The Prospective Role of Acupuncture
in Perioperative Care
Eric Serejski
Distributor: Ebook: Amazon. (c) 2011.
Contents
1. Management of stress and anxiety
3. Management of side effects (nausea, sedation and fatigue) and pain
4. Postoperative and chemotherapy nausea
5. Postoperative complications
Objective
To highlight the prospective role of acupuncture in the following perioperative issues:
- Reduction of the incidence and severity of acute postoperative or posttraumatic pain.
- Enhancement of the patient comfort, satisfaction, and recovery.
- Reduction of postoperative complications and, in some cases, shortening of stays after surgical procedures.
Findings
The provision of acupuncture (AC) and electroacupuncture (EA) in perioperative period may add additional benefits to the conventional systems already in place.
Preoperative AC can promote harmonization of physiological functions as well as participate in stress management, thus inducing positive effects on surgical physical stress and psychological anxiety responses. AC has also shown to provide a more rapid return of consciousness, an absence of hypercapnia and a smaller decrease in pH.
Analgesic AC, used in preoperative, intraoperative, and postoperative phases can decrease pain both before and after surgery, decrease the use of sedatives and analgesics, and provide an improvement in the return to normal self-caring. The preoperative aspect of AC may be beneficial by virtue of the phenomenon of pre-emptive analgesia[1], while postoperative AC seems to impact both pain management, recovery rate, and some complications, thus potentially adding a therapeutic tool in the complex issue of postoperative care.[2]
Additionally, AC has shown to decrease side effects such as nausea and vomiting, dizziness, pruritus, sedation, restlessness, and xerostomia. The antiemetic aspect of AC has been endorsed by the NIH in 1997 and subsequent research continues to support this aspect. AC shows efficacy when applied either intra- or post-operatively either in conjunction with an antiemetic treatment or alone.
Several studies indicate that AC may have a role in the reduction or alleviation of postoperative complications such as reflex retention of the urine, impairment of the drainage function of the bronchi, intestinal paresis, bronchial asthma, vomiting, nausea, pain or itching in the stoma, chill, and hyperthermia.
Another aspect of AC relates to the promotion and enhancement of recovery. General wellbeing improves. Motion range has shown to improve significantly in one study. Another study on the role of AC in oocyte aspiration has shown that the AC group has a significantly higher implantation rate, pregnancy rate, and take-home baby rate per embryo transfer.
Finally, AC and electrical stimulation provides positive effect on wound healing, such as increase of blood supply in the stimulated areas, influence on the rate of wound healing and scar strength, wound contraction, better tensile properties, reduction of wound edema, and healing in a organized manner.
1. Management of stress and anxiety
The positive effects of preoperative preparation on postoperative recovery in patients undergoing elective surgery have been demonstrated. Psychological preparation on pain and recovery after minor gynecological surgery showed that prepared patients request significantly less postoperative analgesia and a tendency to report a more rapid return to full health.[3] Similarly extensive preparation for cardiac surgery has a positive effect on physical well-being and anxiety in patients who were anxious.[4] Relaxation training induces positive effects on surgical physical stress and psychological anxiety responses.[5]
The positive results of pre-operative management of stress and anxiety may be further enhanced by the use of AC during that phase. The effects of AC on depression, anxiety and stress have been positively studied. Eich, in a placebo-controlled, randomized, modified double-blind study, has shown that AC leads to a significant clinical improvement as well as reduction in anxiety symptoms in patients with minor depression or with generalized anxiety disorders.[6] The study of Luo et al has shows that the therapeutic efficacy of EA was equal to that of amitriptyline for depressive disorders. EA had a better therapeutic effect for anxiety somatization and cognitive process disturbance of depressed patients than amitriptyline with less side-effects.[7]
2. Management of pain
While AC has been known since the 70ties to modulate pain and to be used in surgical anesthesia, recent studies provide additional elements of its value in operative setups.
Wu et al have used functional magnetic resonance (MR) imaging to study eventual modifications of the central nervous system following AC stimulation. They found that AC stimulation (at points ST 36 and LI 4) resulted in activation of the hypothalamus and nucleus accumbens and deactivation of the rostral part of the anterior cingulate cortex, amygdala formation, and hippocampal complex, thus activating structures of descending antinociceptive pathway and deactivates multiple limbic areas subserving pain association.[8]
Peri-operative AC has been studied for structural problems and the study of Wang on 132 patients on its role in cases of lumbar disc protrusion refractory to conventional pain treatment showed that AC without oral medication conducted before and after corrective surgery provided decrease of pain both before and after surgery.[9]
Prospective randomized controlled trials have also shown the analgesic efficacy of AC for endoscopic procedures, including colonoscopy and upper endoscopy. AC has also been used for a variety of other conditions including postoperative ileus, achalasia, peptic ulcer disease, functional bowel diseases (including irritable bowel syndrome and nonulcer dyspepsia), diarrhea, constipation, inflammatory bowel disease, expulsion of gallstones and biliary ascariasis, and pain associated with pancreatitis.[10]
Wang’s study found AC to equal oral analgesics for discomfort during colonoscopy: Fifty-nine patients underwent consecutive colonoscopic examination with premedication of EA were compared with conventional meperidine analgesia (MA) in pain relief and changes of neurotransmitters in serum. The results showed that analgesic efficacy of both groups were the same but with less side effects in the EA group especially in regard to dizziness. Serum concentration of beta-endorphin in both groups has a similar curve change at 4 different phases during colonoscopy. Serum concentration of epinephrine, norepinephrine, dopamine and cortisol showed no significant difference between these two groups.[11]
Li’s study found that patients treated with AC before colonoscopy experience less pain and consume fewer sedatives and analgesics than patients prepared with sham or no AC.[12] 36 patients were prepared for colonoscopy with AC, without AC or “non-specific” AC (points not expected to bring about pain relief). In the 12 AC patients mean pain sensitivity, estimated during the examination by means of a visual analog scale, was significantly lower than in the groups without AC or “non-specific” AC. In addition, analgesics and sedatives needed to be given significantly less to those with AC than those without AC or with “non-specific” AC.
The randomized controlled study of Poulain et al involving 250 cancer patients undergoing abdominal or pelvic surgery assessed the use of EA as the sole analgesic within a standard anaesthetic.[13] Whilst there was no difference between the two groups in the anaesthetic dose, all of the patients in the control group required fentanyl whereas only 7 out of the 120 patients in the treatment group (i.e. 5%) needed it, and then at much lower doses than the control group. Furthermore, patients in the treatment group recovered spontaneous respiration and were extubated more quickly than patients in the control group. 74.1 % of patients in the treatment group recovered within 30 minutes following surgery compared to 55 % in the control group, and patients in the treatment group were extubated an average of 36 minutes earlier than those in the control group. Transcutaneous electrical nerve stimulation (TENS) was used for post-operative pain relief in the treatment group, while the control group received non-narcotic analgesics. There was no significant difference in the number of patients complaining of pain, but the requirement for additional pain relief was less in the TENS group. Finally, the return to normal self-caring was significantly improved in the AC group.
Cahn et al found similar results with gastroscopy: The analgesic effect of AC was evaluated by a double-blind controlled trial in 90 patients undergoing gastroscopy. The endoscopy was much easier and better tolerated after real AC had been performed. [14]
Four studies concluded that AC, or AC plus control medication, can be more effective in managing postoperative pain than no treatment or medication alone.[15] Two studies concluded that AC is of value in managing pain following oral surgery.[16]
3. Management of side effects (nausea, sedation and fatigue) and pain
EA in lower abdominal surgery (LI 4 and on peri-incisional locations) was conduced on 110 patients (4 groups). Results showed a decrease in nausea, vomiting, dizziness, pruritis, as well as a decrease in medications used for these conditions.[17]
In Chen’s study, transcutaneous electrical nerve stimulation (TENS) has been used as a supplemental therapy to opioid analgesics for pain relief after surgery. The use of TENS and dermatomal EA decrease of postoperative opiod analgesics requirements and opiod-related side effects (sedation, fatigue and nausea) in total abdominal hysterectomy or myomectomy.[18]
A variant of AC, auricular therapy, was used to test its efficacy in cancer pain and it was found that pain decreased and general wellbeing improved.[19]
Finally, several studies analysed the effect of AC for xerostomia (dryness of the mouth), a condition often observed in late cancer patients. In the study of Rydholm, AC had a dramatic effect on xerostomia and, subsequently, on dysphagia and articulation, with subjects showing definite improvement after 5 treatments.[20]
4. Postoperative and chemotherapy nausea
There is clear evidence that needle AC is efficacious for adult postoperative and chemotherapy nausea and vomiting and probably for the nausea of pregnancy.[21]
Controlled trials comparing AC to preoperative medication, sham needling, and TENS strongly suggest AC’s superiority to the controls in the treatment of postoperative nausea.[22] One study indicates AC to be equal to conventional medication for reducing nausea, and superior in reducing postoperative restlessness.[23] Another study found AC to be more effective than medication in reducing nausea and vomiting, but the results are not statistically significant.[24]
The study of Al-Sadi on the use of intra-operative AC in the prevention of postoperative nausea and vomiting was performed in 81 patients undergoing gynecological laparoscopic surgery (surgery at high incidence of pos-operative nausea and vomiting).[25] The incidence of postoperative nausea or vomiting in hospital was reduced from 65% to 35% compared with placebo and after discharge from 69% to 31%. In this study, AC was administered after anesthesia but before surgery and before administration of morphine. In addition, this study includes stratification of variables recognized to influence incidence of posterorative nausea and vomiting and tests AC as a prophylactic anti-emetic. On the other hand, the study of Weightman et al[26] found no beneficial postoperative anti-emetic effect from PC6 AC. However, AC appeared to be applied intra-operatively after the administration of an I.V. opiod and the subsequent study of Dundee & Ghaly demonstrated that application of AC prior to administration of an opiod has a significant beneficial effect.[27]
A large study concludes that AC is more effective than sham needling or not treatment in prophylactically managing the nausea of chemotherapy.[28] Another study shows that AC, in addition to an antiemetic treatment is more effective than antiemetic drugs alone in preventing nausea and vomiting in chemotherapy patients.[29] Another study reports that acupressure applied repeatedly after chemotherapy can prolong the antiemetic effect of AC.[30]
5. Postoperative complications
Efficacies of two methods of nondrug analgesia: AC (1000 cases) and TENS (91 cases), as well as of narcotic analgesics omnopon and promedol (229 cases) were compared in the immediate and early postoperative period. In 229 cases AC was used for the treatment of other functional complications of the postoperative period. The efficacies of the methods in question were assessed by formalized verbal estimation scales. Narcotic analgesics provided adequate analgesia in 75 to 79% of patients, electrostimulation in 61 to 64%, AC in 50% of patients. AC, though less effective than narcotic analgesics, helped arrest or noticeably alleviate the severity of such postoperative complications as reflex retention of the urine, impairment of the drainage function of the bronchi, intestinal paresis, bronchial asthma, vomiting, nausea, pain or itching in the stoma, chill, hyperthermia in 43 to 81% of cases. The authors come to a conclusion on the desirability of an integrative approach (combined use of drugs and nondrug methods of analgesia) in the management of postoperative pain.[31]
6. Recovery and enhancement
According to the study of He et al, AC seems to be an effective treatment to relieve pain and improve arm-movements after ablation and axillary lymphadenectomy.[32] 48 patients with mammary cancer after ablation and axillary lymphadenectomy were treated with AC; a control group of 32 patients with the same operation but without AC was compared. The results showed a significantly higher maximum abduction angle (AA) at the first treatment immediately after AC without pain with respect to maximum tolerable pain barrier. Between both groups there was a statistically significant difference in the appearance of pain in the operation field in the rest position on the 5th postoperative day, while on the 7th postoperative day and at the time of discharge a significant difference could not be seen. The percentage of patients with pain during arm movements showed a statistically significant difference between both groups on the 5th postoperative day, on the 7th postoperative day and at time of discharge. The differences in the abduction angle between both groups were also statistically significant on the 5th postoperative day at indolency with respect to maximum tolerable pain. The differences in the abduction angle on the 7th postoperative day at indolency and at maximum tolerable pain were statistically significant. This statistically significant difference in the maximum abduction angle between both groups at indolency with respect to maximum tolerable pain could be observed until discharge.
The randomized controlled trial of Stener Victorin E et al evaluated the anaesthetic effect during oocyte aspiration of a paracervical block (PCB) in combination with either EA or intravenous alfentanil. In all, 150 women undergoing in-vitro fertilization (IVF) and embryo transfer were randomized to receive either EA plus PCB or alfentanil plus PCB. Visual analogue scales (VAS) were used to evaluate subjective experiences during oocyte aspiration, and IVF outcome parameters were recorded. No differences in pain directly related to oocyte aspiration, adequacy of anaesthesia during oocyte aspiration, abdominal pain, or degree of nausea were found between the two groups in the VAS ratings. Before oocyte aspiration, the level of stress was significantly higher in the EA group than in the alfentanil group, and the EA group experienced discomfort for a significantly longer period during oocyte aspiration. Compared with the alfentanil group, the EA group had a significantly higher implantation rate, pregnancy rate, and take home baby rate per embryo transfer. In conclusion, EA has been shown to be as good an anaesthetic method as alfentanil during oocyte aspiration, and we suggest that EA may be a good alternative to conventional anaesthesia during oocyte aspiration.[33]
7. Physiological response
Kho’s study evaluated the efficacy of AC and transcutaneous stimulation analgesia, supplemented by small doses of fentanyl compared with moderate-dose fentanyl anaesthesia in 29 patients who underwent surgery for retroperitoneal lymph node dissection. The study describes the anaesthetic techniques and comparison of haemodynamics, demand for analgesics after surgery, recovery and blood gases, restoration of urinary and bowel functions, convalescence in terms of self-reliance and the postoperative course in respect of fatigue and morbidity. A more rapid return of consciousness, an absence of hypercapnia and a smaller decrease in pH were observed in patients who received AC and transcutaneous stimulation. No clinically relevant disadvantages attributable to the method were demonstrated.[34]
Tseng’s study showed attenuation of the catecholamine responses by electroAC (EA) during postoperative recovery period. The study consisted in EA in 10 patients, and placebo treatment in 10 controls, immediately after termination of inhalation for 15 min. During the postoperative recovery period, plasma catecholamine (CA) levels were assessed before (0) and 15 and 30 min after treatment. The time from cessation of inhalation to the first eye opening and to extubation did not differ between groups. The plasma catecholamine levels increased by 30% from 0 to 15 min in the control group but decreased by 6% in the EA group. The levels at 30 min were approximately the same as at time 0. The change in catecholamine levels from 0 to 15 min was significantly lower in the EA groups than the control group.[35]
The large study of Ponomarenko covered several additional effects of post-operative EA: One hundred and eight patients with gastric ulcer subjected to planned and urgent surgery have been treated for postoperative gastric atonia and intestinal paresis using EA. The treatment was effective in 85% of cases, with the efficacy confirmed by clinical results and gastroenterologic findings. EA promoted a decrease in the initially high blood levels of cortisol, aldosterone and histamine, an increase in serotonin and a reduction in gastric juice histamine levels, which were indicative of the analgesic and antihistamine EA effect and attenuation of parasympathetic activity. EA introduction into a complex of postoperative rehabilitation procedures led to reduction of drug doses or total drug replacement, early activation of surgical patients and prompt recovery of normal gastrointestinal evacuation.[36]
Another study from Kho et al, covers the effects of AC and transcutaneous electrical stimulation (TES) on anesthesia in major abdominal operation and on the potential variations of various hormones (adrenaline, noradrenaline, adrenocorticotropic hormone, beta-endorphin, anti-diuretic hormone and hydrocortisone). Post-operatively no differences in the hormonal profiles could be discerned between the groups with or without AC plus. It is concluded that AC and TES have no effect on the cardiovascular response to laryngoscopy and intubation. They can replace moderate-dose fentanyl anaesthesia in major abdominal surgery at the cost of a more enhanced per-operative neuroendocrine stress response, which does not, however, influence the postoperative hormonal profiles nor the rapidity of return to pre-operative values.[37]
8. Acupuncture and Cicatrisation
Experimental studies have shown that the stimulation of areas around wounds with electric current has a positive effect on wound contracture and to increase blood supply in stimulated areas.
Interest in the role of electrical interactions as epigenetic regulators of wound healing had its beginnings nearly 40 years ago. Because the mechanisms of action are not understood (which obviates rational therapy), the empiric application of fields to wounds has produced mixed results. However, taken collectively, numerous human and animal efficacy studies have demonstrated that electrical stimulation of the correct charge, density and total energy causes dramatically improved healing of dermal wounds. Tests on soft tissues of animals have shown that electric stimulation can influence the rate of wound healing and scar strength. Natural epithelial-derived sodium currents have been discovered in the wounds of invertebrates and mammals.[38]
Living tissues possess direct current surface electropotentials that regulate, at least in part, the healing process. Following tissue damage, a current of injury is generated that is thought to trigger biological repair. In addition, exogenous electrical stimuli have been shown to enhance the healing of wounds in both human subjects and animal models. Intractable ulcers have demonstrated accelerated healing and skin wounds have resurfaced faster and with better tensile properties following exposure to electrical currents.[39]
Chu et al observed the effect of 4 and 40 microA direct current (DC) on edema formation after burn injury in rats. Immediately applied, continuous DC reduced burn edema by 17 to 48% at different times up to 48 hours postburn. Neither reversal of electrode polarity nor change in current density had any significant effect on the results of treatment. Starting treatment during the first 8 hours postburn produced the least edema accumulation, but the reduction was significant even when DC was applied 36 hours afterburn. If started immediately after injury, treatment had to be continued a minimum of 8 hours to be most effective. According to the study, direct electric current has a beneficial effect in reducing wound edema after burn injury.[40]
Gentzkow et al discuss recent research and advances in electrical stimulation of wound healing. Based on the latest scientific understanding of the wound healing process, one would expect a beneficial outcome from a therapy what decreases edema, debrides necrotic tissue, attracts neutrophils and macrophages, stimulates receptor sites for growth factors, stimulates growth of fibroblasts and granulation tissue, increases blood flow, stimulates neurite growth, induces epidermal cell migration, prevents post-ischemic oxygen radical-mediated damage, inhibits bacteria, and reduces numbers of mast cells. Taken together, the efficacy studies and the "mechanism of action" studies provide compelling, scientific evidence that electrical stimulation is safe and effective for promoting the healing of dermal wounds.[41]
Stromberg et al further evaluate the effects of electrical currents on wound contraction. Their prospective randomized evaluation of the potential beneficial effects of electrical currents has been studied in 13 wounds in 7 pigs. The effect of electrical current was assessed by evaluation of wound contraction and residual open wound area. A 35 mA unipolar square wave stimulation for one-half hour stimulation periods twice a day showed consistent results in 13 wounds in 7 pigs. Application of negative currents shows no stimulation of wound contracture. In fact, negative currents seemed to retard wound contracture. After two weeks of treatment, the control wound had decreased to 58% of its original size, whereas wounds treated with negative currents were 93% of their original size. On the other hand, negative currents alternating with positive currents increased the rate of wound contraction for the first two to three weeks of treatment. At two weeks these wounds were 18% of their original size and continued to decrease to 5% by three weeks. Wound contraction may be increased by electrical currents. The concept of alternating negative and positive currents has not been previously described and seems to offer some promise in this early study.[42]
Castillo evaluated the effect of electrostimulation on wounds in rats and found the healing to proceed in a thoroughly organized manner. A trial using rats subjected to second degree burns was conducted to evaluate, under scanning electron microscopy (SEM), the healing capabilities of skin to which an antiseptic (iodine) and referred electrical stimulation were applied. Untreated, unharmed skin was also studied as control. Images obtained using SEM revealed that only the repaired skin of the electrostimulated group had an appearance similar to that of the control skin (kappa = 1), and that the overall appearance of the repaired skin was compatible with a well-organized healing process.[43]
Sumano and all found the same organized healing in patients seeking alternative medicine after unsuccessful conventional medical treatment. Electricity was delivered in two forms: (1) For wounds with extensive loss of tissue and/or those that had failed to heal spontaneously, electrical stimulation was delivered via subcutaneously inserted needles surrounding the wound edges and applying a dose charge of 0.6 coulombs/cm2/day; (2) in second degree burn injuries, lesions were covered with gauze soaked in a 10% (w/v) sterile saline solution and the same dose of electricity was applied as for (1). Forty-four patients were treated with electrical stimulation of the skin; 34 in group (1) and 10 in group (2). Following electrostimulation in all patients in both groups healing proceeded in a thoroughly organized manner, almost regardless of the severity of the type of wound or burn treated.[44]
In addition to wound healing, Adamian also found that ES promotes successful taking of dermal autografts. The obtained data show that ES through a current-conducting carbon tissue is promising in the complex of measures for local treatment of burn wounds.[45]
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