Monday, May 2, 2011

Acupuncture-Assisted Anesthesia

ABSTRACT
   The history, mechanisms, and clinical applications of acupuncture in the anesthesia setting are addressed herein. Special emphasis is placed on the role of acupuncture in pre-operative preparation of certain types of patients, intra-operative application of acupuncture-assisted anesthesia, and post-operative management of surgical and anesthesia complications. Advantages of acupuncture analgesia and other symptomatic control, functional maintenance and restoration, reduced mortality, and acceleration of discharge are further explored.
KEY WORDS
   Acupuncture, Anesthesia, Peri-Operative, Pre-Operative, Intra-Operative, Post-Operative
INTRODUCTION
Acupuncture and Modern Medicine
   The clinical efficacy of acupuncture has been reviewed elsewhere. The scientific merits and physiological phenomena achieved through acupuncture have been demonstrated through the use of various types of advanced technologies,1-5 including myoneural electrophysiology studies, radioactive tracer survey and imaging, and single-photon emission computed tomography. Other research, including thermographic studies and studies of kinesiology phenomena, have demonstrated clinical and physiological responses to acupuncture, although the findings remain controversial.
   The growing acceptance of acupuncture is undeniable as seemingly greater numbers of physicians begin to take interest. The National Institutes of Health currently endorses the application of medical acupuncture in many areas. Since February 1996, the Food and Drug Administration has classified acupuncture devices as general medical, rather than investigational, devices.
PRE-OPERATIVE PREPARATION
WITH ACUPUNCTURE

   The primary goal of using acupuncture pre-operatively is to complement and enhance the medical preparation rather than to replace it. Acupuncture preparation of a patient for surgery does not replace a sound medical evaluation and diagnostic testing whenever indicated. Assessments should be made of the potential surgical structures, co-existing anatomical and physiological abnormalities, general physical condition, and the patient's psychological and socioeconomic status. Energetic and meridian conditions must also be addressed. Normalization or optimization allows the patient to safely undergo surgery and recover uneventfully.
During this phase of acupuncture application, the principles used are primarily meridian regulations, optimization of physiological function, and enhancement of endogenous opioid activities for the immediate pre-operative period.
   Korean Hand Acupuncture, Auricular Acupuncture, and a short form of either Traditional Chinese Medicine (TCM) or French Energetic Acupuncture are the most applicable techniques during the pre-operative period. Two of the most commonly applied examples are:
Cardiac Patients
  • Korean Hand Therapy (KHT):12 Shu Mu, Pericardium, KA 18, and KI 11 Shu Mu, Heart, KA 16, and KI 12
  • Auricular Acupuncture: Heart and Kidney points3,29
  • Distinct Meridian: BL 1, SI 10, and HT 1 (K, HT points could be an alternative approach)1,12
  • TCM pattern diagnosis and prescriptions2,3*
  • French Energetics: Shao Yin and Tai Yang regulation, or Distinct Meridians1*
  • Japanese Meridian Therapy30*
    *Constitutional balance

Pulmonary Patients
  • KHT12
  • Auricular Acupuncture: Lung1, 2, Asthma1, 23,29
  • Distinct Meridian: LI 15, LU 1, LI 18, KHT corresponding points. KD 11, KC 1, KD 19
  • TCM 2,3*
  • French Energetics1*
  • Japanese Meridian Therapy30*
    *Note: Items with an asterisk should be applied only by physicians well-trained in those areas.
   Recommendations for the pre-operative acupuncture preparation of patients are primarily safety, simplicity, short-term improvement oriented, and minimal duration. Acupuncture is to be used particularly for cardiac and pulmonary patients who are receiving maximally-tolerated medical treatments and still remain dyspneic, having chest pain, etc. For other symptoms associated with the surgical target, i.e., pain and nausea/emesis, acupuncture should be used only if necessary.
   Other co-existing diseases (diabetes mellitus, for instance) appear to be minimally indicated in acupuncture pre-operative preparation. The patient's blood glucose level usually can be controlled satisfactorily within hours with a computerized insulin pump. Use of acupuncture in this type of case appears redundant and unnecessary.
In other medical conditions including seizure disorder, coagulation disorder, or blood loss, acupuncture should not be used to replace medical treatment; there appears to be little value in the enhanced medical effect of acupuncture within the short pre-operative period in these areas.
INTRA-OPERATIVE PREPARATION
WITH ACUPUNCTURE

Principles of Acupuncture Surgical Analgesics
   Acupuncture does not produce a true anesthesia in any form; it does, however, have a profound analgesic effect and produces sedation.2,8,13-18
Enhancement of Endogenous Opioid Activities
   Numerous studies have demonstrated acupuncture stimulation and induced enhancement of various types of neurotransmitter activities in the central nervous system.2,3,5,8,13,19,20 b-Endorphin activity in the peri-aqueduct increases by 2 to 21/2 times the baseline level; the duration can be up to several hours at times. Other neurotransmitter activities, including serotonin and norepinephrine, have also been demonstrated. Findings indicate that norepinephrine may play some role in the management of acute pain, while serotonin appears to be more important in the control of chronic pain.
   To initiate the endogenous opioid activation effect, points LI 4 for surgical procedures above the clavicle, LI 11 for surgical procedures below the clavicle and above the diaphragm, and LR 3 for procedures on the lower extremities must be selected. These points can sometimes be used in combination to produce an enhanced effect.
   Studies reporting a failure to produce this endogenous opioid activation effect have been shown. However, in reviewing those studies, it appears that the endorphin-related points as described above were not used. In other cases, the points have been stimulated at too high a frequency. According to Stux and Pomeranz,2 the opioid-related stimulation was mediated through the low-frequency stimulation of A-beta fibers. Therefore, the actual needling and the application of electro stimulation should not produce a sharp pain. This stimulation should be applied approximately 20 to 30 minutes immediately prior to surgery to produce the desired level of effectiveness. It has also been suggested that a similar acupuncture application within 24 hours prior to surgery, and then again within 20 minutes prior to surgery, may produce an enhanced effect.
The Nervous System

   The application of acupuncture in the proper combinations can induce a series of changes along the ascending pain pathway and the descending inhibitory system.1,2,9,14-16,21 In this manner, the most significant areas affected seem to involve spinal cord interneuron activation. The activation of these neurons prevents the "wind up" mechanism of intensified pain. Also, the acupuncture activation of Raphe Magnum Nucleus and stimulation of the hypothalamus seem to attenuate acute pain perception.
   Interruption of peripheral nerve (a-delta conduction) is perhaps not a true acupuncture effect. There are several devices available that are able to completely block out the pain from incision. They involve the use of electrical stimulation at a high frequency (200-300 Hz) at the incision site or along the major nerve trunk innervating the incision site. Other alternatives include an electrical stimulator connected to needles along the nerve trunk, or 2 long electrodes that are placed either transcutaneously or percutaneously along both sides of the incision. This type of high-frequency stimulation (>400 Hz) can produce analgesia in less than 5 minutes.
Point Selection
  • LI 4
    Contralateral or bilateral, used for surgeries above the clavicle, and sometimes used in chest surgeries (Chinese). Initiates uterine contraction; contraindicated in pregnancy unless the induction of labor is desired.
    Indications: Relieves pain in the head and otolaryngological conditions, fever, URI, trismus, and urticaria; induces uterine contraction.
  • MH 6
    "Luo Point" of Principle Meridian, "Master Point" of Yin Wei Mo, and "coupled point" of Chong Mo.
    Indications: Mental symptoms of excess Fire, cardiac arrhythmia and angina pectoris, nausea and vomiting, hiccups, and gastrointestinal "fire."
  • TH 6
    Zhigon is the "branch ditch," Fire point, and Luo point.
    Indications: Shoulder and arm pain, chest wall pain, post-thoracotomy, intercostal neuralgia, sore throat, and constipation.
  • TH 5
    Waiguan is the "outer gate," Luo Point, Master Point of Yang Wei, and coupled point of Dai Mo.
    Indications: High fever, chest and neck inflammatory conditions, tinnitus, migraines, enuresis, central nervous system diseases, and upper extremity joint pain.
  • LR 3
    Ta Chong is the "great pouring," Shu/Wood point, and source point.
    Indications: Headaches, vertigo, hypertension, insomnia, hepatitis, mastitis, thrombocytopenia, irregular menstruation, chest wall pain, and urinary retention.
  • ST 36
    Zusanli is "three measures on the leg," he/earth point, and special command point for stomach (strengthening).
    Indications: Gastroenteritis, pancreatitis, digestive disorder, shock, weakness, fatigue, allergies, constipation or diarrhea, lower abdominal distention, breast diseases, and nausea/vomiting.
  • SP 6
    Sanyingjiao is "three yin junction."
    Indications: Abdominal distention, borborygmus, diarrhea, gynecological disorders, urinary retention and incontinence, sexual dysfunction, eczema, and urticaria.
Ear Points (Pain Control-Related)3,29
  • Master Point 1
    Shen Men. Divine Gate. Wonder point.
  • Master Point 2
    Sympathetic.
  • Master Point 3
    Thalamus. Subcortical. Pain control point.
  • Master Point 7
    Tranquilizer point. Relaxation point.
  • Anatomical corresponding points.
  • Lung Point: Skin incision.
KHT (Hand Points)12
  • Corresponding points.
  • Basic prescriptions. Upper Heater/Jiao. Middle Heater/Jiao. Lower Heater/Jiao.
  • Shu Mu points for internal organ surgeries.
Basic Principles Of Electrical Stimulation To Acupoints (Intra-operative And Immediately Pre-Operative)1,2,6,8,9,14,20,22
  • Meridian (Body) Points
    Low frequency direct current 2-4 Hz.
    Ipsilateral or bilateral.
    LI 4 or 11; contralateral.
    Moderate output, starting 20 minutes pre-operatively.
  • Auricular Points
    Low frequency 2-4 Hz, may induce electro-coagulation in 15 minutes, and difficulty in removing the needle. Also may attenuate effects with time.
    Starting at 5 minutes pre-operatively.
  • Local Point/Area Stimulation Adjacent To Surgical Site
    High frequency 400-1000 Hz.
    Graded increase in output intensity according to adaptation.
    10-15 minutes immediately pre-incision, and removal immediately prior to incision/scrubbing.
  • KHT12
    E-beam stimulation after incision to supplement pain control and symptomatic treatments.
General Introduction to Point Combinations for
Surgical Analgesia/Avoidance of Contamination to
Surgical Site)
6,8,13,14,18,21,23-25
  • Skin Incision
    LI 4, LI 11.
    Auricular Therapy: Lung point, Shen Men.
    20-30 minutes of electrical stimulation at 2-4 Hz.
  • Oral, Facial
    LI 4, ST 44, MH 6.
    Auricular Therapy: Tranquilizer, Thalamus, and corresponding points.
  • Chest Wall Procedures
    LI 11, TH 5 or 6, ST 41 or 44.
    Auricular Therapy: Tranquilizer, Thalamus, corresponding points.
  • Intrathoracic Procedures
    LI 11, TH 6, MH 6, CV 17, GV 14.
    Auricular Therapy: Sympathetic, Heart, Lung.
  • Upper Abdominal Procedures
    LI 11, ST 36, SP 6, MH 6.
    Auricular Therapy: Sympathetic, Stomach, Heart, corresponding points.
  • Pelvic Procedures
    LI 11, ST 36, SP 10, MH 6, Dai Mo.
    Auricular Therapy: Pelvis, Sympathetic, corresponding points.
  • Genital-Rectal Procedures
    LU 6, SI 7, SP 6, LR 1, KI 6.
    Auricular Therapy: Sympathetic, Heart, Shen Men.
  • Upper Extremities
    LI 4, TH 5, MH 6, GB 21, and GB 34.
    Auricular Therapy: KI, LU, SP, corresponding points.
  • Lower Extremities
    LI 11, ST 36, GB 34, KI 3, LR 3.
    Auricular Therapy: KI, LU, SP
  • Obstetrical
    • Hyperemesis gravida26
      MH 6, ST 36, 40, LR 3.
      Auricular Therapy: LR, ST Sympathetic (Shen Men).
      KHT: KA 8, 12, 16, 18, KK 9, KF 5
    • Conversion of breech position of fetus
      - Moxibustion BL 67
      - KHT: KA 1, 3, 5, 6, 8, KI 19, KT 23, KF 5
    • Induction of labor (or abortion)
      - LI 4, SP 6
    • Labor (not as effective and convenient as epidural anesthesia)27
      - BI 23, 26, 30, 33, SP 6, LI 4, MH 6, Chong Mo, Dai
  • Other Systems Used Intra-Operatively:
    Nasal, facial, scalp, and "Barefoot Doctor's Anesthesia Points."
   In the intra-operative application of acupuncture, body point needles should be removed if they interfere with the surgical site (likewise, auricular points in facial surgeries). Electrical stimulation is to be used only at points accessible to the anesthesiologist. Additional points may be added through microsystems (e.g., hand, scalp, and auricular points). The number of needles should be kept to a minimum. Continuous electrical stimulation (especially at a high frequency and/or long duration) should be avoided.
POST-OPERATIVE PREPARATION
WITH ACUPUNCTURE

   Acupuncture may be used to enhance and supplement symptomatic medical treatments and to restore physiological functions.1,2,6-8,10-12,22,28 It is not necessary to use acupuncture to completely supplant the use of medications. However, the supplementary use of post-operative acupuncture can decrease the amount of opioids and/or other symptomatic control medications needed to relieve post-operative pain, thus facilitating early ambulation, fluid and food intake, and hospital discharge. Moreover, in situations in which medications are not applicable or effective, acupuncture can be helpful.

  • Acute Pain Management
    Basic principles are the same as intra-operative point combinations, but points closer to the surgical site can be used with proper aseptic techniques.
    KHT (hand acupuncture) system.
    Curious Meridians (very effective in acute conditions).
  • Nausea/Vomiting Control29
    MH 6, ST 36, LR 3.
    Auricular Therapy: Sympathetic, Stomach.
    KHT: KA 8, 12.
  • Post-Extubation Spasm of the Larynx
    MH 6, KI 3.
    Auricular Therapy: Lung points.
    KHT: KE 8, KA 20, 24, KM 5.
  • Urinary Retention
    Deep-drainage K-UB (Distinct Meridian).
    SP 9, LR 8.
    Chong Mo.
    Auricular Therapy: Sympathetic corresponding points.
  • Paralytic Ileus
    LI 11, ST 25, 36, SP 4.
    Auricular Therapy: LI, SI (constipation points).
    KHT: KI 19, KE 22.
  • Hiccups
    MH 6.
    Auricular Therapy: Diaphragm. Stomach. Tranquilizer.
    KHT: KK 9, KB 20, KM 10.
CONCLUSION
   The use of acupuncture to complement medications has many advantages in pre-operative preparation of patients with co-existing diseases. This is especially evident in patients with chronic cardiopulmonary diseases. Pre-operatively, acupuncture treatments can alleviate chronic symptoms and enhance responses to medications within a short period. This effect frequently carries through the intra-operative and post-operative periods to facilitate recovery and early hospital discharge.
   During the immediate pre-operative period, application of acupuncture should be simplified: no more than 1 to 4 body points and/or up to 4 auricular points are used; the duration of stimulation is reduced to 20 minutes.
   Intra-operatively, acupuncture-assisted anesthesia is recommended to bypass the disadvantages of incomplete blockage of pain by the use of acupuncture alone. Moreover, acupuncture enhances the results of regional and local anesthesia, and allows for a reduction in the dose of intravenous opioids and sedatives or the total dose of general anesthetics needed. Further titration and definition of the impact of acupuncture to general anesthesia can be assessed with the aid of moderate anesthesia depth-monitoring devices currently available.
   Post-operatively, the treatment of symptoms can be achieved effectively with proper use of acupuncture in conjunction with medications. The supplementary use of post-operative acupuncture can decrease the need for opioid and/or other symptomatic control medications and thus facilitate early ambulation, fluid and food intake, and discharge.
   The physician should have a thorough understanding of acupuncture theory and point combinations required to achieve the desired effects. According to Eastern philosophy, the role of acupuncture is not to create a super being, but rather to bring the internal universe (body physiology) to a neutral, harmonious, and balanced state. Acupuncture is to be used to help the body adapt to the external universe, and to synchronize with the movements of the Five Elements to survive and maintain health. Without proper pulse, tongue, abdominal diagnoses, and individualized prescription treatment, formulated "cookbook" approaches will yield less than satisfactory results.
   Finally, the practice of acupuncture described herein is, in many ways, contrary to the philosophy of bringing the body to neutral. Peri-operative acupuncture attempts to achieve an abnormal state of sedation, insensitivity to pain, and reduced awareness and concern. This noble purpose is to be carefully pursued, always bearing in mind the physician's oath, "First, Do No Harm."

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