Acupuncture in 21st century anesthesia: is there a needle in the haystack?

Perforating cutaneous vessels: A key feature of acupoints - Anatomical evidence from five-Shu acupoints in the upper limbs

Acupuncture has been proven an effective clinical treatment for numerous pathological conditions and malfunctions. However, substantial anatomical evidence for acupuncture points (APs) and meridians is still lacking, so the location of APs is relatively subjective and understanding of the biological mechanisms of acupuncture is limited. All these problems hinder the clinical applications and worldwide acceptance of acupuncture. Our long-term microsurgery experience has indicated that Perforating Cutaneous Vessels (PCVs) are highly relevant to APs but the anatomical evidence is insufficient. To address this lack, two specimens of fresh adult human upper limbs were dissected using an advanced vascular perfusion-fixation method and then examined. The results show that all 30 five-Shu APs in the upper limbs have corresponding PCVs. Both specimens showed a 100% coincidence rate between APs and PCVs, indicating that PCVs could be critical anatomical features of APs. This study also provides an anatomical basis for locating APs objectively via preliminary detection of PCVs. The findings could lead to a better theoretical understanding of mechanisms of acupuncture and the essence of meridians.

Effect Observation of Electro-Acupuncture Anesthesia Combined with General Anesthesia in Elderly Patients Undergoing Gastrointestinal Tumor Resection

Objective

To investigate the anesthetic effect of electro-acupuncture (EA) anesthesia combined with general anesthesia in elderly patients undergoing gastrointestinal tumor resection, and to analyze the effects of EA anesthesia on inflammatory factors, stress state and T lymphocyte subsets in elderly patients.

Methods

Total of 118 elderly patients who underwent gastrointestinal tumor resection in our hospital from June 2018 to March 2021 were selected and divided into the control group (59 cases) and the observation group (59 cases) according to the random number method. General anesthesia was adopted in the control group and EA anesthesia combined with general anesthesia was adopted in the observation group. The anesthesia effect, stress state, levels of inflammatory factors, T-lymphocyte subsets and adverse reactions were compared.

Results

The VAS score, agitation score and respiratory normalization time in the observation group were lower than those in the control group (p < 0.05). After surgery, the levels of serum Cor, ET, NE and DA in the observation group were lower than those in the control group (p < 0.05). At 24 h after surgery, the levels of serum TNF-α, IL-6 and IL-1β in the observation group were lower than those in the control group (p < 0.05). At 24 h after surgery, the levels of CD3+, CD4+, and CD4+//CD8+ in the two groups were lower than those before surgery, and the levels of CD3+, CD4+, and CD4+//CD8+ in the observation group were higher than those in the control group (p < 0.05). During the hospitalization, the total incidence rate of adverse reactions after anesthesia in the observation group was lower than that in the control group (p < 0.05).

Conclusion

EA anesthesia combined with general anesthesia has good anesthesia effect when used for gastrointestinal tumor resection in the elderly. It can stabilize the internal environment of patients, alleviate postoperative stress response and inflammatory response, and regulate the body immune function. Moreover, it has high safety and can significantly reduce the occurrence of postoperative adverse reactions.

Evaluation of Percutaneous Electrical Nerve Stimulation of the Auricle for Relief of Postoperative Pain Following Cesarean Section

Objective: Percutaneous electrical nerve stimulation is a nonpharmacologic modality of analgesia. This study was conducted to evaluate such a technology (ANSiStim™, DyAnsys Inc., San Mateo, CA) prospectively, in conjunction with standard analgesia per patient demand, for managing postoperative pain following lower-segment cesarean section. Materials and Methods: One hundred parturients were randomized into 2 equal groups (controls and study cases). The latter cohort consisted of parturients for whom nerve stimulation was exerted on the pinna. Pain scores were compared across subjects at corresponding time points with 17 intervals in 48 hours, and, in totality, using estimated area under the curves of numerical scores. Conditional inference analysis was also performed. Results: Ninety-six parturients were finally included. The device was well-tolerated by a majority of parturients. Pain scores were significantly lower in the study group, both at corresponding time intervals and in totality. (H - 15)*(0.74 - H)*(H² - 17H + 110)/440, where H was the corresponding hour, fit the pain scores in the control group. Controls could be detected at the 11 hour with greater pain scores (≥ 4), whereas smaller scores (≤ 2) at the 42nd hour mostly revealed that electrical stimulation was performed (p < 0.001). Requirements for supplementary analgesics were lower for subjects who were given the electroanalgesia. Conclusions: Neurostimulation via the ANSiStim™ is a safe and reasonably effective ambulatory analgesic adjuvant following abdominal delivery. There are no serious adverse effects.

Effect of Auricular Acupuncture on Propofol Induction Dose: Could Vagus Nerve and Parasympathetic Stimulation Replace Intravenous Co-Induction Agents?

Objective: Auricular acupuncture, through a combination of several points, can produce sedative and analgesic effects. The aim of this study was to compare the induction dose of propofol required to obtain a loss of response to verbal commands, with and without a preoperative combination of auricular points. Materials and Methods: This study involved American Society of Anesthesiologists physical status I and II patients, ages 18- 65, of either sex, having elective ambulatory surgery (digestive or gynecologic) under general anesthesia. The subjects were allocated to 2 groups: (1) patients treated by auricular acupuncture (group AA), compared with (2) patients not treated by auricular acupuncture (group NA). Propofol injection was initiated in each group, 10 mg, every 5 seconds, in order for the anesthetist to determine the minimum dose until there was a loss of response to verbal commands (the clinical hypnotic endpoint). At this point, the main outcome-the dose of propofol given-was noted. Results: There were 32 patients in this study (16 in each group). Age, height, weight, and body mass index were similar in the groups (P ≥ 0.05). The required induction propofol dose was 17.7% lower in group AA than in group NA-a statistically significant difference (P ≤ 0.05). The mean induction dose indexed to weight was 2.18 mg/kg (range: 1.53-3.13 mg/kg) in group NA and 1.79 mg/kg (range: 1.12-2.11 mg/kg) in group AA. There were no complications. Conclusions: Auricular acupuncture is a method for stimulating the vagus nerve and parasympathetic nervous system. Preoperative auricular acupuncture enabled reductions of induction doses of propofol for general anesthesia without any clinically important side-effects.

Why We Need Minimum Basic Requirements in Science for Acupuncture Education

As enthusiasm for alternatives to pharmaceuticals and surgery grows, healthcare consumers are turning increasingly to physical medicine modalities such as acupuncture. However, they may encounter obstacles in accessing acupuncture due to several reasons, such as the inability to locate a suitable practitioner, insufficient reimbursement for treatment, or difficulty gaining a referral due to perceived lack of evidence or scientific rigor by specialists. Claims made about a range of treatment paradigms outstrip evidence and students in acupuncture courses are thus led to believe that the approaches they learn are effective and clinically meaningful. Critical inquiry and critical analysis of techniques taught are often omitted, leading to unquestioning acceptance, adoption, and implementation into practice of approaches that may or may not be rational and effective. Acupuncture education for both licensed physicians (DOs and MDs) and non-physicians needs to include science (i.e., explanation of its effects based on contemporary explanations of biological processes), evidence, and critical thinking. Erroneous notions concerning its mechanisms such as moving "stuck Qi (Chi)" or "energy" with needles and that this energy stagnates at specific, tiny locations on the body called acupuncture points lead to mistakes in methodologic design. For example, researchers may select sham and verum point locations that overlap considerably in their neural connections, leading to nonsignificant differences between the two interventions. Furthermore, attributing the effects of acupuncture to metaphorical and arcane views of physiology limits both acceptance and validation of acupuncture in both research and clinical settings. Finally, the content and quality of education and clinical exposure across acupuncture programs varies widely, with currently no minimum basic educational requirements in a scientific methodology. Considering the pressures mounting on clinicians to practice in an evidence-based and scientific manner that also demonstrates cost-effectiveness, acupuncture schools and continuing medical education (CME) courses need to provide their students a strong foundation in rational approaches supported by research.

CME Article: Perceptions of Acupuncture and Acupressure by Anesthesia Providers: A Quantitative Descriptive Study

Background: Randomized controlled trials show that acupuncture and acupressure support anesthesia management by decreasing anxiety, opioid requirements, and treating post-operative nausea and vomiting. Acupuncture and acupressure have demonstrated clinical usefulness but have not yet diffused into mainstream anesthesia practice. To determine why, this study assessed U.S. anesthesia provider's perceptions of acupuncture and acupressure. Methods: After institutional review board approval, 96 anesthesiology departments stratified by geographic region (Northeast, South, West, and Midwest) and institution type (university medical centers, community hospitals, children's hospitals, and veterans affairs hospitals) were selected for participation in an anonymous, pretested, online survey. The target sample was 1728 providers, of whom 292 (54% anesthesiologists, 44% certified registered nurse anesthetists, 2% anesthesiologist assistants) responded, yielding an overall 17% response rate. Results: Spearman correlation coefficient revealed a statistically significant correlation between acupuncture and geographic region, with the West having the highest predisposition toward acupuncture use (rs  = 0.159, p = 0.007). Women are more likely to use acupuncture than men (rs  = -0.188; p = 0.002). A strong effect size exists between acupuncture and country of pre-anesthesia training (rs  = 1.00; 95% CI = 1.08, 1.16). Some providers have used acupuncture (27%) and acupressure (18%) with positive outcomes; however, the majority have not used these modalities, but would consider using them (54%, SD = 1.44 ; acupressure: 60%, SD = 1.32). Seventy-six percent of respondents would like acupuncture education and 74% would like acupressure education (SDs of 0.43 and 0.44, respectively). Conclusions: While most of the U.S. anesthesia providers in this survey have not used these modalities, they nevertheless report a favorable perception of acupuncture/acupressure's role as part of an anesthetic. This study adds to the body of acupuncture and acupressure research by providing insight into anesthesia providers' perceptions of these alternative medicine modalities.

Unanticipated Insights into Biomedicine from the Study of Acupuncture

Research into acupuncture has had ripple effects beyond the field of acupuncture. This paper identifies five exemplars to illustrate that there is tangible evidence of the way insights gleaned from acupuncture research have informed biomedical research, practice, or policy. The first exemplar documents how early research into acupuncture analgesia has expanded into neuroimaging research, broadening physiologic understanding and treatment of chronic pain. The second describes how the acupuncture needle has become a tool to enhance biomedical knowledge of connective tissue. The third exemplar, which illustrates use of a modified acupuncture needle as a sham device, focuses on emergent understanding of placebo effects and, in turn, on insights into therapeutic encounters in treatments unrelated to acupuncture. The fourth exemplar documents that two medical devices now in widespread use were inspired by acupuncture: transcutaneous electrical nerve stimulators for pain control and antinausea wrist bands. The final exemplar describes how pragmatic clinical trial designs applied in acupuncture research have informed current general interest in comparative effectiveness research. In conclusion, these exemplars of unanticipated outcomes of acupuncture research comprise an additional rationale for continued support of basic and clinical research evaluating acupuncture and other under-researched therapies.

Placebo by Proxy--the Influence of Parental Anxiety and Expectancy on Postoperative Morbidities in Children

BACKGROUND

Placebo effects emerging from expectancies of relatives, also known as placebo by proxy, is a rather unexplored field. In this study, we assume a correlation between parental anxiety/expectancy and postoperative morbidities in children. Accordingly, a reduction of parental anxiety is expected to enhance the effect of treatment.

METHODS

From October 2012 to June 2013, parents of 282 children completed a self-report closed-ended questionnaire embedded in a main RCT at three ambulatory care centers.

RESULTS

There were no significant associations between parental expectancy or anxiety and children experiencing vomiting and pain.

CONCLUSION

The present study is the first to investigate placebo by proxy in acupuncture treatment for children. The findings were not able to demonstrate any placebo effect by proxy. Unknown confounders and limitations of methods may have contributed to the negative findings. Thus, the findings must be read with precaution, as the possibility of a type II error cannot be excluded.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01729052.

Strong Manual Acupuncture Stimulation of "Huantiao" (GB 30) Reduces Pain-Induced Anxiety and p-ERK in the Anterior Cingulate Cortex in a Rat Model of Neuropathic Pain

Persistent neuropathic pain is associated with anxiety. The phosphorylation of extracellular signal-regulated kinase (p-ERK) in the anterior cingulate cortex (ACC) plays an important role in pain-induced anxiety. Acupuncture is widely used for pain and anxiety. However, little is known about which acupuncture technique is optimal on pain-induced anxiety and the relationship between acupuncture effect and p-ERK. The rat model was induced by L5 spinal nerve ligation (SNL). Male adult SD rats were randomly divided into control, SNL, strong manual acupuncture (sMA), mild manual acupuncture (mMA), and electroacupuncture (EA) group. Bilateral "Huantiao" (GB 30) were stimulated by sMA, mMA, and EA, respectively. The pain withdrawal thresholds (PWTs) and anxiety behavior were measured, and p-ERK protein expression and immunoreactivity cells in ACC were detected. PWTs increased significantly in both sMA and EA groups. Meanwhile, anxiety-like behavior was improved significantly in the sMA and mMA groups. Furthermore, the overexpression of p-ERK induced by SNL was downregulated by strong and mild manual acupuncture. Therefore, strong manual acupuncture on bilateral "Huantiao" (GB 30) could be a proper therapy relieving both pain and pain-induced anxiety. The effect of different acupuncture techniques on pain-induced anxiety may arise from the regulation of p-ERK in ACC.

Acupuncture for Pediatric Pain

Chronic pain is a growing problem in children, with prevalence as high as 30.8%. Acupuncture has been found to be useful in many chronic pain conditions, and may be of clinical value in a multidisciplinary treatment program. The basic principles of acupuncture are reviewed, as well as studies exploring basic mechanisms of acupuncture and clinical efficacy. Conditions commonly treated in the pediatric pain clinic, including headache, abdominal pain, fibromyalgia, juvenile arthritis, complex regional pain syndrome, cancer pain, as well as perioperative pain studies are reviewed and discussed. Areas in need of further research are identified, and procedural aspects of acupuncture practice and safety studies are reviewed. Acupuncture can be an effective adjuvant in the care of pediatric patients with painful conditions, both in a chronic and an acute setting. Further studies, including randomized controlled trials, as well as trials of comparative effectiveness are needed.