The Efficacy of Acupuncture in Post-Operative Pain Management: A Systematic Review and Meta-Analysis. PLoS One. 2016;11:e0150367. [PMID: 26959661 PMCID: PMC4784927 DOI: 10.1371/journal.pone.0150367]

Acupuncture and Postoperative Pain Reduction

PURPOSE OF REVIEW

Acupuncture is an analgesic technique that has long been utilized in Eastern medicine. In recent times, various acupuncture techniques have been used in integrated pain management approaches in Western medicine. It has even been adopted as an analgesic method in surgical patients. Currently, no review exists regarding various acupuncture techniques used in perioperative pain management and data describing the utility of these techniques. This paper synthesizes the latest literature regarding the role of acupuncture in perioperative pain management. The authors sought to describe various acupuncture modalities used to help manage surgical pain and synthesize the current body of literature to help readers make informed judgements on the topic.

RECENT FINDINGS

Patients undergoing abdominal, spine/neuro, and gynecologic pelvic surgery generally benefit from acupuncture. Out of the various acupuncture techniques, electroacupuncture, transcutaneous electric acupoint stimulation, and traditional total body acupuncture seem to be most promising as adjuncts to multimodal perioperative analgesia. Benefits include improved analgesia and/or reduced narcotic requirements, decrease in PONV, and shorter time to return of bowel function. Acupuncture is a low-risk method that has the potential to enhance perioperative analgesia, decrease opioid requirement, and reduce unwanted side effects of anesthesia, surgery, and opioid administration such as nausea/vomiting. Given the variety of patient populations, various acupuncture techniques, and small patient populations for most current studies; it remains difficult to determine which acupuncture method would most benefit specific patients. Future studies with more robust sample sizes and prospective comparison on acupuncture technique would help better characterize acupuncture's role in perioperative pain management.

Effect of electroacupuncture on discomfort during gastroscopy: a study protocol for a randomized controlled trial

Background

Gastroscopy procedures are frequently performed under general sedation to minimize discomfort. Patients who refuse a sedative injection may experience more discomfort and adverse reactions such as pain and nausea. These instances reduce patient compliance and willingness to participate in future procedures. Acupuncture has been shown to have an anti-nausea and analgesic effect; however, there is limited data available that demonstrates the efficacy of acupuncture when applied before gastroscopy.

Methods

A total of 60 participants will be randomly assigned to the electroacupuncture (EA) group and the sham electroacupuncture (SEA) group at a ratio of 1:1. Acupuncture treatment will be performed before gastroscopy for a duration of 30 min. All patients will complete detailed questionnaires at 30 min and 7 days post-procedure to record the severity of their symptoms. The primary outcome will be the average of 4 standard visual analogue scale (VAS) scores in the categories of nausea, vomiting, throat discomfort, and agitation as reported by the patient. The secondary outcomes will be patient’s anxiety level as recorded by the 6-item short form of the State-Trait Anxiety Inventory (STAI-S6) and Amsterdam Pre-Operative Anxiety and Information Scale (APAIS), preference in a future endoscopy, pulse oxygen saturation (SpO2), heart rate (HR), and blood pressure (BP). Anxiety scales will be assessed before and after acupuncture; others will be completed at 30 min and 7 days post-procedure. The duration of the gastroscopy and the number of biopsies will be recorded after operation.

Discussion

This randomized controlled trial will explore the feasibility of the further clinical application of electroacupuncture for the improvement of patient discomfort during gastroscopy without systemic sedation.

Trial registration

ChiCTR2000040726. This trial has been approved by the Ethics Committee of Shanghai Municipal Hospital of Traditional Chinese Medicine (2020SHL-KY-11). Registration date 12 August 2020.

Acupuncture therapy as an Evidence-Based Nonpharmacologic Strategy for Comprehensive Acute Pain Care: the Academic Consortium Pain Task Force White Paper Update

Background

A crisis in pain management persists, as does the epidemic of opioid overdose deaths, addiction, and diversion. Pain medicine is meeting these challenges by returning to its origins: the Bonica model of multidisciplinary pain care. The 2018 Academic Consortium White Paper detailed the historical context and magnitude of the pain crisis and the evidence base for nonpharmacologic strategies. More than 50% of chronic opioid use begins in the acute pain care setting. Acupuncture may be able to reduce this risk.

Objective

This article updates the evidence base for acupuncture therapy for acute pain with a review of systematic reviews and meta-analyses on postsurgical/perioperative pain with opioid sparing and acute nonsurgical/trauma pain, including acute pain in the emergency department.

Methods

To update reviews cited in the 2018 White Paper, electronic searches were conducted in PubMed, MEDLINE, CINAHL, and the Cochrane Central Register of Controlled Trials for “acupuncture” and “acupuncture therapy” and “acute pain,” “surgery,” “peri-operative,” “trauma,” “emergency department,” “urgent care,” “review(s) ,” “systematic review,” “meta-analysis,” with additional manual review of titles, links, and reference lists.

Results

There are 22 systematic reviews, 17 with meta-analyses of acupuncture in acute pain settings, and a review for acute pain in the intensive care unit. There are additional studies of acupuncture in acute pain settings.

Conclusion

The majority of reviews found acupuncture therapy to be an efficacious strategy for acute pain, with potential to avoid or reduce opioid reliance. Future multicenter trials are needed to clarify the dosage and generalizability of acupuncture for acute pain in the emergency department. With an extremely low risk profile, acupuncture therapy is an important strategy in comprehensive acute pain care.

Patient Attitudes Toward Acupuncture in the Perioperative Setting

Introduction: Acupuncture is a potential treatment option for pain, nausea, vomiting, anxiety, and agitation in the perioperative period. Patient preference for participating in acupuncture in the perioperative period is not well understood. The aim of this study was to quantify patient interest in perioperative acupuncture, explore the relationship between acupuncture interest, insurance coverage and patient cost, and identify clinical factors associated with patient interest in acupuncture. Materials and Methods: Adult patients evaluated in the Preoperative Evaluation Clinic at the Mayo Clinic in Phoenix, AZ, between June 2019 and July 2019, received a voluntary survey to assess their attitudes toward receiving acupuncture in the perioperative period. Patient interest in acupuncture to help treat pain, anxiety, and postoperative nausea and vomiting, as well as their willingness to pay for such services, were assessed. Demographic data, American Society of Anesthesiologists (ASA) physical class, scheduled procedure, and insurance coverage were extracted from the medical record. Univariate analysis was performed to estimate interest in acupuncture. Results: Three hundred and seven respondents were included in this study with a response rate of 60.4%. A total of 68.4% of study participants were interested in receiving perioperative acupuncture. Of those interested in acupuncture, 86.7% were interested if acupuncture was offered at no cost (either free or fully covered by insurance). A total of 47.1% of those patients interested in acupuncture would be interested if the cost of acupuncture was between 20 and 50 U.S. dollars. A total of 8.6% would be interested in acupuncture if patients were expected to pay the full cost of treatment (estimated 175 U.S. dollars). Age, sex, ASA status, type of surgery, risk of procedure, and Medicare/Medicaid coverage were not statistically associated with interest in acupuncture. Conclusions: When there is little to no direct cost to the patient, the majority of patients are interested in acupuncture in the perioperative period.

The Role of Acupuncture in Relieving Post-Hemorrhoidectomy Pain: A Systematic Review of Randomized Controlled Trials

Background

Post-hemorrhoidectomy pain (PHP) remains one of the complications of hemorrhoidectomy and can delay patient's recovery. Current clinical guideline on PHP remains skeptical on the effectiveness of acupuncture, which has been applied for PHP in practice with inconsistent evidence.

Objectives

This systematic review aimed to evaluate the effectiveness of acupuncture on PHP by reviewing existing evidence.

Methods

Nine databases such as PubMed and Embase were searched for randomized controlled trials (RCTs) from inception to 30th September 2021. The outcome measures on pain level after hemorrhoidectomy, dose of rescue analgesic drug used, quality of life, adverse events, etc., were extracted and analyzed in a narrative approach.

Results

Four RCTs involving 275 patients were included in the analysis. One study showed that the visual analog scale (VAS) score was significantly lower in the electro-acupuncture (EA) group compared to that in the sham acupuncture (SA) group at 6, 24 h after surgery and during the first defecation (p < 0.05). Similar trends were found in the verbal rating scale (VRS) and Wong-Baker Faces scale (WBS) score but at different time points. Another study also found EA was effective on relieving pain during defecation up to 7 days after surgery when compared with local anesthetics (p < 0.05). However, two studies evaluating manual acupuncture (MA) compared with active medications for PHP showed inconsistent results on effectiveness. Variability was found in the quality of included studies.

Conclusions

Although benefit of acupuncture on PHP, especially EA on defecation after surgery, was observed at some time points, evidence on effectiveness of acupuncture on PHP was not conclusive.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, PROSPERO, identifier: CRD42018099961.

Understandings of acupuncture application and mechanisms

Acupuncture involves the stimulation of acupoints, which are located at specific sites of the human body, by insertion of fine metal needles, followed by manipulation. Acupuncture has been proven to be an effective treatment in pain relief. Available evidence showed that acupuncture alleviates acute pain in conditions such as postoperative pain, acute back pain, labour pain, primary dysmenorrhea, tension-type headaches and migraines. In addition, acupuncture relieves chronic pain, for example, low back pain (LBP), knee osteoarthritis (KOA), headache, shoulder pain, and neck pain. For other diseases like insomnia, drug addiction and stroke, more high-quality randomized control trials (RCTs) are needed to confirm the efficacy of acupuncture, although there are particular difficulties surrounding adequate blinding and control group designs. Recent biomedical technology unveils the mechanisms of acupuncture. Studies have found that adenosine triphosphate (ATP) and transient receptor potential vanilloid (TRPV) channels are involved in the stimulation of acupuncture at the acupoint area. In the central nervous system (CNS), neurotransmissions including opioids, serotonin, norepinephrine, orexin and endocannabinoid are modulated by acupuncture to induce analgesia. Moreover, acupuncture reduces cyclooxygenase-2 (COX-2) and prostaglandin E2 (PGE2) levels on the peripheral level by acting on the hypothalamic-pituitary-adrenal (HPA) axis, mediating peripheral opioid release. Acupuncture helps to treat insomnia by inhibiting sympathetic activity and down-regulating the HPA axis. Additionally, acupuncture reduces the effects of positive and negative reinforcements by modulating dopamine release in the nucleus accumbens. Recently, i-needles have been developed to allow for the analysis of metagenomics, meta-transcriptomics, and host-microbiome relationships following acupuncture, while skin implantable microsensors or needle-shaped microsensors are feasible for monitoring real-time microenvironmental changes in acupoints and even target organs. These studies may further accelerate the understanding of acupuncture's action mechanism.

Effect of Inpatient Integrative Medicine Consultation on 30-Day Readmission Rates: A Retrospective Observational Study at a Major U.S. Academic Hospital

Objectives: The prevalence of inpatient integrative medicine (IM) consult services is increasing among academic health care institutions. The diversity of services between institutions, as well as the novel nature of such interventions, makes it challenging for health care administrators to determine the cost/benefit of adding such a program to their institution. The main purpose of this study was to examine the performance of the new University of California, Los Angeles (UCLA) East-West (EW) consult service as measured by 30-day readmission rates and lengths of stay. Design: This is a retrospective observational case-control study with participants matched to themselves. Setting: UCLA Santa Monica Hospital, a 281-bed academic tertiary care hospital near Los Angeles, California. Subjects: Patients who had received an EW consultation during the inaugural 20 months of the program (2018-2020), and who had been hospitalized in the prior 2 years from the date of their first EW consult. Intervention: Inpatient East-West consultation, which may include counseling, acupuncture and/or trigger point injections depending on medical necessity. Outcome Measures: Thirty-day readmission rates and lengths of hospital admission were compared between the hospitalization that included an EW consult (which included the use of acupuncture and/or trigger point injections when appropriate) and any prior admissions during the 2 years before that EW consult. Secondary outcomes included quantitative analysis of average number of treatments and qualitative assessment of integrative treatment(s) received, conditions treated, and reasons that EW treatment may have been deferred during a consult. Results: One hundred sixty-five unique patients met the study criteria. The EW consultation was associated with clinically relevant, statistically significant decreased 30-day readmission rates (33.0% vs. 4.6%, p < 0.001, odds ratio [OR] 0.10, 95% confidence interval [CI] 0.06-0.17). This effect was similar when limiting the analysis to pain-related admissions (32.3% vs. 3.4%, p < 0.001, OR = 0.07, 95% CI 0.03-0.16). Hospital admissions with EW consults were found to have a statistically significant increased length of stay (7.03 days vs. 5.40 days, p < 0.001). Conclusion: The EW medicine, an example of IM, correlates with a reduced risk of 30-day readmission and with modestly increased lengths of stay.

Preoperative electroacupuncture for postoperative nausea and vomiting in laparoscopic gynecological surgery: a randomized controlled trial

Objective:

We aimed to evaluate the effectiveness and safety of preoperative electroacupuncture (EA) on the incidence of postoperative nausea and vomiting (PONV), and severity of postoperative pain, in gynecological patients undergoing laparoscopic surgery. The effects of EA administered at different preoperative time points were compared.

Methods:

A total of 413 patients undergoing elective laparoscopic gynecological surgery were randomly allocated into 4 groups receiving EA the day before surgery (Group Pre, n = 103), 30 min before (Group 30, n = 104) or both (Group Comb, n = 103), or usual care alone (Group Usual, n = 103). All acupuncture groups had usual care. The incidence of PONV and pain at 24 h were primary outcomes. Secondary outcomes included the severity of postoperative nausea, vomiting and pain, requirement for antiemetic medication and quality of recovery (QoR)-15 scores after surgery.

Results:

There were significant differences between the four groups in nausea and vomiting incidence (0–24 h), postoperative antiemetic use (0–48 h), and postoperative pain (0–6 h), with the EA groups recording the lowest levels. Regarding primary outcomes, incidence of nausea and vomiting at 6-24 h was 28/11/18/11% (p = 0.003) 23/5/8/9% (p < 0.001), respectively, for Groups Usual/Pre/30/Comb. Accordingly, EA reduced the incidence of nausea and vomiting at 6-24 h by 61/34/60% and 79/65/61% for Groups Pre/30/Comb, respectively. Regarding secondary outcomes, incidence of nausea and vomiting at 0-6 h was 20/9/11/7% (p = 0.013) and 17/7/9/6% (p = 0.021), respectively, for Groups Usual/Pre/30/Comb. Rescue antiemetics at 0–6 h were required by 18/4/11/4% (p = 0.001) in Groups Usual/Pre/30/Comb. The mean numerical rating scale (NRS) pain score (0–10) at 0–6 h was significantly different between groups (2.45/1.89/2.01/1.97 for Groups Usual/Pre/30/Comb, p = 0.024). There were no significant differences between the three EA-treated groups.

Conclusion:

In gynecological patients undergoing laparoscopic surgery and treated with multimodal antiemetic methods, one session of preoperative EA may be a safe adjunctive treatment for PONV prophylaxis. Optimal timing of EA requires further verification.

Trial registration number:

ChiCTR-INR-16010035 (Chinese Clinical Trial Registry).

Effectiveness of Acupuncture for Pain Control After Cesarean Delivery: A Randomized Clinical Trial

IMPORTANCE

A pharmacological approach to pain control after cesarean delivery is often insufficient on its own. Acupuncture is a promising method for mitigating postoperative pain and reducing postoperative opioid requirements.

OBJECTIVE

To evaluate the efficacy and effectiveness of acupuncture as an adjunctive therapy for pain control after cesarean delivery, compared with a placebo intervention and standard care alone.

DESIGN, SETTING, AND PARTICIPANTS

This single-center, placebo-controlled, patient- and assessor-blinded randomized clinical trial was conducted from January 13, 2015, to June 27, 2018, at a tertiary university hospital in Greifswald, Germany. Participants were women who were scheduled for elective cesarean delivery under spinal anesthesia and were randomized to either the acupuncture group (n = 60) or placebo group (n = 60). Another 60 consecutive patients who met the eligibility criteria and received the standard postoperative analgesia were selected to form a nonrandomized standard care group. The intention-to-treat analysis was performed from August 19, 2019, to September 13, 2019.

INTERVENTIONS

In addition to standard pain treatment, each patient in the acupuncture group received auricular and body acupuncture with indwelling intradermal needles, whereas patients in the placebo group were treated with nonpenetrating placebo needles.

MAIN OUTCOMES AND MEASURES

The primary outcome was pain intensity on movement, which was measured using an 11-item verbal rating scale. Secondary outcomes were analgesia-related adverse effects, analgesics consumption, time to mobilization and Foley catheter removal, quality of patient blinding to randomization, and patient satisfaction with treatment of pain.

RESULTS

A total of 180 female patients (mean [SD] age, 31 [5] years) were included in the intention-to-treat analysis. The mean pain intensity on movement in the acupuncture group on the first postoperative day was lower than in the placebo group (4.7 [1.8] vs 6.0 [2.0] points; Cohen d, 0.73; 95% CI, 0.31-1.01; P = .001) and the standard care group (6.3 [1.3] points; Cohen d, 1.01; 95% CI, 0.63-1.40; P < .001). On the first postoperative day, 59 patients (98%) in the acupuncture group were fully mobilized vs 49 patients (83%) in the placebo group (relative risk [RR], 1.18; 95% CI, 1.06-1.33; P = .01) and 35 patients (58%) in the standard care group (RR, 1.69; 95% CI, 1.36-2.09; P < .001). The Foley catheter was removed in a total of 57 patients (93%) from the acupuncture group vs 43 patients (72%) from the placebo group (RR, 1.33; 95% CI, 1.12-1.57; P = .003) and 42 patients (70%) from the standard care group (RR, 1.37; 95% CI, 1.14-1.62; P = .002). Other parameters were comparable across the 3 study groups.

CONCLUSIONS AND RELEVANCE

Results of this trial showed that acupuncture was safe and effective in reducing pain and accelerating mobilization of patients after cesarean delivery. With consideration for personnel and time expenditures, acupuncture can be recommended as routine, supplemental therapy for pain control in patients after elective cesarean delivery.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02364167.

Efficacy and Safety of Transcutaneous Electrical Acupoint Stimulation (TEAS) for Postoperative Pain in Laparoscopy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

This meta-analysis aimed to assess the efficacy and safety of transcutaneous acupoint electrical stimulation (TEAS) for postoperative pain in laparoscopy. The review has been registered on the "INPLASY" website and the registration number is INPLASY202150101.

METHODS

Relevant randomized controlled trials are selected from seven electronic databases (PubMed, the Cochrane Library, Embase, China National Knowledge Infrastructure, Chongqing VIP Information, WanFang Data, and Chinese Biomedical Database) from their inception up to November 30, 2020. Twenty-eight studies were included in this meta-analysis, and the statistical analyses and the exploration of heterogeneity sources were conducted by Stata 15.0 software. Besides, the bias assessment of the included studies was evaluated using the Cochrane risk of bias tool.

RESULTS

In total, 28 RCTs covering 2787 participants were included. The meta-analysis suggested that TEAS can effectively relieve pain in the short term after laparoscopy, reduce the postoperative consumption of rescue analgesics, improve the quality of life of patients, and shorten the length of hospitalization. And no serious adverse events are related to TEAS. Therefore, TEAS is relatively safe and efficacy for clinical application. The most used acupoints were Hegu (LI14), Neiguan (PC6), and Zusanli (ST36).

CONCLUSIONS

TEAS can be recommended as a complementary and alternative therapy for the treatment of postoperative pain after laparoscopy. However, the included RCTs had some methodological limitations. Therefore, larger-size, more rigorous, and higher-quality RCTs are needed in the future to further explore the efficacy and safety of TEAS for postoperative pain after laparoscopy.

Effects of non-pharmacological coping strategies for reducing labor pain: A systematic review and network meta-analysis

BACKGROUND

Facilitating the childbirth process is a global issue. Many strategies have been developed to cope with labor pain and improve the delivery experience and satisfaction of pregnant women. The results of different types of medical intervention on women's expectant pain have been varied. Therefore, this systematic review was aimed at summarizing the body of evidence regarding the effects of various non-pharmacological coping strategies for reducing labor pain.

METHODS

The review was conducted according to guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We systematically searched the articles published between 1989 and 2020 in six electronic databases: PubMed, MEDLINE, CINAHL, WOS, PsycARTICLES, and Airiti Library, and the reference lists of the Clinical Trial Registry. Twenty studies were identified, with eight eligible studies included in the Bayesian network meta-analysis.

RESULTS

Eight studies with 713 participants were included in the meta-analysis with nine different non-pharmacological strategies for reducing labor pain. The traditional meta-analysis demonstrated that the non-pharmacological coping strategies were effective in reducing labor pain. Of these interventional strategies, the ranking probabilities analysis of the network meta-analysis suggested that the Bonapace Method may be the most effective strategy in reducing labor pain, followed by acupressure.

CONCLUSIONS

Non-pharmacological coping strategies can reduce labor pain while maintaining an effective and satisfactory delivery experience. This systematic review, by synthesizing the body of evidence, demonstrated that non-pharmacological coping strategies are effective in reducing labor pain. Furthermore, as demonstrated in the network meta-analysis, the Bonapace Method, modulating birth pain by involving the father, is the most effective non-pharmacological intervention for reducing labor pain.

Comparative analysis of two laser wavelengths in the stimulation of acupuncture points for analgesic effects in an animal model

This study compares the effectiveness of two laser wavelengths for stimulating acupoints in an experimental model of acute postoperative pain. Forty-five Wistar rats were randomly assigned to receive treatment on their left hind paw, contralateral to a surgical procedure. Laser treatments were performed with Green Laser-GL (532 nm, 70 mW and 7 J/cm² of energy), Red Laser-RL (660 nm, 100 mW and 7 J/cm² of energy), or with Laser Off-LO. After each application, the animals were evaluated with a Von Frey analgesiometer to check for painful sensitivity on their right (with surgery) and left (without surgery) hind paws. Neuropeptides and cytokine levels in the incision site tissue of the right paw were measured by ELISA after 1, 6 and 24 hours. It was possible to observe that, in this pain model, both lasers promoted analgesia and that the GL altered the levels of TNF-α and IL-1β.

Comparison between acupuncture therapy and gabapentin for chronic pain: a pilot study

BACKGROUND

We examined whether the effect of true electroacupuncture on pain and functionality in chronic pain participants can be differentiated from that of medication (gabapentin) by analyzing quantitative sensory testing (QST).

METHODS

We recruited chronic back and neck pain participants who received six sessions (twice weekly) of true electroacupuncture versus sham electroacupuncture or 3 weeks of gabapentin versus placebo treatment. QST profiles, pain scores, and functionality profile were obtained at baseline (visit 1) and after three sessions (visit 4) or six sessions (visit 7) of acupuncture or 3 weeks of gabapentin or placebo.

RESULTS

A total of 50 participants were analyzed. We found no differences in QST profile changes (p = 0.892), pain reduction (p = 0.222), or functionality (p = 0.254) between the four groups. A major limitation of this pilot study was the limited number of study participants in each group.

CONCLUSION

This pilot study suggests that a large-scale clinical study with an adequate sample size would be warranted to compare acupuncture and medication therapy for chronic pain management.

TRIAL REGISTRATION NUMBER

NCT01678586 (ClinicalTrials.gov).

Transcutaneous electrical acupoint stimulation combined with electroacupuncture for rapid recovery of patients after laparotomy for gastrointestinal surgery: a study protocol for a randomised controlled trial

INTRODUCTION

Abdominal surgery is associated with common complications, including decreased or poor appetite, abdominal distension, abdominal pain caused by decreased or absent gastrointestinal motility, anal arrest with flatus and defecation, and nausea and vomiting resulting from the use of anaesthetics and opioid analgesics. These complications seriously affect postoperative recovery, prolong hospital stay and aggravate patient burden. This study aims to investigate for the first time the efficacy of transcutaneous electrical acupoint stimulation (TEAS) combined with electroacupuncture (EA) therapy for rapid recovery after laparotomy for gastrointestinal surgery. There have been no clinical studies of this combination therapy.

METHODS AND ANALYSIS

This will be a prospective, single-centre, three-arm, randomised controlled trial. A total of 480 patients undergoing abdominal surgery will be stratified according to surgery type (ie, gastric or colorectal procedure) and randomised into three groups; namely, the EA, TEAS +EA and control groups. The control group will receive enhanced recovery after surgery (ERAS)-standardised perioperative management, including preoperative education, optimising the anaesthesia scheme, avoiding intraoperative hypothermia, restrictive fluid infusion and reducing surgical trauma. The EA group will receive EA stimulation at LI4, PC6, ST36, ST37 and ST39 based on the ERAS-standardised perioperative management. Moreover, the TEAS +EA group will receive ERAS-standardised perioperative management; EA stimulation at the LI4, PC6, ST36, ST37 and ST39; and TEAS stimulation at ST21 and SP15. The primary outcome will be the GI-2 (composite outcome of time to first defaecation and time to tolerance of a solid diet). Secondary outcomes will include the time of first passage of flatus, time to first defaecation, time to tolerance of a solid diet, time to first ambulation, hospital duration from operation to discharge, pain and nausea vomiting scores on the Visual Analogue Scale, medication use, incidence of postoperative complications and evaluation of treatment modality acceptability. All statistical analyses will be performed based on the intention-to-treat principle.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Ethics Committee on Biomedical Research, West China Hospital of Sichuan University (approval number: 2021; number 52). The results are expected to be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2100045646.

Integrative traditional Chinese medicine for lumbar disc herniation after surgery: A protocol for systematic review and meta-analysis

BACKGROUND

Patients with lumbar disc herniation, who undergo spine surgery, occasionally complain of pain and functional disability. Fortunately, the concept of enhanced recovery after surgery has emerged recently. As a result, patients seek traditional Chinese medicine after spine surgery. This systematic review will thoroughly analyze and synthesize evidence on integrative traditional Chinese medicine therapy for lumbar disc herniation after surgery.

METHODS

The following databases will be utilized to search for pertinent studies: the Cochrane Central Register of Controlled Trials, MEDLINE/PubMed, EMBASE, Chinese National Knowledge Infrastructure, Japan Medical Abstracts Society, and 7 Korean databases (the Korean Studies Information Service System, Korean Association of Medical Journal Editors, National Digital Science Library, Database Periodical Information Academic Korean Traditional Knowledge Portal, Oriental Medicine Advanced Searching Integrated System, and Korean National Assembly Digital Library). The risk of bias of the selected studies will be assessed according to the Cochrane assessment tool for risk of bias. For articles that used the same measurements, a meta-analysis will be conducted to synthesize the results of each trial. Pain severity will be the primary outcome, while the results of functional questionnaires and range of motion, etc, will be the secondary outcomes.

RESULTS AND CONCLUSION

Since this protocol does not include any data from patients, ethics approval is not required. The results of this review will be disseminated through a peer-reviewed journal.

REGISTRATION NUMBER

DOI 10.17605/OSF.IO/KP47A (https://osf.io/kp47a).

Acupuncture against chronic postsurgical pain in non-small cell lung cancer patients: A protocol of randomized controlled trial

INTRODUCTION

Video-assisted thoracoscopic lobectomy is the prior recommended treatment for non-small cell lung cancer (NSCLC), with the advantages of small trauma, less postoperative pain, and quick recovery. However, a large number of patients may suffer chronic postsurgical pain (CPSP), which makes the patients unwilling to practice pulmonary exercises, and it would directly affect patient's cough, sputum expectoration, and mobility. Opioids could greatly improve the quality of postoperative analgesia and the quality of life after surgery, but it is accompanied with obvious side effects. A number of clinical studies have proved that acupuncture could improve postoperative pain and reduce opioid use. In this study, we try to conduct a randomized controlled study to evaluate the efficacy and safety of plum-blossom needle acupuncture combined with Tramadol in improving CPSP after lobectomy in NSCLC patients.

METHODS

Patients will be randomly divided into treatment group (acupuncture plus Tramadol) and control group (sham acupuncture plus Tramadol) with a random number table in 1:1 ratio. The patients, outcome assessor, and statistician will be blinded. The outcomes are changes of numerical rating scale, Karnofsky performance score, brief pain inventory, blood routine, liver and kidney function. The data will be analyzed by SPSS 22.0.

CONCLUSIONS

The results will help to evaluate the efficacy and safety of plum-blossom needle acupuncture in improving CPSP after lobectomy in NSCLC patients.

Postoperative pain after clitoral reconstruction in women with female genital mutilation: An evaluation of practices

INTRODUCTION

More than 200 million women and girls have undergone genital mutilation. Clitoral reconstruction (CR) can improve the quality of life of some of them, but is accompanied by significant postoperative pain.

OBJECTIVE

Assess and describe the management of postoperative pain after CR, and the practices amongst specialists in different countries.

METHODS

Between March and June 2020, 32 surgeons in 14 countries (Germany, Austria, Belgium, Burkina Faso, Canada, Ivory Coast, Egypt, Spain, United States of America, France, the Netherlands, Senegal, Switzerland, Sweden) responded to an online questionnaire on care and analgesic protocols for CR surgery.

RESULTS

At day 7 post CR, 97% of the surgeons observed pain amongst their patients, which persisted up to 1 month for half of them. 22% of the participants reported feeling powerless in the management of such pain. The analgesic treatments offered are mainly step II and anti-inflammatory drugs (61%). Screening for neuropathic pain is rare (3%), as is the use of pudendal nerve block, used by 8% of the care providers and only for a small percentage of women.

CONCLUSION

Pain after CR is frequent, long-lasting, and potentially an obstacle for the women who are willing to undergo clitoral surgery and also their surgeons. Most surgeons from different countries follow analgesic protocols that do not use the full available therapeutic possibilities. Early treatment of neuropathic pain, optimisation of dosing of standard analgesics, addition of opioids, use of acupuncture, and routine intraoperative use of pudendal nerve block might improve the management of pain after CR.

Postoperative pain: a review of emerging therapeutic options

INTRODUCTION

Postoperative pain is often managed by opioid medications, even though they carry a risk of adverse effects such as vomiting, constipation, sedation, respiratory depression and physical dependence. Furthermore, opioid use in the healthcare setting has likely contributed to the epidemic. However, the mismanagement of postoperative pain can result in delayed recovery time, impaired physical function, increased risk of morbidity and mortality, chronic pain, and higher healthcare costs.

AREAS COVERED

This review explores emerging therapeutic options and strategies in the management of acute postoperative pain and focuses on opioid-sparing, multimodal analgesia. This includes regional anesthetic techniques, non opioid pharmacotherapy, novel opioids and non-pharmacologic therapy. We have also discussed examples of novel analgesics and formulations which have potential benefits in reducing postoperative pain and opioid use after surgery.

EXPERT OPINION

The development of novel regional anesthesia techniques allows for opioid minimization in increasing number of surgical procedures. This synergizes with the availability of novel non-opioid analgesic adjucts. In addition, several novel opioid drugs have been developed which may be pathway selective and associated with less adverse effect than conventional opioids.

Integration of Doctor of Acupuncture and Oriental Medicine Students in a Trauma Center's Acute Pain Service: In-Person and Remote Training and Patient Care

Objective

Evidence of effectiveness and demand for acupuncture to treat acute pain conditions is growing, as is the need for acupuncturists trained to deliver patient care in a hospital setting. This articles describes collaboration between Bastyr University and Harborview Medical Center to incorporate Doctor of Acupuncture and Oriental Medicine (DAOM) students into a trauma hospital setting.

Materials and Methods

A model was developed to integrate DAOM students into an Anesthesiology Acute Pain Service to provide acupuncture to postoperative inpatients. That in-person model pivoted to remote student education and patient self-care education during the COVID 19 outbreak. A review was conducted of 323 consecutive patients who received acupuncture while they were hospitalized.

Results

The review of 323 consecutive patients who received acupuncture for pain during their hospital admission indicated that as few as one acupuncture treatment resulted in clinically significant benefits. No serious complications or safety concerns were reported.

Conclusions

Collaboration between academic and clinical programs can provide the structure to integrate acupuncture into hospital settings safely and with benefit to patients and students.

Clinical and Economic Evaluation of Acupuncture for Opioid-Dependent Patients Receiving Methadone Maintenance Treatment: The Integrative Clinical Trial and Evidence-Based Data

Objective: From the health care and societal perspectives, this study aimed to evaluate the clinical and economic effects of acupuncture as an adjunctive therapy for patients receiving methadone maintenance treatment (MMT). Methods: We conducted a parallel-arm RCT in China in 2019. Patients were included who met the diagnostic criteria and receive MMT for more than 30 days. Patients were randomly assigned to the exposed group (acupuncture plus MMT) or control group (MMT) at a 1:1 ratio. Daily methadone dosage, drug cravings using the VAS score, and insomnia using the Pittsburgh Sleep Quality Index (PSQI) were chosen as the effectiveness indexes, and the quality-adjusted life years (QALYs) was chosen as the utility index. Results: Overall, 123 patients were included. The exposed group was significantly (P < 0.05) better than the control group in the improvement of daily methadone dosage (17.68 vs. 1.07), VAS (38.27 vs. 2.64), and PSQI (2.18 vs. 0.30). The QALY was 0.0784 (95%CI: 0.0761-0.0808) for the exposed group and 0.0762 (95%CI: 0.0738-0.0787) for the control group. The total cost of the exposed group (2869.50 CNY) was higher than the control group (2186.04 CNY). The ICER of daily methadone dosage (41.15), VAS (17.86), and PSQI (313.51) were shown to be economically efficient. While ICUR (310,663.64 CNY/QYLY) was higher than the cost suggested by WHO. Conclusion: Acupuncture as an adjuvant therapy for MMT patients realizes its cost-effectiveness by reducing the dosage of methadone, improving drug cravings, and alleviating insomnia. It helps to improve quality of life, but since its cost exceeds what society is willing to pay, further study is needed.

Strategies for Optimizing Perioperative Pain Management for the Cancer Patient

Effective management of pain in patients with cancer impacts quality of life and willingness to receive disease-directed treatment. This review focuses on preoperative, intraoperative, and postoperative strategies for management of perioperative pain in the patient with cancer. Managing perioperative pain in special populations, including patients with preoperative opioid use, those with a history of substance abuse, and patients near the end of life are also addressed.

The efficacy and safety of transcutaneous electrical acupoint stimulation (TEAS) for postoperative pain in laparoscopy: A protocol for systematic review and meta-analysis of randomized controlled trials

BACKGROUND

With the promotion of the concept of "minimally invasive" surgery, the advantages of laparoscopic surgery are increasingly manifested. However, the postoperative pain of laparoscopic surgery brings difficulties and challenges to patients' rehabilitation. Transcutaneous electrical acupoint stimulation (TEAS) is a non-invasive treatment, which can exert the dual efficacy of acupuncture and electrical stimulation. The efficacy and safety of TEAS for postoperative pain after laparoscopy based on randomized controlled trials (RCTs) need to further evaluate.

METHODS

A comprehensive and systematic literature searching will mainly perform on 7 electronic databases (PubMed, the Cochrane Library, Embase, China National Knowledge Infrastructure, Chongqing VIP Information, WanFang Data, and Chinese Biomedical Database) from their inception up to November 30, 2020. We will also search for ongoing or unpublished studies from other websites (eg, PROSPERO, ClinicalTrials.gov, and Chinese Clinical Trial Registry) and do manual retrieval for potential gray literature. Only the relevant RCTs published in English or Chinese were included. Two independent investigators will independently complete literature selection, assessment of risk bias, and data extraction, the disagreements will be discussed with the third party for final decisions. The primary outcome measures: the pain intensity (eg, VAS) and the consumption of postoperative analgesics. The secondary outcome measures: the postoperative quality of life, the duration of hospitalization, and the incidence of adverse reactions and serious events. Assessment of bias risk will follow the Cochrane risk of bias tool. Data processing will be conducted by Stata 15.0 software.

RESULTS

We will evaluate the efficacy and safety of TEAS for postoperative pain after laparoscopy based on RCTs.

CONCLUSION

This study can provide more comprehensive and strong evidence of whether TEAS is efficacy and safe for postoperative pain in laparoscopic surgery.

Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations

OBJECTIVE

Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families.

PURPOSE

The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed.This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients.

ACTION STATEMENTS

The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method.The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.

Do acupuncture services reduce subsequent utilization of opioids and surgical interventions compared to noninvasive therapies among patients with pain conditions?

OBJECTIVE

To compare prescribed opioid use and invasive surgical interventions between patients using acupuncture and those using non-steroidal anti-inflammatory drugs (NSAIDs)/Physical Therapy (PT).

DESIGN

Retrospective observational study of administrative claims.

SETTING

Large commercial insurance plan.

SUBJECTS

52,346 each treated with either acupuncture or NSAIDs/PT.

METHODS

Users of acupuncture and NSAIDs/PT were identified from January 1, 2014 to December 31, 2017. The first date of each service was defined as the index date. Acupuncture patients were 1:1 propensity score matched to the NSAIDs/PT group on baseline characteristics. Outcomes included opioid use, subsequent invasive surgical procedures, healthcare utilization such as hospitalizations or emergency department (ED) visits, and costs. These were assessed in the 12-month period before index date (baseline) and 12-month period following index date (follow-up) using difference-in-difference (DID) analysis. Results for opioid use were stratified by those with and without baseline opioid use.

RESULTS

The acupuncture group had fewer patients initiating opioids post-index both among those with (49.2% vs. 56.5%, p < 0.001) and without (15.9% vs. 22.6%, p < 0.001) baseline opioid use. There was a small increase in invasive surgical procedures with acupuncture (3.1% vs. 2.8% p = 0.006). A reduction in ED visits was observed with acupuncture (DID -4.3% for all-cause; -3.3% for pain-related, all p < 0.001). Acupuncture was associated with higher total medical and pharmacy costs (DID +$1,331 per patient, p = 0.006).

CONCLUSIONS

Acupuncture showed a modest effect in reducing opioid use and ED visits. More research on acupuncture's place in emergency care, pain relief, and comparison to other types of non-opioid treatment is needed.

Acupuncture combined with multidisciplinary care for recovery after traumatic multiple rib fractures: a prospective feasibility cohort study

INTRODUCTION

Acute pain significantly delays early physiological recovery and results in chronic functional disability in patients with traumatic multiple rib fractures (MRFs). This prospective cohort study aimed to investigate the feasibility of acupuncture combined with multidisciplinary care during recovery in patients with traumatic MRFs.

METHODS

Twenty patients with traumatic MRFs who were admitted to a regional trauma centre in South Korea were enrolled. A combination of acupuncture and multidisciplinary inpatient ward management was provided at the trauma ward. Patients were permitted to continue acupuncture treatments at outpatient clinics for 3 months after the traumatic events. Clinical outcomes, including pain, acute physiological recovery, quality of life, patient satisfaction with the care provided, respiratory function and use of opioids, were evaluated up to 6 months after trauma.

RESULTS

Seventeen (85%) participants completed the 6-month follow-up. One patient withdrew consent during admission due to discomfort after three sessions of acupuncture. The proportion of patients with above-moderate level of pain decreased from 95% at baseline to 41% at 6 months. Quality of life appeared to deteriorate consistently throughout the study period. Around 80% of respondents expressed satisfaction with the acupuncture treatments and stated that they found acupuncture to be acceptable. Over 94% of respondents reported slight or considerable improvement.

CONCLUSION

The provision of acupuncture combined with multidisciplinary care for recovery in patients with traumatic MRFs was feasible in a regional trauma centre in South Korea. Randomised trials are needed to investigate the role of acupuncture combined with multidisciplinary care in the future.

TRIAL REGISTRATION NUMBER

KCT0002911 (Clinical Research Information Service).

Risks and Safety of Extended Auricular Therapy: A Review of Reviews and Case Reports of Adverse Events

OBJECTIVE

Auricular acupuncture (AA) and extended auricular therapy (AT) are a part of acupuncture practice shown to benefit patients with pain, anxiety, and other conditions, with cost-effective access enhanced when given in a group setting. Yet there are safety concerns and risks, perhaps unnecessary risks, that attend embedded, indwelling needles applied to the ear as a means of extended AT.

METHODS

Electronic searches were conducted in PubMed, MEDLINE, CINAHL and Cochrane Central Register of Controlled Trials (CENTRAL) for "auriculotherapy," "auricular acupuncture" or "auricular acupressure," "safety," "adverse events," "chondritis," and "perichondritis," with additional manual review of titles, links, and reference lists. Individual auricular therapy adverse event (AE) case reports were included, as well as systematic reviews and or meta-analyses if they evaluated AEs associated with AT.

RESULTS

Nineteen auricular AE case reports and nine safety reviews of or including auriculotherapy were included. Ten systematic reviews of AT with eight specific reviews of auricular acupressure (AP) were also included.

CONCLUSIONS

The primary AE risks is infection, perichondritis, and chondritis stemming from embedded or indwelling needles or potential inadvertent needlesticks from contaminated roaming sharps. Extended AP i.e., application of spheres, preferably seeds (natural, nontoxic botanical Vaccaria seeds) provides clinical benefit without the risks associated with embedded needles. More research is needed to establish if embedded needles at the ear are even necessary or have any advantage over in-session auricular acupuncture for immediate pain relief followed by ear acupressure.

American Society of Hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain

BACKGROUND

The management of acute and chronic pain for individuals living with sickle cell disease (SCD) is a clinical challenge. This reflects the paucity of clinical SCD pain research and limited understanding of the complex biological differences between acute and chronic pain. These issues collectively create barriers to effective, targeted interventions. Optimal pain management requires interdisciplinary care.

OBJECTIVE

These evidence-based guidelines developed by the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in pain management decisions for children and adults with SCD.

METHODS

ASH formed a multidisciplinary panel, including 2 patient representatives, that was thoroughly vetted to minimize bias from conflicts of interest. The Mayo Evidence-Based Practice Research Program supported the guideline development process, including updating or performing systematic reviews. Clinical questions and outcomes were prioritized according to importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE evidence-to-decision frameworks, to assess evidence and make recommendations, which were subject to public comment.

RESULTS

The panel reached consensus on 18 recommendations specific to acute and chronic pain. The recommendations reflect a broad pain management approach, encompassing pharmacological and nonpharmacological interventions and analgesic delivery.

CONCLUSIONS

Because of low-certainty evidence and closely balanced benefits and harms, most recommendations are conditional. Patient preferences should drive clinical decisions. Policymaking, including that by payers, will require substantial debate and input from stakeholders. Randomized controlled trials and comparative-effectiveness studies are needed for chronic opioid therapy, nonopioid therapies, and nonpharmacological interventions.

Acupuncture for blunt chest trauma: A protocol for a double-blind randomized control trial

INTRODUCTION

Blunt chest trauma (BCT) accounts for up to 65% of polytrauma patients. In patients with 0 to 2 rib fractures, treatment interventions are typically limited to oral analgesics and breathing exercises. Patients suffering from BCT experience symptoms of severe pain, poor sleep, and inability to perform simple daily life activities for an extended period of time thereafter. In this trial, we aim to investigate the efficacy of acupuncture as a functional and reliable treatment option for blunt chest trauma patients.

METHODS

The study is designed as a double-blind randomized control trial. We will include 72 patients divided into 2 groups; the acupuncture group (Acu) and placebo group (Con). The acupuncture group will receive true acupuncture using a uniquely designed press tack needle. The control group will receive placebo acupuncture treatment through the use of a similarly designed press tack needle without the needle element. The acupoints selected for both groups are GB 34, GB 36, LI 4, LU 7, ST 36, and TH 5. Both groups will receive 1 treatment only following the initial visit to the medical facility and upon diagnosis of BCT. Patient outcome measurements include: Numerical Rating Scale, Face Rating Scale, respiratory function flowmeter, Verran Snyder-Halpern sleep scale, and the total amount of allopathic medication used. Follow-up time will be scheduled at 4 days, 2 weeks, and lastly 3 months.

EXPECTED OUTCOME

The results of this study can potentially provide a simple and cost-effective analgesic solution to blunt chest trauma patients. This novel study design can serve as supporting evidence for future double-blind studies within the field of acupuncture.

OTHER INFORMATION

The study will be conducted in the thoracic surgical department and acupuncture department in China Medical University Hospital, Taichung, Taiwan. The study will be conducted on blunt chest trauma patients and is anticipated to have minimum risk of adverse events. Enrollment of the patients and data collection will start from March 2020. Study completion time is expected in March 2022.

PROTOCOL REGISTRATION

(CMUH109-REC1-002), (NCT04318496).

Healthcare Professionals' Attitudes to Integration of Acupuncture in Western Medicine: A Mixed-Method Systematic Review

BACKGROUND

Acupuncture is practiced in many Western countries with increasing evidence supporting its use across the healthcare system. However, this nonpharmacological intervention is yet to be widely integrated into hospitals. Fundamental to the integration of any innovation into healthcare systems is the attitudes of healthcare professionals.

AIMS

To explore healthcare professionals' attitudes towards acupuncture and identify the enablers and barriers to integration in the hospital setting.

DESIGN

This review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines; we conducted a mixed-method systematic review following Joanna Briggs Institute Reviewer's Manual 2017.

DATA SOURCES

PubMed, CINAHL, AMED, EMBASE, Cochrane Library, and SCOPUS were searched from their inception to December 2019 using different combination of keywords.

METHODS

Attitude and perception data were extracted from the articles and constructs were categorized as barriers and enablers. A convergent integrated approach was adopted whereby qualitative data themes were integrated with quantitative data constructs to generate descriptive codes around enablers and barriers at intrapersonal, interpersonal, and environmental levels according to the framework proposed by Manias et al. (2014).

RESULTS

Twenty-six studies comprising 19 survey and seven interview studies were identified, with 24 articles (92%) reporting positive attitudes, supporting the integration of acupuncture into Western medicine. Enablers identified were prior positive experience, belief in the treatment's efficacy, and patient demand. Barriers were lack of evidentiary knowledge or experience; lack of resources such as time, providers, and funding; and paradigm differences. Twenty studies (77%) focused on medical doctors or medical student perceptions. A conceptual framework for implementing and integrating acupuncture into Western medicine is proposed.

CONCLUSION

Healthcare professionals' attitudes to acupuncture are positive. Barriers to integrating acupuncture into the hospital system exist at intrapersonal, interpersonal, and external levels, with lack of resources being the key barrier. Nurses' role in facilitating integration into Western medical pain management practice provides an avenue for future research. The proposed conceptual framework provides guidance for nursing researchers interested in the role of acupuncture and integrated medicine in patient-centric, value-based healthcare.

Significant Pain Reduction in Hospitalized Patients Receiving Integrative Medicine Interventions by Clinical Population and Accounting for Pain Medication

Background: Prior research has reported that integrative medicine (IM) therapies reduce pain in inpatients, but without controlling for important variables. Here, the authors extend prior research by assessing pain reduction while accounting for each patient's pain medication status and clinical population. Methods: The initial data set consisted of 7,106 inpatient admissions, aged ≥18 years, between July 16, 2012, and December 15, 2014. Patients' electronic health records were used to obtain data on demographic, clinical measures, and pain medication status during IM. Results: The final data set included first IM therapies delivered during 3,635 admissions. Unadjusted average pre-IM pain was 5.33 (95% confidence interval [CI]: 5.26 to 5.41) and post-IM pain was 3.31 (95% CI: 3.23 to 3.40) on a 0-10 scale. Pain change adjusted for severity of illness, clinical population, sex, treatment, and pain medication status during IM was significant and clinically meaningful with an average reduction of -1.97 points (95% CI: -2.06 to -1.86) following IM. Adjusted average pain was reduced in all clinical populations, with largest and smallest pain reductions in maternity care (-2.34 points [95% CI: -2.56 to -2.14]) and orthopedic (-1.71 points [95% CI: -1.98 to -1.44]) populations. Pain medication status did not have a statistically significant association on pain change. Decreases were observed regardless of whether patients were taking narcotic medications and/or nonsteroidal anti-inflammatory drugs versus no pain medications. Conclusions: For the first time, inpatients receiving IM reported significant and clinically meaningful pain reductions during a first IM session while accounting for pain medications and across clinical populations. Future implementation research should be conducted to optimize identification/referral/delivery of IM therapies within hospitals. Clinical Trials.gov #NCT02190240.

Chinese Association for the Study of Pain: Expert consensus on chronic postsurgical pain

Chronic postsurgical pain is a common surgical complication that severely reduces a patient’s quality of life. Many perioperative interventions and management strategies have been developed for reducing and managing chronic postsurgical pain. Under the leadership of the Chinese Association for the Study of Pain, an editorial committee was formed for chronic postsurgical pain diagnosis and treatment by experts in relevant fields. The editorial committee composed the main content and framework of this consensus and established a working group. The working group conducted literature review (1989-2020) using key words such as “surgery”, “post-surgical”, “post-operative”, “pain”, “chronic”, and “persistent” in different databases including MEDLINE, EMBASE, PubMed, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews. Only publications in the English language were included. The types of literature included systematic reviews, randomized controlled studies, cohort studies and case reports. This consensus was written based on clinical practice combined with literature evidence. The first draft of the consensus was rigorously reviewed and edited by all the editorial committee experts before being finalized. The level of evidence was assessed by methodological experts based on the Oxford Centre for Evidence-Based Medicine Levels of Evidence. The strength of recommendation was evaluated by all editorial committee experts, and the opinions of most experts were adopted as the final decision. The recommendation level “strong” generally refers to recommendations based on high-level evidence and consistency between clinical behavior and expected results. The recommendation level “weak” generally refers to the uncertainty between clinical behavior and expected results based on low-level evidence.

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.

Optimizing Pain Control and Minimizing Opioid Use in Trauma Patients

Adverse effects of opioids and the ongoing crisis of opioid abuse have prompted providers to reduce prescribing opioids and increase use of multiple nonpharmacologic therapies, nonopioid analgesics, and co-analgesics for pain management in trauma patients. Nonopioid agents, including acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, central α2 agonists, and lidocaine, can be used as adjuncts or alternatives to opioids in the trauma population. Complementary therapies such as acupuncture, virtual reality, and mirror therapy are modalities that also may be helpful in reducing pain. Performing pain assessments is fundamental to identify pain and evaluate treatment effectiveness in the critically ill trauma patient. The efficacy, safety, and availability of opioid-sparing therapies and multimodal pain regimens are reviewed.

Efficacy and safety of acupuncture treatment as an adjunctive therapy after knee replacement: Single-center, pragmatic, randomized, assessor blinded, pilot study

INTRODUCTION

Total knee replacement (TKR) is a surgical procedure that is being increasingly performed as a result of population aging and the increased average human life expectancy in South Korea. Consistent with the growing number of TKR procedures, the number of patients seeking acupuncture for relief from adverse effects, effective pain management, and the enhancement of rehabilitative therapy effects and bodily function after TKR has also been increasing. Thus, an objective examination of the evidence regarding the safety and efficacy of acupuncture treatments is essential. The aim of this study is to verify the hypothesis that the concurrent use of acupuncture treatment and usual care after TKR is more effective, safe, and cost-effective for the relief of TKR symptoms than usual care therapy alone.

METHODS/DESIGN

This is an open-label, parallel, assessor-blinded randomized controlled trial that includes 50 patients with TKR. After screening the patients and receiving informed consent, the patients are divided into two groups (usual care + acupuncture group and usual care group); the patients will then undergo TKR surgery and will be hospitalized for 2 weeks. The patients will receive a total of 8 acupuncture treatments over 2 weeks after surgery and will be followed up at 3, 4, and 12 weeks after the end of the intervention. The primary outcome is assessed using the Korean version of the Western Ontario and McMaster Universities Arthritis Index (K-WOMAC), and the secondary outcome is measured using the Numerical Rating Scale (NRS), Risk of Fall, and Range of Motion (ROM). Moreover, the cost per quality-adjusted life years (QALYs) is adopted as a primary economic outcome for economic evaluation, and the cost per NRS is adopted as a secondary economic outcome.

ETHICS AND DISSEMINATION

This trial has received complete ethical approval from the Ethics Committee of Catholic Kwandong University International St. Mary's Hospital (IS17ENSS0063). We intend to submit the results to a peer-reviewed journal and/or conferences.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03633097.

Evaluating Acupuncture for the Treatment of Chemotherapy-induced Peripheral Neuropathy: An Integrative Review

The purpose of this integrative review of the literature is to synthesize the current evidence and identify gaps in knowledge regarding the effectiveness of acupuncture to treat chemotherapy-induced peripheral neuropathy (CIPN). PubMed, CINAHL, Web of Science, and Cochrane Review databases were searched using inclusion criteria: keywords acupuncture, cancer, and peripheral neuropathy, published in English, between 2009 and 2019. Sixteen articles met the inclusion criteria. The literature indicates that acupuncture is generally well tolerated by patients with cancer, and a majority of patients with CIPN reported decreased pain and increased quality of life after receiving acupuncture treatment. A comprehensive understanding of the ability of acupuncture to treat CIPN is limited by variability of acupuncture techniques and inconsistency in measures of evaluation.

Impact of Auricular Neurostimulation in Patients Undergoing Colorectal Surgery with an Enhanced Recovery Protocol: A Pilot Randomized, Controlled Trial

BACKGROUND

Narcotics are the cornerstone of postoperative pain control, but the opioid epidemic and the negative physiological and psychological effects of narcotics implore physicians to utilize nonpharmacological methods of pain control.

OBJECTIVE

This pilot study investigated a novel neurostimulation device for postoperative analgesia. We hypothesized that active neurostimulation would decrease postoperative narcotic requirements.

DESIGN

This was a placebo-controlled, double-blinded trial.

SETTINGS

This trial was conducted at an academic medical center and a Veterans Affairs hospital.

PATIENTS

This trial included adult patients who underwent elective bowel resection between December 2016 and April 2018.

INTERVENTIONS

Patients were randomly assigned to receive an active or inactive (sham) device, which was applied to the right ear before surgery and continued for 5 days.

MAIN OUTCOME MEASURES

The primary outcome was total opioid consumption. The secondary outcomes included pain, nausea, anxiety, return of bowel function, complications, 30-day readmissions, and opioid consumption at 2 weeks and 30 days.

RESULTS

A total of 57 patients participated and 5 withdrew; 52 patients were included in the analysis. Twenty-eight patients received an active device and 24 received an inactive device. There was no difference in total narcotic consumption between active and inactive devices (90.79 ± 54.93 vs 90.30 ± 43.03 oral morphine equivalents/day). Subgroup analyses demonstrated a benefit for patients after open surgery (p = 0.0278). When patients were stratified by decade, those aged 60 to 70 and >70 years derived a benefit from active devices in comparison with those aged 30 to 40, 40 to 50, and 50 to 60 years old (p = 0.01092). No serious adverse events were related to this study.

LIMITATIONS

This study was limited by the small sample sizes.

CONCLUSIONS

No difference in opioid use was found with auricular neurostimulation. However, this pilot study suggests that older patients and those with larger abdominal incisions may benefit from auricular neurostimulation. Further investigation in these high-risk patients is warranted. See Video Abstract at http://links.lww.com/DCR/B452.ClinicalTrials.gov identifier: NCT02892513.

IMPACTO DE LA NEUROESTIMULACIN AURICULAR EN PACIENTES SOMETIDOS A CIRUGA COLORRECTAL CON UN PROTOCOLO DE RECUPERACIN MEJORADA UN ENSAYO PILOTO ALEATORIZADO Y CONTROLADO

ANTECEDENTES:Los narcóticos son la piedra angular del control del dolor postoperatorio, pero la epidemia de opioides y los efectos fisiológicos y psicológicos negativos de los narcóticos incentivan a los médicos a que utilicen métodos no farmacológicos de control del dolor.OBJETIVO:Este estudio piloto investigó un nuevo dispositivo de neuroestimulación para analgesia postoperatoria. Hipotetizamos que la neuroestimulación activa disminuiría los requerimientos narcóticos postoperatorios.DISEÑO:Este fue un ensayo doble ciego controlado con placebo.ESCENARIO:Esto se llevó a cabo en un centro médico académico y en un hospital de Asuntos de Veteranos (Veterans Affairs hospital).PACIENTES:Este ensayo incluyó pacientes adultos que se sometieron a resección intestinal electiva entre diciembre de 2016 y abril de 2018.INTERVENCIONES:Los pacientes fueron asignados al azar para recibir un dispositivo activo o inactivo (falso), que se aplicó al oído derecho antes de la cirugía y se mantuvo durante 5 días.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue el consumo total de opioides; los resultados secundarios incluyeron dolor, náusea, ansiedad, retorno de la función intestinal, complicaciones, reingresos a 30 días y consumo de opioides a 2 semanas y a 30 días.RESULTADOS:Participaron un total de 57 pacientes y 5 se retiraron; Se incluyeron 52 pacientes en el análisis. Veintiocho pacientes recibieron un dispositivo activo y 24 recibieron un dispositivo inactivo. No hubo diferencias en el consumo total de narcóticos entre los dispositivos activos e inactivos (90.79 ± 54.93 vs 90.30 ± 43.03 equivalentes de morfina oral [OME] / día). Los análisis de subgrupos demostraron un beneficio para los pacientes después de cirugía abierta (p = 0.0278). Cuando los pacientes se estratificaron por década, aquellos de 60-70 y > 70 años obtuvieron un beneficio de los dispositivos activos en comparación con los de 30-40, 40-50 y 50-60 años (p = 0.01092). No hubo eventos adversos graves relacionados con este estudio.LIMITACIONES:Este estudio estuvo limitado por los pequeños tamaños de muestra.CONCLUSIONES:No se encontró diferencia en el uso de opioides con la neuroestimulación auricular. Sin embargo, este estudio piloto sugiere que los pacientes mayores y aquellos con incisiones abdominales más grandes pueden beneficiarse de la neuroestimulación auricular. Está justificada la investigación adicional en estos pacientes de alto riesgo. Consulte Video Resumen en http://links.lww.com/DCR/B452. (Traducción-Dr. Jorge Silva Velazco).

Acupuncture for Rehabilitation After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: There is an increasing interest in acupuncture for promoting post-operative rehabilitation, but the effectiveness of acupuncture for rehabilitation after total knee arthroplasty (TKA) remains controversial.

Objective: This study aims to investigate the effect of acupuncture on rehabilitation after TKA.

Methods: Database searches of PubMed, EMBASE, CINAHL, and China National Knowledge Infrastructure (CNKI) were conducted to obtain articles published until August 2020. All identified articles were screened, and data from each included study were extracted independently by two investigators. Meta-analysis was performed to examine the effects of acupuncture on pain, range of knee motion, function, and nausea/vomiting after TKA.

Results: A total of nine randomized clinical trials were included according to the inclusion and exclusion criteria in this review. Compared with routine treatment, acupuncture combined with routine treatment showed a significantly greater pain reduction at 8, 12, 24, and 48 h post-operatively after TKA. Meanwhile, we found that the acupuncture groups showed a significant function improvement and a lower percentage of nausea/vomiting in comparison with the control groups after operation. However, acupuncture groups demonstrated no statistically significant improvement in post-operative pain at 4 h, 7 days, 14 days, and more than 21 days, and no significant difference in range of knee motion was observed between the acupuncture groups and control groups after surgery.

Conclusions: Acupuncture, as a supplementary treatment after TKA, could improve function and reduce nausea/vomiting. However, the effect of acupuncture on pain relief may be mainly achieved within post-operative 48 h, and it had no efficacy in improving range of knee motion. More large-scale and high-quality studies are warranted.

Transcutaneous Electrical Acupoint Stimulation Reduces Postoperative Analgesic Requirement in Patients Undergoing Inguinal Hernia Repair: A Randomized, Placebo-Controlled Study

Given the rising rate of opioid-related adverse drug events during postsurgical pain management, a nonpharmacologic therapy that could decrease analgesic medication requirements would be of immense value. We designed a prospective, placebo-and-randomized controlled trial to assess the clinical effect of transcutaneous acupoint electrical stimulation (TEAS) on the postoperative patient-controlled analgesia (PCA) requirement for morphine, as well as side effects and recovery profile after inguinal hernia repair. Seventy-one subjects undergoing inguinal hernia repair with a standardized anesthetic technique were randomly assigned to one of three analgesic treatment regimens: PCA + TEAS (n = 24); PCA + sham-TEAS (no electrical stimulation) (n = 24), and PCA only (n = 23). The postoperative PCA requirement, pain scores, opioid-related side effects, and blood cortisol levels were recorded. TEAS treatment resulted in a twofold decrease in the analgesic requirement and decreased pain level reported by the patients. In addition, a significant reduction of cortisol level was reported in the TEAS group at 24 h postoperatively compared to the sham and control groups. We conclude that TEAS is a safe and effective option for reducing analgesic consumption and postoperative pain following inguinal hernia repair.

Provider Perspectives of Battlefield Acupuncture: Advantages, Disadvantages and Its Potential Role in Reducing Opioid Use for Pain

Nonpharmacological options to treat pain are in demand, in part to address the opioid crisis. One such option is acupuncture. Battlefield acupuncture (BFA) is an auricular needling protocol currently used to treat pain in the Veterans Health Administration. We aimed to identify the advantages and disadvantages of BFA from providers’ perspectives.

Electroacupuncture: A New Approach for Improved Postoperative Sleep Quality After General Anesthesia

General anesthesia produces a state of drug-induced unconsciousness that is controlled by the extent and duration of administered agents. Whether inhalation or intravenous in formulation, such agents may interfere with normal sleep-wake cycles, impairing postoperative sleep quality and creating complications. Electroacupuncture is a new approach widely applied in clinical practice during recent years. This particular technology helps regulate neurotransmitter concentrations in the brain, lowering norepinephrine and dopamine levels to improve sleep quality. It also alleviates surgical pain that degrades postoperative sleep quality after general anesthesia by downregulating immune activity (SP, NK-1, and COX-1) and upregulating serotonin receptor (5-HT1AR, 5-HT2AR) and endocannabinoid expression levels. However, large-scale, multicenter studies are still needed to determine the optimal duration, frequency, and timing of electroacupuncture for such use.

Acupuncture in persons with an increased stress level-Results from a randomized-controlled pilot trial

Background

In today’s Western societies a high percentage of people experience increased or chronic stress. Acupuncture could serve as treatment for persons affected adversely by the increased stress.

Methods

The AkuRest study was a two-centre randomized controlled pilot study in adult persons with increased stress levels. Participants were randomly allocated to one of three groups: verum acupuncture treatment, sham acupuncture, and a waiting control group. The feasibility of the study was assessed. In addition, effects on stress level (measured by the Perceived Stress Questionnaire (PSQ-20)) and other variables were assessed at the end of treatment and a 3-month follow-up.

Results

Altogether, N = 70 persons were included in the study. At the end of the treatment 15.7% were lost to follow-up. The adherence to the protocol was good: 82.9% of the participants completed 100% of their treatment. The stress level of the participants was high at baseline (mean PSQ-20 score 75.5, SD = 8.2). Effect sizes (ES) at T1 showed that verum and sham acupuncture were superior to the waiting condition in reducing stress (ES (verum) = -1.39, 95%-CI = [-2.11; -0.67]: ES (sham) = -1.12, CI = [-1.78;-0.44]). At follow-up, effect sizes were in favour of the verum group (as compared to sham). However, confidence intervals and t-tests showed that these differences were not significant.

Conclusion

The pilot study demonstrated the feasibility of the acupuncture RCT in persons with increased stress levels. Estimated parameters can be used to design a larger RCT to prove the–here indicated—efficacy of verum acupuncture to decrease stress.

Trial registration number

ISRCTN15259166.

GABAergic Inhibition of Spinal Cord Dorsal Horns Contributes to Analgesic Effect of Electroacupuncture in Incisional Neck Pain Rats

Background

Acupuncture has shown to be effective in relieving post-surgical pain. Nonetheless, its underlying mechanisms remain largely unknown. In the present study, we investigated the effect of electroacupuncture (EA) on the expression of GABA, GABA-A receptor (R) and GABA-BR in the spinal cord dorsal horns (DHs), and the involved neural cells in rats with incisional neck pain.

Materials and Methods

Male SD rats were randomly divided into control, model, Futu (LI18), Hegu-Neiguan (LI4-PC6), and Zusanli-Yanglingquan (ST36-GB34) groups. The incisional neck pain model was established by making a longitudinal incision and repeated mechanical separation along the thyroid gland region. EA (2Hz/100Hz, 1mA) was applied to LI18, LI4-PC6, ST36-GB34 separately for 30min, once at 4, 24 and 48h after incision. The local thermal pain threshold (TPT) of the focus was measured and the expression of GABA, and GABAR proteins and mRNAs detected by immunofluorescence stain and quantitative RT-PCR, respectively.

Results

The analgesic effect of LI18 and LI4-PC6 was superior to that of ST36-GB34 in incisional neck pain rats. Moreover, the EA stimulation of LI18 or LI4-PC6 increased the expression of GABA and GABA-Aα2 and GABA-Aβ3, GABA-B1, and GABA-B2 mRNAs in spinal DHs 4h after surgery, while GABA-A and GABA-B antagonists inhibited the analgesic effect of LI18. Immunofluorescence double staining showed that GABA was expressed on astrocytes and neurons, and GABA-B expressed only on neurons.

Conclusion

EA of both LI18 and LI4-PC6 has a good analgesic effect in incisional neck pain rats, which is closely related to their effects in upregulating the expression of GABA and its receptors in spinal DHs. The effects of LI18 and LI4-PC6 EA are obviously better that those of ST36-GB34 EA, and GABA is expressed on neurons and astrocytes.

Integrative Medicine in Plastic Surgery: A Systematic Review of Our Literature

BACKGROUND

Surveys have reported that as high as 80% of plastic surgery patients utilize integrative medicine approaches including natural products (NPs) and mind-body practices (MBPs). Little is known regarding the evidence of benefit of these integrative therapies specifically in a plastic surgery patient population.

METHODS

We conducted a systematic review of studies in MEDLINE, PubMed, and EMBASE (inception through December 2016) evaluating integrative medicine among plastic surgery patients. Search terms included 76 separate NP and MBP interventions as listed in the 2013 American Board of Integrative Health Medicine Curriculum. Two independent reviewers extracted data from each study, including study type, population, intervention, outcomes, conclusions (beneficial, harmful, or neutral), year of publication, and journal type. Level of evidence was assessed according to the American Society of Plastic Surgeons Rating Levels of Evidence and Grading Recommendations.

RESULTS

Of 29 studies analyzed, 13 studies (45%) evaluated NPs and 16 (55%) studied MBPs. Level II reproducible evidence supports use of arnica to decrease postoperative edema after rhinoplasty, onion extract to improve scar pigmentation, hypnosis to alleviate perioperative anxiety, and acupuncture to improve perioperative nausea. Level V evidence reports on the risk of bleeding in gingko and kelp use and the risk of infection in acupuncture use. After year 2000, 92% of NP studies versus 44% of MBP studies were published (P = 0.008).

CONCLUSIONS

High-level evidence studies demonstrate promising results for the use of both NPs and MBPs in the care of plastic surgery patients. Further study in this field is warranted.

Effects of transversus abdominis plane block versus quadratus lumborum block on postoperative analgesia: a meta-analysis of randomized controlled trials

Background

Trunk block technique has been used in postoperative analgesia for patients undergoing surgery, specifically, transversus abdominis plane block (TAPB) and quadratus lumborum block (QLB) have been proved effective. The purpose of this meta-analysis is to evaluate the effects of TAPB and QLB in postoperative analgesia.

Methods

Online databases, including MEDLINE, EMBASE, Cochrane Library (&Trail), Web of Science, CNKI, Wanfang and QVIP were applied to collect the randomized controlled trials (RCTs) from inception to Dec. 9th, 2019. Twenty-two studies were finally included containing 777 patients in the TAPB group and 783 cases in QLB group. RCTs comparing TAPB and QLB in postoperative analgesia were included in this meta-analysis. The indicators including total analgesia consumption postoperatively, operative time, duration of anesthesia, visual analogue scale (VAS) score at 24 h postoperatively, duration of postoperative analgesia, the number of patients requiring analgesia postoperatively and adverse reactions were analyzed.

Results

our findings showed that morphine consumption (mg) (WMD = 3.893, 95%CI: 2.053 to 5.733, P < 0.001), fentanyl consumption (μg) (WMD = 23.815, 95%CI: 15.521 to 32.109, P < 0.001), VAS score at 24 h postoperatively (WMD = 0.459, 95%CI: 0.118 to 0.801, P = 0.008), the number of patients requiring analgesia postoperatively (WMD = 3.893, 95%CI: 2.053 to 5.733, P < 0.001), and the incidence of dizziness (WMD = 2.691, 95%CI: 1.653 to 4.382, P < 0.001) in TAPB group were higher than in QLB group.

Conclusions

QLB is superior to TAPB in reducing morphine consumption, fentanyl consumption, VAS score at 24 h postoperatively, the number of patients requiring analgesia postoperatively, and the incidence of dizziness.

A mechanistic approach to HPLC analysis, antinociceptive, anti-inflammatory and postoperative analgesic activities of panch phoron in mice

Background

Panch phoron is a mixture of five spices containing an equal proportion of Foeniculum vulgare (fennel), Trigonella foenum-graecum Linn (fenugreek), Nigella sativa (black cumin), Cuminum cyminum (cumin) and Brassica nigra (black mustard). The mixture is commonly used in Bangladeshi cuisine and possesses many pharmacological effects. In this study, we evaluated the antinociceptive and anti-inflammatory activities of aqueous panch phoron extract (PPE) in vivo, its possible mechanism of action and phytochemical analysis by High-Performance Liquid Chromatography (HPLC). We also investigated the effect of PPE on postoperative pain in mice.

Methods

HPLC was carried out using LC-20A Modular HPLC system to identify the bioactive compounds present in PPE. Five groups of Swiss albino male mice (n = 6 per group) were orally treated with 10 ml/kg of distilled water or 10 mg/kg of sodium diclofenac or three doses of PPE (100 mg/kg, 300 mg/kg, 500 mg/kg). In vivo assessment was carried out by the writhing test, tail-flick test, formalin test, and carrageenan induced paw edema test. The opioid antagonist, naloxone was used in the acetic acid test to evaluate the involvement of opioid receptors. To assess the effect of PPE in postoperative pain, mice that underwent sciatic nerve surgery were measured for the paw withdrawal latency in a hot water bath.

Results

In HPLC analysis, different types of phenolic compounds and flavonoids, including catechin hydrate, para-coumaric acid, vanillic acid, and syringic acid were detected. Treatment with PPE exhibited dose-dependent antinociceptive and anti-inflammatory activities in pain models (p < 0.05). Furthermore, naloxone did not reverse the effect of PPE in the writhing test. Mice that underwent sciatic nerve surgery showed that the paw withdrawal latency increased gradually over 7 days.

Conclusions

Our results demonstrate that PPE has significant antinociceptive and anti-inflammatory activities and can provide significant postoperative analgesia.

Consensus Statement for the Prescription of Pain Medication at Discharge after Elective Adult Surgery

This Consensus Statement provides recommendations on the prescription of pain medication at discharge from hospital for opioid-naïve adult patients who undergo elective surgery. It encourages health care providers (surgeons, anesthesiologists, nurses/nurse practitioners, pain teams, pharmacists, allied health professionals, and trainees) to (1) use nonopioid therapies and reduce the prescription of opioids so that fewer opioid pills are available for diversion and (2) educate patients and their families/caregivers about pain management options after surgery to optimize quality of care for postoperative pain. These recommendations apply to opioid-naïve adult patients who undergo elective surgery. This consensus statement is intended for use by health care providers involved in the management and care of surgical patients. A modified Delphi process was used to reach consensus on the recommendations. First, the authors conducted a scoping review of the literature to determine current best practices and existing guidelines. From the available literature and expertise of the authors, a draft list of recommendations was created. Second, the authors asked key stakeholders to review and provide feedback on several drafts of the document and attend an in-person consensus meeting. The modified Delphi stakeholder group included surgeons, anesthesiologists, residents, fellows, nurses, pharmacists, and patients. After multiple iterations, the document was deemed complete. The recommendations are not graded because they are mostly based on consensus rather than evidence.