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ARTICLE
ANESTHESIA
Acupuncture-Assisted
Anesthesia
Yue-Pang Mok, MD
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
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
KHT (Hand
Points)12
Basic Principles
Of Electrical Stimulation To Acupoints (Intra-operative And Immediately
Pre-Operative)1,2,6,8,9,14,20,22
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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AUTHOR INFORMATION
Dr (Patrick) Yue-Pang Mok is a Board-certified Anesthesiologist and
specialist in Pain Management. He is a Diplomate of American Board of
Pain Medicine. Dr Mok practices Pain Management in Akron, Ohio, and
Medical Acupuncture in Medina, Ohio.
Yue-Pang Mok,
MD
3593 S. Arlington Rd, Suite C
Akron, OH 44312
Phone: 330-896-1517
Fax: 330-896-2450
E-mail: YPMOK@aol.com
Or
Ohio Pain Services, Inc
970 E Washington St
Medina, OH 44256
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