Best Practice & Research Clinical Anaesthesiology Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Acupuncture and related techniques are increasingly practised in anaesthesia. This paper reviewsthe current evidence and applicability of acupuncture and related techniques for anaestheticprocedures and postoperative nausea and vomiting. Recent evidence suggests that manualacupuncture is effective for reducing preoperative anxiety and for postoperative pain relief.
Current available data do not support the use of acupuncture as an adjunct to the generalanaesthetic in the intraoperative setting. There are extensive and good quality data to support theuse of P6 acupoint stimulation techniques for preventing postoperative nausea and vomiting incombination with or as an alternative to conventional anti-emetics. The use of acupuncture forlabour pain management appears promising but requires further research. Patient selection,acupoint selection, needling techniques, and mode of acupuncture need to be considered whenapplying acupuncture and related techniques in the perioperative setting. There are guidelines forthe conduct and reporting of acupuncture research, and these should be followed to improve thequality of studies.
Key words: evidence-based medicine; acupuncture; perioperative care; postoperative nauseaand vomiting; pain.
Acupuncture is an integral part of an ancient Chinese system of medicine that has beenused for more than 2500 years to treat diseases and relieve pain.The process ofacupuncture involves the use of small needles placed at specific points along the energymeridians in the body to regulate the flow of qi (vital energy) along these pathways tohelp restore the patient to health. Non-invasive techniques of acupuncture includemanual acupressure, acupressure wristbands, transcutaneous electrical stimulation,moxibustion, and laser stimulation. Compared to invasive manual acupuncture, * Corresponding author. Tel.: C852 2732 2735; fax: C852 2637 2422.
E-mail address: [email protected] (A. Lee).
1521-6896/$ - see front matter Q 2005 Elsevier Ltd. All rights reserved.
non-invasive stimulation techniques require less practitioner time spent directly withthe patient and facilitates standardization of acupoint stimulation.
Official reviews conducted in the United States, United Kingdom, Europe and Canada suggest that acupuncture appears to be effective for postoperative dental pain,postoperative nausea and vomiting (PONV), and chemotherapy-related nausea andFor chronic pain and neck pain, the evidence is considered inconclusive anddifficult to In the last decade, there has been growing interest in the use ofacupuncture and related techniques in anaesthesia. Although there is increasingevidence that acupuncture evokes changes via the nervous there is muchscepticism among anaesthetists about its effectiveness.
This paper reviews the current evidence and applicability of acupuncture and related techniques for anaesthetic procedures and PONV using an evidence-based approach.
For detailed background, theory, mechanism of action of acupuncture, andperioperative studies of acupuncture published to the end of 2003, the reader isreferred to a review by Chernyak and Sessler Methodological quality of primary acupuncture and related techniquestudies One of the arguments for not supporting the use of acupuncture in anaesthetic practiceis that the methodological rigour of clinical trials of acupuncture and related techniquesis generally poor.Some of the methodological flaws in clinical trials of acupuncture andrelated techniques are similar to randomised controlled trials in conventional medicine:inadequate allocation concealment, no blinding, and loss to follow-up. In addition tothese flaws, specific problems unique to acupuncture randomised controlled trials aretreatment effectsmatching sham control, and heterogeneity of acupoints. Theseissues are discussed in more detail below.
Treatment effects of complex non-pharmacological interventions In a conventional drug trial, diagnosis determines the eligibility for the trial and occursbefore the drug intervention. Talking and listening to the patient are separate from thedrug intervention. In comparison, treatment factors that are characteristic ofacupuncture include, in addition to the needling, the diagnostic process and aspectsof talking and listening to the patient (which may be different at each acupuncturesession). Therefore, it has been suggested that the use of placebo- or sham-controlledtrial designs for acupuncture interventions may lead to false-negative results. There is considerable controversy as to the appropriate placebo as a controlintervention in acupuncture studies. ‘Sham acupuncture’ (acupuncture at randompoints on the body surface that are thought to be inactive and are not located inthe meridian) is often used. A recent functional magnetic resonance imaging showed that acupuncture at Hegu LI4, a major analgesia acupoint, evoked specific activation inthe middle temporal gyrus and cerebellum, along with deactivation areas in the middlefrontal gyrus and inferior parietal lobule, compared with the effects of shamacupuncture.These findings suggest that real acupuncture induces specific patternsof brain activity different to sham acupuncture, which may explain the therapeuticeffects of real acupuncture.
Recent evidence suggests that the Streitberger needle is promising as a valid and convincing placebo needle for use in acupuncture trials.As the needle is pushed againstthe skin, it causes a pricking sensation, but as increased pressure is applied, the shaft ofthe needle disappears into the handle, giving the impression that the needle is actuallyentering the skin.Most patients were unable to discriminate between the realacupuncture needle and the Streitberger needle by penetration; however, only 60%found similarities between real acupuncture and placebo acupuncture.The authorsconcluded that further work on inter-tester reliability and standardization of techniqueis needed before the Streitberger needle is valid and reliable as a placebo needle.
Many different acupoints can be stimulated to treat the same disease or syndrome. Forexample, for PONV the Neiguan P6 is the most common single acupoint studied,although there are more than 30 classic acupoints described as being effective fornausea and vomiting. Such simplification may not always be appropriate and may resultin the treatment failure seen in many studies.The selection of acupoints is discussed inmore detail in the latter part of this chapter.
A recent guideline on design, implementation and reporting of clinical research on acupuncture and related techniques has been published and may improve the quality oftrials conducted in the Several complementary medicine journals have nowadapted the STRICTA guidelines to improve standards for reporting interventions incontrolled trials of acupuncture.These guidelines may lead to greater ease ininterpreting the results of trials and systematic review of acupuncture and relatedtechniques.
METHODOLOGICAL QUALITY OF SYSTEMATIC REVIEWS OF ACU-PUNCTURE AND RELATED TECHNIQUE STUDIES Anaesthetists are increasingly using systematic reviews for patient management. Aresystematic reviews of acupuncture and related techniques in the anaesthetic settingreliable? The answer is unclear as there are no data. However, a recent study showedthat the quality of reporting complementary and alternative medicine systematicreviews (acupuncture, homeopathy, cognitive behaviour therapy) is at least as good asthat found for conventional medicine, and is not affected by inclusion or exclusion oflanguage other than English.Publication bias may be problematic in systematic reviewof acupuncture, as one study found that all primary trials originating in China, Japan,Hong Kong and Taiwan were all positive.The implication of this is that the efficacy ofacupuncture may be over-estimated. As more systematic reviews of acupunctureand related techniques are published in anaesthesia, the quality of these systematicreviews and consideration of publication bias should be assessed.
In order to apply the evidence on acupuncture and related techniques, anaesthetistsmust know how to obtain this information efficiently. Good sources of informationabout acupuncture and related techniques include electronic searching of MEDLINE,EMBASE, the Cochrane Library and CISCOM database. The CISCOM database wasdeveloped by the United Kingdom Research Council for Complementary Medicine andcontains articles on complementary and alternative medicine published in the medicalliterature.Apart from the mainstream anaesthetic journals, the following journalshave published acupuncture and related techniques in the anaesthesia setting and maybe useful sources of evidence to consider: Acupuncture in Medicine, Journal of Alternativeand Complementary Medicine and Evidence-based Complementary and Alternative Medicine.
Convincing evidence from randomised controlled trials and systematic reviews ofperioperative applications of acupuncture and related techniques are available inanaesthesia. Below is a selection of current evidence published in the last 2 years (2004to September 2005). For earlier studies, refer to the review by Chernyak and Sessler.
Several randomised controlled trials of auricular acupuncture at ‘master cerebral point’,‘tranquilizer point’ and ‘relaxation’ suggest that it is effective for treatment ofpreoperative anxiety in surgical patients.More recently, auricular acupuncture hasbeen extended to parents of children undergoing surgery.Mothers of childrenundergoing general anaesthesia for outpatient surgery were randomised to auricularacupuncture or sham acupuncture (auricular press needles at the shoulder, wrist andextraneous auricular point). After induction, maternal anxiety in the acupuncturegroup, as measured by the State Trait Anxiety Inventory, was slightly lower than that inthe sham group (42.9G10 versus 49.5G11, respectively; PZ0.014). An importantoutcome of the study was that children whose mothers received the acupunctureintervention were significantly less anxious on entry to the operating room and duringintroduction of the anaesthesia mask. No side-effects were reported in the study.
More recently, the same group of investigators examined the effect of acupressure on the Yintang point (midpoint between the two eyebrows) on preoperative parentalanxietyParents were randomised to an acupressure bead with occlusive tapecovering at the Yintang point or sham acupressure above the lateral border of the lefteyebrow (same dermatomal distribution as the Yintang point) for 20 minutes in thepreoperative holding area. Parents in the acupressure group had significantly lessanxiety at 20 minutes post-intervention compared with parents in the sham group(37G10 versus 45G13, respectively, PZ0.03). The main advantage of acupressureover auricular acupuncture at the Yintang point for preoperative anxiety was that therewas less discomfort.
In contrast, there was no difference in the reduction of preoperative anxiety levels in a randomised controlled trial of acupuncture versus sham acupuncture at the Yintangpoint in patients undergoing minor or moderate surgeryThe differences in results between these studiesmay be due to different techniques and the way in whichanxiety was measured (State Trait Anxiety Inventoryand verbal score scaleIngeneral, the results appear to be favourable for the use of acupuncture and relatedtechniques for preoperative anxiety.
INTRAOPERATIVE ACUPUNCTURE-ASSISTED ANAESTHESIA Interest in the role of acupuncture for anaesthesia grew following the reports ofsurgery being performed with only acupuncture as an anaesthetic in China by Westernphysicians more than 30 years agoHowever, it became clear from subsequentresearch that acupuncture does not provide true anaesthesia or unconsciousness butrather provides analgesia and sedation.Nevertheless, on the basis of the involvementof endogenous opioid peptides along the pain pathway proposed by Pomeranz andChiufocus has shifted towards the role of acupuncture in reducing intraoperativeanaesthetic and opioid requirements.
In a recent review, Chernyak and Sessler concluded that although acupuncture may reduce the anaesthetic requirement in some volunteer studies, the reduction was notclinically important. In addition, intraoperative acupuncture stimulation did not alterthe analgesic requirement.This has been supported by the findings of another recentsystematic reviewwhere real acupuncture was not significantly different from placeboacupuncture as an adjunctive analgesic during surgery. This conclusion was latersupported by a recent well-designed randomised controlled trial by Usichenko et al.Although the German group had demonstrated a significant reduction in postoperativeanalgesic requirement and pain score in patients after total hip arthroplasty withauricular acupuncture, the intraoperative fentanyl requirement and duration of generalanaesthesia were similar in both acupuncture and control groups. Hence, thecurrently available data do not support the use of acupuncture as an adjunct to thegeneral anaesthetic in the intraoperative setting.
Recent evidencesuggests that acupuncture may be effective for postoperative painrelief, but it probably requires a high level of expertise and training of the practitioner. Ina recent randomised controlled trialpatients in the acupuncture group received presssteel needles at several points (hip joint, shenmen, lung and thalamus of the ipsilateralear) compared to the control group receiving sham needles on the non-acupuncturepoints of the helix, fixed with flesh-coloured adhesive tape. Compared with the controlgroup, the acupuncture group required significantly less analgesia (32%) during the first36 hours after surgery and had a longer time to first request for analgesia.Alsopatients in the acupuncture group had a significantly lower pain score at all timeintervals compared with sham controls.The success of blinding was confirmed in thisstudy as more than 80% of patients from both acupuncture and control groups believedthat they had received true acupuncture.
The overall incidence of PONV is reported to be about 38% and may reach 79% in high-risk patients.The current consensus strategy is to identify high-risk patients, avoidemetogenic stimuli, and use multimodal therapy.Acupuncture and related techniqueswere identified as important non-pharmacological interventions to consider.
Several reviews have confirmed the effectiveness of acupuncture and related techniques in preventing PONV at the P6 acupoint.Although the earlier reviewsuggested that acupuncture is ineffective for PONV in it became clear in asubsequent reviewthat acupuncture for PONV is as effective in children as in adults.
A plausible explanation is that acupuncture was administered after induction ofanaesthesia which failed to elicit the anti-emetic effect of acupunctureTheeffectiveness of acupuncture-related techniques for the prevention of PONV inchildren has been reaffirmed by recent studies.Two acupuncture-relatedtechniques were recently compared with anti-emetics in paediatric patients: laseracupuncture versus metoclopramide versus sham laserat P6 acupoint, andacustimulation with capsicum plaster versus ondansetron versus sham plaster at P6acupoint.In these randomised placebo-controlled trials, it was found that theseacupuncture-related techniques significantly reduced the incidence of PONV and wereas effective as the anti-emetics.In a separate randomised controlled trial oftranscutaneous electrical acupoint stimulation versus ondansetron versus control (notreatment), acupoint stimulation was effective for prevention of PONVMoreover, itseffect is comparable to ondansetron.The application of these acupuncture-relatedtechniques was initiated prior to induction of anaesthesia in all three paediatric studies,and there were very few side-effects.
However, there is a recent conflicting report on the timing of acupuncture stimulation in relation to the induction of anaesthesia. In a randomised placebo-controlled patient- and observer-blinded trial, Streitberger et alshowed nodifference between applying acupuncture before or after induction of anaesthesia.
The main finding was that acupuncture significantly reduced the incidence ofpostoperative vomiting, but not nausea, in patients undergoing gynaecological orbreast surgery. One plausible explanation for this conflicting result is that, as theauthors also suggested, Neiguan P6 is hardly the only point to prevent PONV, and thatother acupuncture points may be required to supplement the P6 effect In a study to evaluate the efficacy of transcutaneous electrical acupoint stimulation in combination with ondansetron, the device was most effective for reducing PONV whenapplied after plastic surgery rather than before surgeryUnlike many previous studiesof acupuncture and related techniques for prevention of PONV, patient satisfaction wasmeasured. Patients receiving peri- or postoperative acustimulation therapy hadsignificantly higher satisfaction with the quality of recovery and anti-emetic manage-ment than patients receiving preoperative acustimulation.As there is a paucity ofwell-designed studies with direct comparisons of the timing of acupoint stimulation,the question of when to apply acupoint stimulation remains unclear.
The use of acupuncture for postoperative laryngospasm and cardiovascularresuscitation has been reviewed, and the evidence does not support its use in thesesettings due to conflicting results or insufficient data.
In a randomised double-blind sham-controlled study, Park et showed that capsicum plaster on the Korean hand acupuncture point K-A20 significantly reducedthe incidence of postoperative sore throat compared with sham and placebo controlgroups (0 versus 16 and 19%, respectively). Although further evaluation is required, thisearly result appears to be promising and may be considered in patients with a high riskof developing postoperative sore throat, such as in patients with anticipated difficultairway intubation.
A systematic review of three randomised controlled trials of women in laboursuggests that acupuncture alleviates pain and reduces analgesic consumption comparedwith control groups (relative risk 0.36, 95% confidence interval 0.24–0.54). Commonacupoints used during labour in all three trials included in the systematic review were:Baihui GV20 (tension), Taichong LV3 (cervix rigidity), Kunlun UB60 (back pain in earlylabour), Ciliao UB32 (back pain later in labour) and Hegu LI4 and Sanyinjiao SP6 (strongpain during contractions). No adverse events were reported in any of the trials includedin the review.The authors concluded that the effectiveness of acupuncture for labourpain is promising but uncertain, mainly due to paucity of primary trials in the area.
Following the publication of the systematic review, acupressure at the SP6 acupoint for 30 minutes was effective for decreasing labour pain for up to 60 minutesafter the acupressure intervention—mean pain score in acupressure group versus sham(SP6 touch) group were 7.7G1.5 versus 8.9G1.7, respectively—but there was nodifference in the use of analgesia (PZ0.20).The total labour time (3 cm cervicaldilatation to full dilatation) was significantly shorter (P!0.01) in the Sanyinjiao SP6acupressure group (108G52 minutes) than in the sham group (146G61 minutes).Based on these findingsacupuncture and related techniques are promisinginterventions to consider for labour pain management.
GENERAL PRINCIPLES OF APPLYING ACUPUNCTUREAND RELATED TECHNIQUES Although a thorough understanding of the theory of traditional Chinese medicine isadvisable, there are several factors which should be considered when applyingacupuncture in the perioperative setting, including patient selection, acupoint selection,needling techniques, and mode of acupuncture.
Chernyak and Sessler have summarized some of the important aspects of patientselection for perioperative acupuncture and related techniques. Acupuncture in youngadults is generally more effective than in elderly patients, with the exception of smallchildren who would normally be uncooperative with Furthermore, a betterresult is expected from patients with a good attitude towards and faith in acupuncture,and acupuncture is less effective in severely ill patients. Moreover, approximately 10% ofpopulation are ‘non-responders’ in whom typical physiological responses cannot be elicited with acupuncture stimulation, and hence test needling prior to treatment isrecommended.
The detailed prescription of acupoint selection based on traditional Chinese medicine isbeyond the scope of this article. Nevertheless, the point selection in patients presentingfor anaesthesia would depend on the purpose of the acupuncture (such as analgesia orPONV), the patient’s overall condition, and the type of operation.
Yintang pointand auricular Shenmenare common points used for preoperative anxiolysis. For PONV, Neiguan P6 is commonly employed.However, one should note that due to the variation in patients’ conditions, differentaetiologies for the same symptoms, and other factors, it would be inappropriate toassume that one single or specific set of acupoints for the treatment of a diseasecondition will always be effective. For example, PONV may be drug-induced or surgery-related, and would have a different management approach, as in the case of strabismussurgery. Neiguan P6 acupressure prior to induction of anaesthesia was shown to beineffective in children undergoing strabismus surgery.However, the incidence ofPONV was significantly reduced after strabismus surgery in a randomised controlledtrial using acupoints for meridians associated with the eThese results suggestedthat PONV in strabismus surgery may be surgery-related rather than drug-induced.
The points chosen for acupuncture and related techniques can be considered at three levelsthe local points, the distant points, and the points along the course of theaffected meridian. Local points refer to the acupoints located near the affected area.
Wushu GB27, Weidao GB28, Qixue KI13 and Siman KI14 (acupoints located at thelower abdomen and groin, respectively) have been used as acupuncture anaesthesiaduring inguinal hernia repair in a small study.Some reactive acupoints, usually belowthe elbows and knees, are helpful for painful conditions at remote body regiForexample, Hegu LI4 (located between the thumb and index finger) is traditionally usedfor facial and oral pain; Zusanli ST36 (near the proximal tibia) is used for abdominal pain;Lieque LU7 (near the wrist at the radial side) is used for head and neck discomfort; andWeizhong BL40 (situated at the popliteal fossa) is helpful for back pain.Acupointsfrom the meridian that passes through the surgical area or the meridian stronglyassociated with the organ undergoing surgery (the ‘organ phenomenon’) can beselected for postoperative pain control. Moreover, back shu points of the viscera arelocated bilaterally 1.5 cun (about 2.5–3 cm) lateral to the posterior midline (the bladdermeridian) and may be useful for postoperative deep visceral In addition, the patient’s comfort and convenience have to be taken into account when selecting the acupoints. Therefore, acupoints located at the limbs and auricularpoints are usually preferable to those at the trunk. Nevertheless, preoperativeintradermal needle to the back shu points have been successfully used for postoperativeanalgesia as an adjunct to epidural morphine in patients undergoing abdominalsurgery.
In order to achieve a good effect of acupuncture, it is crucial to obtain De-qi duringneedling. De-qi (which means arrival of qi) refers to a specific sensation of soreness,numbness, distension or heaviness around the acupoint after the needle is inserted to a certain depth. At the same time, experienced acupuncturists may also feel tensenessand tightness around the needle.If the De-qi sensation cannot be obtained at needleinsertion, manual manipulation of the needle by twirling, rotating, lifting or thrusting isperformed until it is achieved. The De-qi sensation experienced by healthy volunteershas been verified and is different from the pain sensation from needle pricking.Indeed, increased skin blood flow to Hegu LI4 and Quchi LI11 (near the elbow) isassociated with De-qi sensation during acupuncture stimulation of Hegu LI4 involunteers.
Acupuncture-related techniques include: acupressure, electroacupuncture, transcu-taneous electrical acustimulation, laser acustimulation, and more recently, capsicumplaster acustimulation. Compared with manual acupuncture, these techniques have thefollowing advantages: (1) they are less painful and hence are more acceptable topatients, especially small children; (2) they require less specialist training; (3) they areless labour-intensive; and (4) they provide better analgesia when electroacupuncture isused. In a recent review, Rowbothamconcluded that various acupuncture-relatedtechniques are effective for the prevention of PONV, and as these techniques are nottime-consuming and do not required specially trained personnel, he has advocated theirwidespread use.
The analgesic effect of electroacupuncture was reported to be different according to the frequency of stimulation used, suggesting that different neurotransmitters areinvolved.High frequency (100 Hz) was reportedly to provide better postoperativepain control in patients undergoing abdominal surgery compared with low frequency(2 Acupressure and transcutaneous electrical acustimulation have a long historyand a favourable safety profile. Laser acustimulation (with the precaution of eyeprotection) was advocated for use in paediatric patients for the prevention of PONV.Capsicum plaster developed in Korea was found to be effective in PONV when appliedto the Korean hand acor at the Neiguan P6, and also for treatment ofpostoperative sore throat.As capsicum plaster is not readily available, the widespreaduse of this simple technique has yet to be determined.
Manual acupuncture requires specialist training and is labour-intensive and time-consuming, which limits its applicability in many units. However, recent evidencesuggests that manual acupuncture is effective for reducing preoperative anxiety and forpostoperative pain relief. Current available data do not support the use of acupunctureas an adjunct to the general anaesthetic in the intraoperative setting. The results fromrecent studies of non-invasive techniques and systematic reviews of acupointstimulation techniques suggest that they are effective for preventing postoperativenausea and vomiting in combination with—or as an alternative to—conventional anti-emetics. The use of acupuncture for labour pain management appears promising butrequires further research. Patient selection, acupoint selection, needling techniques andmode of acupuncture are important factors to consider when applying acupuncture andrelated techniques in the perioperative setting.
† guidelines to improve standards for reporting interventions in controlled trials of acupuncture and related techniques exist and should be followed in futurestudies † current available data do not support the use of acupuncture as an adjunct to the general anaesthetic in the intraoperative setting † there is extensive and good evidence to support the use of acupuncture and related techniques for the prevention of postoperative nausea and vomiting † patient selection, acupoint selection, needling techniques, and mode of acupuncture need to be considered when applying acupuncture and relatedtechniques in the perioperative setting † the quality of systematic reviews of perioperative applications of acupuncture † further research is warranted to evaluate the optimal timing (preoperative, postoperative, perioperative) of acupuncture and related techniques † the value of acupuncture and related techniques for treating postoperative † the efficacy of capsicum plaster acustimulation appears favourable but requires † the role of acupuncture for labour pain needs to be defined more clearly *1. Chernyak GV & Sessler DI. Perioperative acupuncture and related techniques. Anesthesiology 2005; 102: 2. Birch S, Hesselink JK, Jonkman FAM et al. Clinical research on acupuncture. Part 1. What have reviews of the efficacy and safety of acupuncture told us so far? J Altern Complem Med 2004; 10: 468–480.
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