rapkin et al., 1991;
Ross, 1982). Other trials where the aim of hypnotic suggestions was to
influence the diameter of certain vessels were also successful. With the
help of hypnosis, Klapow, Patterson, and Edwards (1996) increased the
circulation of the lower extremity of patients suffering from Burger’s
disease. Zachariae, Oster, and Bjerring (1994) decreased blood perfu-
sion of ultraviolet B radiation-induced erythema. Reinhard, Hüsken-
Janssen, Hatzmann, and Schiermaier (2009) decreased the resistance of
the umbilical artery in pregnant women. In all of these studies, sug-
gestions were given either personally (verbally) or via audiotape. There
was no significant difference between these two methods of hypnosis
administration (Montgomery et al., 2002).
The research hypothesis of our study was that among patients who
undergo hip or knee prosthesis surgery with spinal anesthesia, patients
who receive positive suggestions without a hypnotic induction before
 POSITIVE SUGGESTIONS’ EFFECT ON TRANSFUSION NEED 407

the intervention (personally) and during the surgery (using audiotape)

will lose less blood than patients who do not receive any positive sug-
gestions. Thus, our primary objective was to compare the necessity
of red blood cell transfusion of patients receiving and not receiving
positive suggestions.

Method

To test our hypothesis, we performed a randomized, prospective

clinical trial between April 2011 and January 2013. Eligible patients
were to undergo a total hip or knee arthroplasty surgery with spinal
anesthesia at the Department of Orthopedic Surgery at the University
of Debrecen. The study was authorized by the Institutional Ethical
Committee. Before enrollment, all patients gave their written informed
consent.
Upon enrollment, patients were randomized into two groups.
Patients in the suggestion group received not only the usual informa-
tion from their surgeon and anesthesiologist but they also participated
in a personal verbal discussion about the expected events with a third
doctor. This third doctor was the same person (C.S.) for all patients;
although she was an orthopedic surgeon (i.e., not a psychologist), she
did not operate on any of the enrolled patients. During this semi-
standardized discussion, not only extra information was given but
also direct suggestions to decrease the bleeding. Furthermore, this dis-
cussion presented the opportunity to personalize the suggestions to
the questions and concerns of each patient. Then, during the surgery,
patients listened to a 90-minute audiotape of suggestions connected
by relaxing music. This included suggestions aimed at relaxing the
patient, reframing the meaning of intraoperative noises, decreasing
postoperative pain, and—most important—giving direct suggestions
to decrease blood loss in the perioperative period. For example, “Your
body withdraws the redundant blood from the surgical field. Only as
much blood flows there as is required to supply the tissues with suf-
ficient nutrition and oxygen . . .. There is no need for bleeding.” The
complete text of these suggestions is available from the first author;
part of it with explanations is published in Szeverenyi, Csernátony,
Balogh, and Varga (2013). Patients in the control group received care
as usual (i.e., information given by their surgeon and anesthesiologist).
No hypnotic assessment was performed at the beginning of the study.
We did not find it necessary, partly because we were not to perform
hypnosis, partly because we wanted to avoid mentioning the term hyp-
nosis to the patients, since we did not want to influence the effect of
the intervention. We wanted to develop a method that is effective and
usable routinely with any patient (not only with highly hypnotizable
408 CSENGE SZEVERÉNYI ET AL.

ones) and by health professionals who are trained in suggestion inter-

vention but not necessary in hypnotherapy. Our approach was based
on using suggestive techniques while providing information to the
patients (see this method in several areas of medicine in Varga, 2011).
Patients were randomized in a 1:1 ratio to these two treatment
groups, using a stratified block design (with block size of 4) via tossing
a coin. The randomization was stratified by two factors that are thought
to influence blood loss (Enqvist et al., 1995). These were the type of the
surgery (cemented vs. noncemented hip prosthesesis vs. knee prosthe-
sis) and the experience of the surgeon (experienced vs. inexperienced).
The latter factor affects the surgical technique and the length of the oper-
ation, which might have an indirect effect on bleeding. Surgeons who
have been doing arthroplasties for at least 5 years after their specialty
exam were considered experienced.
It is known that the number of required red blood cell transfu-
sions during or after arthroplasties is further influenced by patient
age, preoperative hemoglobin level, and patient weight (Ahmed, Chan,
Jenkins, Brenkel, & Walmsley, 2012; Kotzé, Carter, & Scally, 2012;
Noticewala, Nyce, Wang, Geller, & Macaulay, 2012). Considering these
and other factors that influence other objectives of the study, we aimed
to define a patient population that is homogenous from a medical
point of view. Therefore, the following patients were excluded from
the study: patients with hemorrhagic disorders, congenital or acquired
immunodeficiency, diabetes mellitus, moderate and severe heart fail-
ure (New York Heart Association Functional Class III-IV), alcoholism,
liver failure, body mass index (BMI) of 40 or higher, Jehovah’s Witnesses
(who refuse blood transfusions), and patients with defective hear-
ing (who cannot hear the suggestions). Furthermore, those patients
who received general anesthesia and those with surgical complication
leading to increased bleeding (such as bone fracture or vessel injury)
would also be excluded from the analysis after randomization. To rule
out hemorrhagic disorders, laboratory tests of hemostasis were rou-
tinely checked for each patient before surgery, including International
Normalized Ratio (INR), activated partial thromboplastin time (APTT),
and Thrombin Time (TT). For all patients included in the analysis,
the operation was performed with spinal anesthesia, but, because the
patients received narcotics and sedatives as well (midazolam, nalbufine,
propofol, fentanyl, droperidol), most of them were sleeping lightly.
(There was no difference in the amount of tranquillizers between the
two treatment groups.) According to their pharmacological descrip-
tion, none of the used medication has any effect on bleeding (European
Medicines Agency, 2016).
The decision whether or not to transfuse to a specific patient is
regulated by our institutional protocol. During the surgery, the anesthe-
siologist decides on the need of transfusion if the estimated blood loss
 POSITIVE SUGGESTIONS’ EFFECT ON TRANSFUSION NEED 409

reaches 500 ml. After the operation, the orthopedic surgeon on duty
decides based on the hemoglobin level: It should not decrease below
100 g/l on the day of the surgery and below 90 g/l from Postoperative
Day 2 on.
Throughout the study, we recorded the number of units of red blood
cell transfusions during and after the intervention (one unit is equal to
200 ml red blood). To prove our hypothesis, the ideal would have been
to directly measure the blood loss as well. At the time the study was
designed, the primary objective also included measurement of blood
loss during and after the intervention. However, for technical reasons,
it was impossible to gain exact measures: We had to face already at the
beginning of the study that the blood flowing onto the isolation textile
is immeasurable and thus data collection was also imprecise. Therefore,
we did not collect and analyze these data and used the amount of blood
transfusions as a surrogate endpoint to assess blood loss. Due to stan-
dard institutional guidelines, we believe this is an adequate endpoint to
address our research hypothesis.
In clinical practice, 2 units of red blood cells are always given at a
time. The only way to receive an odd number of units is when, even
though the medics indicated two units, it was technically not possible
to receive both. Thus, for our primary endpoint it makes complete sense
that patients for whom 1 or 3 units were recorded are categorized as
those who received 2 or 4 units, respectively. Furthermore, because in
these types of operations, within the population specified for this study,
it is very rare to receive more than 4 units of red blood, all patients
receiving at least 4 units were grouped together. Thus, we would cate-
gorize the patients into three groups based on how many units of red
blood they received (0, 2, and 4 units).

Statistical Analysis
Ordinal logistic regression was applied to model the number of red
blood cell units received. For the other variables, the difference between
treatment groups was tested using an unpaired t test (age, BMI, baseline
INR, APTT, TT, duration of surgery) or Pearson chi-square test (gen-
der). Hemoglobin and hematocrit values were also represented per time
point: before the surgery, on the day of the surgery—after the potential
intraoperative transfusions—and on the second and sixth postoperative
days (PO2, PO6).

Results

From the 120 eligible patients in the examined period, 116 signed
the informed consent form and were randomized: 57 patients to the
suggestion group and 59 to the control group. Based on the previously
410 CSENGE SZEVERÉNYI ET AL.

defined exclusion criteria, 21 of the 116 randomized patients were later

excluded from the analysis. Of the remaining 95 patients, 45 belonged
to the suggestion group and 50 to the control group.
Table 1 shows that there was no significant difference between
treatment groups in gender, age, and BMI. Furthermore, there was
also no significant difference between treatment groups in baseline
hemostasis laboratory parameters (INR, APTT, TT). There was also no
significant difference in the mean duration of the surgical intervention.
Furthermore, as was expected due to the stratified randomization, there
was no difference between treatment groups in the performed surgical
types and in the surgeons’ experience (see Tables 2 and 3).
The vast majority of the patients (more than 90%) received 0, 2, or
4 units of red blood. Very few patients received an odd number of
units (2 patients received 1 unit—1 each in the suggestion and control
groups; 3 patients received 3 units—1 in the suggestion group, 2 in the
control group). Furthermore, as expected, very few patients received
more than 4 units of blood (1 patient received 5 units, 2 received 6 units,
and 1 received 8 units—all in the control group). These subjects, as
described in the method section, were grouped with the subjects who
received 4 units.
Figure 1 displays the frequencies for the number of units of red blood
cells. It can be noted that most of the patients are in the two-unit cate-
gory in both groups (51% and 54%). However, the proportion of patients

Table 1
Demography, Baseline Characteristics, and Duration of Surgical Intervention

Suggestion Control Total

n = 45 n = 50 N = 95 p value

Mean age (SD), year 67.1 (7.50) 64.6 (9.98) 65.8 (8.94) .173
Mean BMI (SD), kg/m2 29.1 (4.33) 29.0 (4.64) 29.1 (4.47) .868
Male, n (%) 13 (29%) 18 (36%) 31 (32.6%) .46
Female, n (%) 32 (71%) 32 (64%) 64 (67.4%)
Mean Baseline 0.94 (0.051) 0.94 (0.055) 0.94 (0.052) .780
INR∗ (SD)
Mean Baseline 28.6 (2.82) 28.8 (2.54) 28.7 (2.67) .809
APTT∗ (SD), second
Mean Baseline 17.0 (1.66) 16.7 (1.47) 16.9 (1.57) .393
TT∗ (SD), second
Mean duration of 110.0 (28.9) 109.5 (27.26) 109.7 (27.9) .931
surgical
intervention (SD),
minute

Note. SD = Standard Deviation; BMI = body mass index, INR = International Normalized
Ratio; APTT = activated partial thromboplastin time; TT = Thrombin Time.
∗ Suggestion: n = 41, Control: n = 40.
 POSITIVE SUGGESTIONS’ EFFECT ON TRANSFUSION NEED 411

Table 2
Distribution of Patients by Type of Surgery Performed

Number of Patients (%)

Suggestion Control Total

Type of surgery n = 45 n = 50 N = 95

Noncemented hip 17 (37.8%) 18 (36.0%) 35 (36.8%)

Cemented hip 10 (22.2%) 12 (24.0%) 22 (23.2%)
Hybrid hip∗ 0 1 (2.0%) 1 (1.1%)
Knee 18 (40%) 19 (38.0%) 37 (38.9%)
∗ Hybrid hip: one component of the prosthesis is cemented, the other is noncemented.

Table 3
Distribution of Patients by the Experience of the Surgeon

Number of Patients (%)

Suggestion Control Total

Experience of the Surgeon n = 45 n = 50 N = 95

Experienced 33 (34.7%) 38 (40.0%) 71 (74.7%)

Inexperienced 12 (50.0%) 12 (50.0%) 24 (25.3%)

who did not need red blood cell transfusion is higher for the suggestion
group (42.2%) than for the control group (26%). Consistently, the pro-
portion of patients in the four-unit category is lower for the suggestion
group (6.7%) than for the control group (20%). The results of the ordinal
logistic regression indicate that less transfusion was needed in the sug-
gestion group: odds ratio (Suggestion Group vs. Control Group) of 2.369
(p value = .0036). Interesting to note that when looking at the intra- and
the postoperative transfusions separately, this significant difference in
the total number seems to be driven by the difference in both the intra-
and the postoperative transfusions (see Table 4).
There was no difference between treatment groups in hemoglobin
and in hematocrit measured before the operation, on the day of
the operation (after the transfusion), and on the second and sixth
postoperative days (see Figure 2).

Discussion

In our study, we found that the necessity for blood transfusions sig-
nificantly and clinically relevantly decreased in the suggestion group
compared to the control group. In other words, the same hemoglobin
and hematocrit level could be achieved with fewer transfusions in the
412 CSENGE SZEVERÉNYI ET AL.

Figure 1. Distribution of Patients by the Amount of Red Blood Cell Transfusion Received.

Table 4
Distribution of Patients by the Amount of Blood Transfused During and After
Operation

Number of Patients (%)

Suggestion Control Total

Number of units of red blood cell received n = 45 n = 50 N = 95

During Operation
0 36 (80.0%) 33 (66.0%) 69 (72.6%)
2 9 (20.0%) 16 (32.0%) 25 (26.3%)
4 0 1 (2.0%) 1 (1.1%)
After Operation
0 26 (57.8%) 23 (46.0%) 49 (51.6%)
2 18 (40.0%) 22 (44.0%) 40 (42.1%)
4 1 (2.2%) 5 (10.0%) 6 (6.3%)
Total
0 19 (42.2%) 13 (26.0%) 32 (33.7%)
2 23 (51.1%) 27 (54.0%) 50 (52.6%)
4 3 (6.7%) 10 (20.0%) 13 (13.7%)

suggestion group. This result is consistent with that of other studies

that dealt with the effectiveness of suggestions during the perioperative
period aiming to decrease blood loss (Enqvist et al., 1995; Hart, 1980;
Rapkin et al., 1991; Ross, 1982). The novelty of our results is that the
suggestions in our study were not given under hypnosis.
In our study, we did not induce hypnosis because our secondary
aim was to demonstrate that the applied communication method can
be learned and used by all doctors without being a hypnotherapist.
One possibility for further research is to test if formal hypnosis would
increase the effect and/or to test if the efficacy of the suggestion
 POSITIVE SUGGESTIONS’ EFFECT ON TRANSFUSION NEED 413

Figure 2. Hemoglobin and Hematocrit Levels Before and After the Surgery.

method is related to hypnotizability. A recent meta-analysis shows that,

although hypnosis effect sizes are usually higher than that of sugges-
tive interventions (without hypnosis), this difference is not significant
(Kekecs, Nagy, & Varga, 2014).
Also note that we cannot be sure whether the significant effect was
due to the suggestions given during the interview or via the audio-
taped material—although they might facilitate each other. In addition,
the verbal suggestions were semi-standardized discussions that may act
as a confounding variable due to the personalization. Another question
around the audiotaped material is whether the effect was really due to
the suggestions or to the more relaxed state. A further research possibil-
ity is to check the difference if one group receives only suggestions for
relaxation.
Another limitation of the study was the impossibility to blind the
study, since we wanted to have a “care as usual” group, where the
patients do not have additional discussions and do not listen to any
special audiotaped material but who hear the noises of the surgery.
Nevertheless, we do not believe that the fact that the caregivers poten-
tially could be aware of the randomized treatment group significantly
influenced the amount of blood transfused, first, because the indication
for red blood cell transfusions is strictly regulated in our department
and, second, because both the intraoperative and postoperative trans-
fusions decreased—whereas these are decided by different caregivers
(anesthesiologist vs. orthopedic surgeon on duty).

Conclusion

Hip and knee arthroplasties are long and stressful interventions

for the patients. The extent of intraoperative blood loss sometimes
414 CSENGE SZEVERÉNYI ET AL.

necessitates blood transfusions during and after the operation. Giving

blood to the patient has many risks and is expensive to the health care
institutes. In our study, we showed that positive suggestions applied
both before and during the surgery decrease the required units of red
blood transfused. The results are in line with other evidence indicating
that the recovery of the patients in stressful situations can be enhanced
by correctly applied suggestions (Kekecs & Varga, 2011; Varga, 2005).
Finally, their application is cheap and does not require extra time from
the physician. Thus, we propose this method as part of the daily work
in the clinical practice.

Funding

The mp3 players were bought by the University of Debrecen.

No other financial support was received.

References

Abbas, K., Murtaza, G., Umer, M., Rashid, H., & Qadir, I. (2012). Complications of total
hip replacement. Journal of College of Physicians and Surgeons Pakistan, 22, 575–578.
Ahmed, I., Chan, J., Jenkins, P., Brenkel, I., & Walmsley, P. (2012). Estimating
the transfusion risk following total knee arthroplasty. Orthopedics, 35, 1465–1471.
doi:10.3928/01477447-20120919-13
Ashton, C., Whitworth, G., Seldomridge, J., Shapiro, P., Weinberg, A., Michler, R., & Oz,
M. C. (1997). Self-hypnosis reduces anxiety following coronary artery bypass surgery:
A prospective, randomized trial. Journal of Cardiovascular Surgery, 38, 69–75.
Bejenke, C. J. (1996). Painful medical procedures. In J. Barber (Ed.), Hypnosis and suggestion
in the treatment of pain (pp. 209–265). New York, NY: W. W. Norton.
Charoencholvanich, K., & Siriwattanasakul, P. (2011). Tranexamic acid reduces blood loss
and blood transfusion after TKA: A prospective randomized controlled trial. Clinical
Orthopaedics and Related Research, 469, 2874–2880. doi:10.1007/s11999-011-1874-2
Cheek, D. B. (1969). Communication with the critically ill. American Journal of Clinical
Hypnosis, 12, 75–85. doi:10.1080/00029157.1969.10734309
Cowan, Jr., G., Buffington, C., Cowan, G., & Hathaway, D. (2001). Assessment
of the effects of a taped cognitive behavior message on postoperative compli-
cations (therapeutic suggestions under anesthesia). Obesity Surgery, 11, 589–593.
doi:10.1381/09608920160556779
de Jonge, T. (2012). Pharmacological reduction of bleeding during hip endoprosthetic
replacement. Orvosi Hetilap, 153, 1607–1612. doi:10.1556/OH.2012.29455
Disbrow, E., Bennett, H., & Owings, J. (1993). Effect of preoperative suggestion on
postoperative gastrointestinal motility. Western Journal of Medicine, 158, 488–492.
Eberhart, L., Döring, H., Holzrichter, P., Roscher, R., & Seeling, W. (1998).
Therapeutic suggestions given during neurolept-anaesthesia decrease post-
operative nausea and vomiting. European Journal of Anaesthesiology, 15, 446–452.
doi:10.1097/00003643-199807000-00010
Enqvist, B., von Konow, L., & Bystedt, H. (1995). Pre- and perioperative suggestion in
maxillofacial surgery: Effects on blood loss and recovery. International Journal of Clinical
and Experimental Hypnosis, 43, 284–294. doi:10.1080/00207149508409971
 POSITIVE SUGGESTIONS’ EFFECT ON TRANSFUSION NEED 415

European Medicines Agency (EMA). (2016). European Medicines Agency. Retrieved from
http://www.ema.europa.eu/ema/
Ewin, D. M. (2011). Laws of hypnotic suggestions. In K. Varga (Ed.), Beyond the words:
Communication and suggestion in medical practice (pp. 100–106). New York, NY: Nova
Science.
Ghoneim, M., Block, R., Sarasin, D., Davis, C., & Marchman, J. (2000). Tape-recorded hyp-
nosis instructions as adjuvant in the care of patients scheduled for third molar surgery.
Anesthesia & Analgesia, 90, 64–68. doi:10.1097/00000539-200001000-00016
Hart, R. (1980). The influence of a taped hypnotic induction treatment procedure on the
recovery of surgery patients. Psychiatric Medicine, 28, 324–332.
Jonas, S., Smith, H., Blair, P., Dacombe, P., & Weale, A. (2013). Factors influencing length of
stay following primary total knee replacement in a UK specialist orthopaedic centre.
The Knee, 20(5), 310–315.
Kekecs, Z., Jakubovics, E., Varga, K., & Gombos, K. (2014). Effects of patient education and
therapeutic suggestions on cataract surgery patients: A randomized controlled clinical
trial. Patient Education and Counseling, 94, 116–122. doi:10.1016/j.pec.2013.09.019
Kekecs, Z., Nagy, T., & Varga, K. (2014). The effectiveness of suggestive techniques in
reducing postoperative side effects: A meta-analysis of randomized controlled trials.
Anesthesia & Analgesia, 119, 1407–1419. doi:10.1213/ANE.0000000000000466
Kekecs, Z., & Varga, K. (2011). Pozitív szuggesztiós technikák a szomatikus orvoslás-
ban [Positive suggestion techniques in somatic medicine]. Orvosi Hetilap, 152, 96–106.
doi:10.1556/OH.2011.29015
Kekecs, Z., & Varga, K. (2013). Positive suggestion techniques in somatic medicine: A
review of the empirical studies. Interventional Medicine & Applied Science, 5, 101–111.
doi:10.1556/IMAS.5.2013.3.2
Kiss, G., & Butler, J. (2011). Hypnosis for cataract surgery in an American Society
of Anesthesiologists physical status IV patient. Anaesthesia and Intensive Care, 39,
1139–1141.
Klapow, J., Patterson, D., & Edwards, W. (1996). Hypnosis as an adjunct to medical care
in the management of Burger’s disease: A case report. American Journal of Clinical
Hypnosis, 38, 271–276. doi:10.1080/00029157.1996.10403351
Kotzé, A., Carter, L., & Scally, A. (2012). Effect of a patient blood management programme
on preoperative anaemia, transfusion rate, and outcome after primary hip or knee
arthroplasty: A quality improvement cycle. British Journal of Anaesthesia, 108, 943–952.
doi:10.1093/bja/aes135
Lang, E., Benotsch, E., Fick, L., Lutgendorf, S., Berbaum, M., Berbaum, K., & Spiegel, D.
(2000). Adjunctive non-pharmacological analgesia for invasive medical procedures: A
randomised trial. Lancet, 355, 1486–1490. doi:10.1016/S0140-6736(00)02162-0
Mauer, M., Burnett, K., Ouellette, E., Ironson, G., & Dandes, H. (1999). Medical hypnosis
and orthopedic hand surgery: Pain perception, postoperative recovery, and thera-
peutic comfort. International Journal of Clinical and Experimental Hypnosis, 47, 144–161.
doi:10.1080/00207149908410027
Meyer, E. C., & Lynn, S. J. (2011). Responding to hypnotic and nonhypnotic
suggestions: Performance standards, imaginative suggestibility, and response
expectancies. International Journal of Clinical and Experimental Hypnosis, 59, 327–349.
doi:10.1080/00207144.2011.570660
Miskovits, E. (2008). Transzfúziós Szabályzat [Transfusion regulation]. Budapest, Hungary:
Hungarian National Blood Transfusion Service.
Montgomery, G., Bovbjerg, D., Schnur, J., David, D., Goldfarb, A., Weltz, C., & Silverstein,
J. H. (2007). A randomized clinical trial of a brief hypnosis intervention to control side
effects in breast surgery patients. Journal of the National Cancer Institute, 99, 1304–1312.
doi:10.1093/jnci/djm106
416 CSENGE SZEVERÉNYI ET AL.

Montgomery, G., David, D., Winkel, G., Silverstein, J., & Bovbjerg, D. (2002). The effec-
tiveness of adjunctive hypnosis with surgical patients: A meta-analysis. Anesthesia &
Analgesia, 94, 1639–1645.
Nilsson, U., Rawal, N., Uneståhl, L., Zetterberg, C., & Unosson, M. (2001). Improved
recovery after music and therapeutic suggestions during general anaesthesia: A
double-blind randomised controlled trial. Acta Anaesthesiologica Scandinavica, 45,
812–817. doi:10.1034/j.1399-6576.2001.045007812.x
Noticewala, M., Nyce, J., Wang, W., Geller, J., & Macaulay, W. (2012). Predicting need
for allogeneic transfusion after total knee arthroplasty. The Journal of Arthroplasty, 27,
961–967. doi:10.1016/j.arth.2011.10.008
O’Shea, J., Dodd, L., Panayiotou, S., & Palmer, S. (2011). Self-induced hypnosis for bilat-
eral ankle arthroscopy. British Journal of Anaesthesia, 106, 282. doi:10.1093/bja/aeq387
Rapkin, D., Straubing, M., & Holroyd, J. (1991). Guided imagery, hypnosis and recov-
ery from head and neck cancer surgery: An exploratory study. International Journal of
Clinical and Experimental Hypnosis, 39, 215–226. doi:10.1080/00207149108409637
Reinhard, J., Hüsken-Janssen, H., Hatzmann, H., & Schiermaier, S. (2009). Changes in
resistance of the umbilical artery, foetal movements and short time variation through
clinical hypnosis–preliminary results. Zeitschrift Für Geburtshilfe Und Neonatologie, 3,
23–26. doi:10.1055/s-0028-1128127
Ross, D. (1982). The use of hypnosis in the control of surgical bleeding and post-operative
edema. Dissertation Abstracts International, 43, 1266.
Schlanger, J., Fritúz, G., & Varga, K. (2013). Therapeutic suggestion helps to cut back on
drug intake for mechanically ventilated patients in intensive care unit. Interventional
Medicine & Applied Science, 5, 145–152. doi:10.1556/IMAS.5.2013.4.1
Szeverenyi, C., Csernátony, Z., Balogh, A., & Varga, K. (2013). Examples of positive sug-
gestions given to patients undergoing orthopaedic surgeries. Interventional Medicine &
Applied Science, 5, 112–115. doi:10.1556/IMAS.5.2013.3.3
Szilágyi, A., Diószeghy, C., Benczur, L., & Varga, K. (2007). Effectiveness of psychological
support based on positive suggestion with the ventilated patient. European Journal of
Mental Health, 2, 149–170. doi:10.1556/EJMH.2.2007.2.2
Szilágyi, A., Diószeghy, C., Fritúz, G., Gál, J., & Varga, K. (2014). Shortening the
length of stay and mechanical ventilation time by using positive suggestions via
MP3 players for ventilated patients. Interventional Medicine & Applied Science, 6, 3–15.
doi:10.1556/IMAS.6.2014.1.1
Varga, K. (2005). Suggestive communication in somatic medicine. Budapest, Hungary:
National Institute for Addictions.
Varga, K. (2011). Beyond the words: Communication and suggestion in medical practice. New
York, NY: Nova Science.
Varga, K. (2013). Suggestive techniques connected to medical interventions. Interventional
Medicine & Applied Science, 5, 95–100. doi:10.1556/IMAS.5.2013.3.1
Varga, K., Diószeghy, C., & Fritúz, G. (2007). Suggestive communication
with the ventilated patient. European Journal of Mental Health, 2, 137–147.
doi:10.1556/EJMH.2.2007.2.1
Yang, Z., Chen, W., & Wu, L. (2012). Effectiveness and safety of tranexamic acid in reduc-
ing blood loss in total knee arthroplasty: A meta-analysis. Journal of Bone and Joint
Surgery, 94, 1153–1159. doi:10.2106/JBJS.K.00873
Zachariae, R., Oster, H., & Bjerring, P. (1994). Effects of hypnotic suggestions on ultraviolet
B radiation-induced erythema and skin blood flow. Photodermatology Photoimmunology
and Photomedicine, 10, 154–160.
 POSITIVE SUGGESTIONS’ EFFECT ON TRANSFUSION NEED 417

Effekte positiver Suggestionen im Falle der Notwendigkeit von

Bluttransfusionen bei orthopädischen Eingriffen

Csenge Szeverényi, Zoltán Csernátony, Ágnes Balogh, Tünde Simon, und

Katalin Varga
Abstract: Diese Studie untersuchte, ob positive Suggestionen, die periop-
erativ ohne hypnotische Induktion gegeben wurden, die Notwendigkeit
der Bluttransfusionen bei Patienten, bei denen eine Hüft-oder Knie-TEP
unter Spinalanästhesie eingesetzt wurde, reduzierten. Es wurde keine
hypnotische Erhebung durchgeführt. 59 Patienten wurden wahllos einer
Suggestionsgruppe (n = 45) und einer Kontrollgruppe (n = 50) zugeteilt.
Patienten der Suggestionsgruppe erhielten verbale Suggestionen vor und
aufgenommene Suggestionen während der Operation, um Blutverlust, Angst
und postoperative Schmerzen zu reduzieren und eine schnelle Heilung
zu fördern. Unsere Studie zeigte, daß die perioperative Anwendung pos-
itiver Suggestionen die Notwendigkeit von Bluttransfusionen signifikant
vermindert.
Stephanie Reigel, MD

Les effets de suggestions positives sur la nécessité d’une transfusion

sanguine pendant une chirurgie orthopédique

Csenge Szeverényi, Zoltán Csernátony, Ágnes Balogh, Tünde Simon et

Katalin Varga
Résumé: Cette étude a permis de vérifier si des suggestions positives
faites sans induction hypnotique pendant la période périopératoire peuvent
réduire le besoin d’une transfusion sanguine chez des patients subissant
une arthroplastie totale de la hanche ou du genou avec rachianesthésie.
Aucune évaluation hypnotique n’avait été effectuée au préalable. Quatre-
vingt-quinze patients ont été aléatoirement affectés au groupe recevant des
suggestions hypnotiques (n = 45) ou au groupe témoin (n = 50). Les sujets
du groupe affectés aux suggestions hypnotiques ont reçu celles-ci de façon
verbale avant la chirurgie et de façon enregistrée pendant la chirurgie,
ces suggestions visant à réduire la perte de sang, l’anxiété et la douleur
postopératoire, et à favoriser un rétablissement rapide. Notre étude a per-
mis de montrer que l’utilisation de suggestions positives pendant la période
périopératoire diminue significativement la nécessité d’une transfusion.
Johanne Reynault
C. Tr. (STIBC)

Efectos de sugerencias positivas sobre la necesidad de transfusión de

glóbulos rojos en cirugías ortopédicas.

Csenge Szeverényi, Zoltán Csernátony, Ágnes Balogh, Tünde Simon, y

Katalin Varga
Resumen: Este estudio examinó si sugerencias positivas transmitidas sin
inducción hipnótica en el periodo preoperatorio reducen la necesidad de
418 CSENGE SZEVERÉNYI ET AL.

transfusión de glóbulos rojos en pacientes sometidos a una artroplastia de

cadera o rodilla con anestesia epidural. No se realizó una evaluación hip-
nótica. Noventa y cinco pacientes fueron aleatoriamente asignados al grupo
de sugerencias (n = 45) o al control (n = 50). Los pacientes en el grupo experi-
mental recibieron sugerencias verbales antes de y sugerencias audiograbadas
durante la cirugía para la reducción de pérdida de sangre, ansiedad, dolor
postoperatorio y una recuperación rápida. Nuestro estudio mostró que el uso
de sugerencias positivas durante el periodo preoperatorio significativamente
reduce la necesidad de transfusión.
Omar Sánchez-Armáss Cappello
Autonomous University of San Luis Potosi,
Mexico