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Perioperative acupuncture: why are we not using it?
  1. T I Usichenko1,
  2. K Streitberger2
  1. 1Department of Anaesthesiology and Intensive Care Medicine, University Medicine of Greifswald, Greifswald, Germany
  2. 2University Department of Anesthesiology and Pain Therapy, Inselspital, University Hospital of Bern, Switzerland
  1. Correspondence to Dr Taras Usichenko, Department of Anaesthesiology and Intensive Care Medicine, University Medicine of Greifswald, Fleischmannstr. 42-44, Greifswald 17475, Germany; taras{at}uni-greifswald.de

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Acupuncture is mostly known to the general readership for its analgesic effects.1 Focusing on the treatment of acute postoperative pain, a meta-analysis of 15 randomised controlled trials (RCTs) comparing acupuncture with sham control in the management of postoperative pain showed that acupuncture decreased both pain intensity and opioid consumption up to 72 h after surgery.2 This opioid reduction effect was associated with a decreased incidence of opioid-related side effects such as nausea, dizziness, sedation, pruritus and urinary retention. More evidence is provided by two trials3 ,4 which suggest that the perioperative administration of acupuncture may be a useful adjunct for postoperative analgesia.

The study by Ntritsou et al3 confirms the conclusions of this meta-analysis and again demonstrates the benefits of postoperative acupuncture listed above. Besides the importance of confirming the evidence from previous studies, there are several interesting aspects in this investigation which are worthy of comment.

Ntritsou et al used a pragmatic approach, where acupuncture for postoperative pain relief was performed immediately at the end of surgery in the operating room. This postoperative approach means that acupuncture interferes much less with the running of the operation. The results confirm the previously described effect of acupuncture point stimulation on postoperative pain5 and suggest the same effectiveness as when the stimulation is started before surgery.6

Moreover, the choice of acupuncture points was more practical than in other investigations in which acupuncture point stimulation was superior to a variety of control conditions.2 Points LI4 and ST36 are easier to access for stimulation during the surgery than segmental paravertebral points, although both locations produce the same clinical effect in the treatment of postoperative pain after abdominal surgery.5

It seems likely that the short-term analgesic effect clearly demonstrated in the study by Ntritsou et al might be prolonged by exploiting the benefits of indwelling fixed needles, as was previously shown in several trials of perioperative acupuncture. Kotani et al7 enrolled 175 patients scheduled for major abdominal surgery who received preoperatively an epidural catheter in combination with acupuncture or non-invasive sham acupuncture in a random manner. In the acupuncture group, the intradermal needles were placed paravertebrally at BL18 to BL24 and BL20 to BL26. The needles were kept in place up to 4 days after surgery. Patients with acupuncture required significantly less additional morphine and reported less pain as well as lower rates of nausea and vomiting. Plasma concentrations of cortisol and adrenalin, as the biomarkers of stress, were also lower in the acupuncture treated group than in the sham acupuncture group.

Auricular stimulation of indwelling fixed needles alone allows a reduction of at least 40% in the postoperative analgesic requirement in patients scheduled for orthopaedic surgery.8 ,9 Disposable indwelling auricular needles are inserted before induction of anaesthesia at MA-TF1 (Shenmen), MA-IC1 (Lung) and the corresponding MA-AH4 (Hip) or MA-AH3 (Knee). Also, the MA-AT1 (Thalamus) could be added. The needles should be fixed with adhesive tape and retained in situ as long as the postoperative pain persists. The advantage of this method is that patients are able to stimulate the indwelling fixed needles themselves as soon as their pain level becomes intolerable.

Overall, postoperative pain is probably the best ‘evidence-based’ condition among the other popular clinical indications for acupuncture. Modern data demonstrate that acupuncture can be effectively used within the clinical pathways of perioperative medicine (figure 1). Several RCTs suggest that auricular acupuncture is at least as effective as benzodiazepines in the treatment of preoperative anxiety but lacks the side effects of these sedative drugs.10 ,11 Two excellent experimental investigations showed that auricular stimulation can reduce the dose of the volatile anaesthetic desflurane required to inhibit the movement of extremities in response to noxious electrical stimulation in healthy volunteers.12 ,13

Figure 1

The benefits of indwelling acupuncture needles inserted once before surgery without involving additional staff. PONV, postoperative nausea and vomiting.

Moreover, perioperative acupuncture seems to accelerate the recovery of bowel peristaltic function after surgery. Zhang et al applied electrical stimulation to ST36 in 20 patients after colorectal surgery and compared them with 20 patients randomised to the sham control procedure.4 In the electroacupuncture group the times from surgery to the first bowel movement and passage of flatus were clearly shorter than in the control group.

Despite two positive systematic reviews of RCTs on acupuncture for postoperative pain relief,2 ,14 implementation in the clinical routine might still be a long way off. According to the evidence described above, the usefulness of acupuncture in the routine performance of anaesthesia is obvious, as is its safety,2 but the rigorous evaluation of cost-effectiveness is still lacking. Beyond this argument, even the prophylaxis of postoperative nausea and vomiting (PONV) using PC6 stimulation—which is easy to perform, simple to learn, well-proven15 and recommended in international evidence-based guidelines16—still has not been implemented as routine in anaesthesia. A disappointed Professor John Dundee, who was a pioneer in the evaluation of the efficacy of PC6, challenged his colleagues before he died in 1991: “I have proved that acupuncture is highly effective as a postoperative antiemetic. Why are you not using it?”17 Since then, evidence of the antiemetic effect of PC6 has risen and more positive studies have been published in high-ranking journals. However, the controversy about the efficacy of PC6 stimulation still exists,18 and it has taken a long time for some hospitals gradually to integrate the stimulation of PC6 into clinical pathways.19 Acupuncture was not integrated even in a hospital where the reduction of nausea in children had been clearly shown.20

How long will it take until acupuncture will be accepted as an adjunctive therapy in postoperative pain? It should be easy and probably beneficial for many patients to combine acupuncture at PC6 with other corporal and auricular acupuncture points for postoperative pain control. Since the best results for acupuncture in postoperative pain control have been obtained by electrical stimulation at the classical points LI4 and ST36 and the use of indwelling permanent needles at acupuncture points (including auricular points and segmental paravertebral acupuncture points), it is expedient to include these options in the clinical routine of perioperative acupuncture. As a supplementary effect, the stimulation of ST36 appears to accelerate the recovery of gastrointestinal motility after surgery.

Considering the whole perioperative period, a combination of the stimulation of body and auricular acupuncture points using indwelling fixed needles, inserted before surgery, could cover premedication, intraoperative and postoperative analgesia as well as the prevention and treatment of PONV and postoperative bowel paralysis—without involving additional staff (figure 1).

In summary, there is good evidence for the effectiveness of perioperative acupuncture in the treatment of postoperative pain and the prevention of PONV with a very low risk of side effects. Most of the acupuncture applications described here are entirely practicable and could be implemented into the clinical routine as a complementary method in the perioperative setting.

Acknowledgments

The authors thank Mr Alexey Adulov and Mr Yuriy Krasyuk for their assistance in the preparation of figure 1.

References

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Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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