Acupuncture in Anaesthesia
Dr Konrad Streitberger
Clinic of Anaesthesiology, University of Heidelberg , Heidelberg, Heidelberg
Despite the long history of acupuncture, the first surgery in acupuncture analgesia without additional anaesthetics was reported to be performed in 1958 in China. This impressive introduction of acupuncture into anaesthesia was part of the political concept of Mao Tse Tung to combine traditional Chinese medical techniques and modern western medical concepts. The enthusiastic reports from China inspired acupuncturists and anaesthetists in the seventies, mainly from Austria and Germany to introduce acupuncture analgesia for surgery and to develop combined anaesthetic techniques. But these techniques remained in an experimental status and in competition to the modern anaesthetics they were never used widely in routine situations.
In Europe and America acupuncture became mostly popular in the treatment of chronic pain conditions. Nevertheless according to a NIH consensus conference on acupuncture in 1997 the best evidence of the efficacy of acupuncture is shown in two other, more anaesthesia relevant conditions. According to the literature it was stated that promising results showed efficacy of acupuncture in adult postoperative and chemotherapy nausea and vomiting and postoperative dental pain (NIH 1998).
The purpose of this review is to show the history and potential of acupuncture in anaesthesia from the view of western medical journals.
The first report of acupuncture analgesia for surgery in a western medical journal can be found in 1971 in JAMA (Dimmond 1971). One year later in 1972 the first surgery in acupuncture analgesia in Europe was reported from Vienna, Austria, when a tonsillectomy was successful performed without any other anaesthetics (Benzer 1972). These procedures needed intensive preoperative preparation of the patient, usually additionally premedication and sometimes if necessary application of local anaesthetic or intravenous analgesics during surgery. Later especially in Europe acupuncture analgesia was combined with general anaesthesia to improve patients comfort. Induction usually was performed with barbiturate and muscle relaxans and controlled ventilation was maintained with oxygen and nitroxide. With this combination rapid recovery, cardiovascular stability and reduction in the need for opioid drugs was reported in heart surgery (Herget 1976), as well as in thyroid surgery, abdominal surgery and eye surgery. All together more than 700 cases of acupuncture analgesia were reported 1976 in the German Journal "Anaesthetist" Volume 25.
Later also some controlled studies were performed. In the Lancet 1978 acupuncture analgesia was reported to be more effective than sham acupuncture for gastroscopy (Cahn 1978). In a study using acupuncture analgesia for abdominal surgery (Kho 1991) 90% less fentanyl was necessary than without acupuncture. In Oocyte aspiration for IVF (Stener-Victorin 1999) acupuncture compared to alfentanil showed no difference in pain or nausea but more stress and discomfort with acupuncture.
Only a few studies were performed to investigate the effect of acupuncture on volatile anaesthetic consumption. In a recent investigation TENS of an auricular acupuncture point was able to decrease volatile anaesthetic requirement of desflurane in volunteers (Greif 2002).
Depending on the author or the location of the surgery a variety of acupuncture points were described for acupuncture analgesia. Distal points like LI 4, PC 6, ST 36 are used as well as segmental points, paraincisional points or ear acupuncture points. The needles were stimulated manually or electrical (1-200 Hz, 1-40mA). Usually stimulation of the acupuncture points started about 20 minutes before surgery and was continued during operation.
In most of the reports also disadvantages of acupuncture analgesia like time intensity, lack of complete analgesia, possible non-responders, discomfort and awareness were discussed.
According to a review of Ernst and Pittler 1998, results of studies about acupuncture for postoperative dental pain were very promising. Results of studies about other postoperative pain conditions were contradictory. The reduction of postoperative pethidine with electroacupuncture after abdominal surgery in a controlled pilot study could not be repeated in a larger study by the same investigators (Christensen 1993). In knee arthroscopy (Gupta 1999) acupuncture could not reduce postoperative pain. In contrast recent studies showed decrease of postoperative opioid consumption by TENS (Chen 1998) or intradermal needles (Kotani 2001).
The most randomised controlled trials (RCT) in acupuncture exist for stimulation of PC6 for the prevention of PONV. In a review of 33 antiemesis Trials, 21 were about PONV (Vickers 1996). A Meta-analysis in 1999 found 19 RCT with different stimulation at PC6, like acupressure, manual acupuncture electroacupuncture and TENS with an overall good result concerning early nausea and vomiting (Lee 1999) except for children. But recent studies showed also significant effects for children in prevention of PONV with Korean hand acupressure (Schlager 2000) or intraoperative acupuncture and postoperative electrical stimulation at PC6 (Rusy 2002).