Anesthesia For A Patient
With Complex Congenital Anomalies
Yuan-Chi Lin, MD
To describe the use of acupuncture anesthesia for a patient with complex
A 25-year-old woman with achondroplastic dwarfism and multiple congenital
vascular aneurysms scheduled for bilateral myringotomy tube placement.
HISTORY OF PRESENT ILLNESS
The patient had chronic serous otitis media, eustachian tube dysfunction,
and mixed hearing loss in both ears. She was scheduled for bilateral
tympanostomy and ventilation tube insertion. Her complicated medical
history included achondroplastic dwarfism, multiple congenital aneurysms,
chronic headache, chronic back pain, and mitral valve placement. Due
to the complexity of her underlying conditions and the risk of general
anesthesia, the patient and the surgeon requested acupuncture anesthesia
for the surgery.
Medications included Digoxin 0.05 mg orally twice daily, warfarin 2
The patient had no history of drug allergy.
PAST SURGICAL HISTORY
Mitral valve replacement, cleft palate surgery, and multiple iliac artery
and femoral artery vascular reconstructive surgeries for aneurysms.
The patient was a bright, recent college graduate with no family history
of similar congenital disease.
PHYSICAL EXAMINATION AND DIAGNOSIS
The patient appeared anxious, was small (weighing 14 kg), and was able
to use a motorized wheelchair without difficulty. She was afebrile with
a heart rate of 90/min and respiration rate of 18/min. Blood pressure
was 120/72 mm Hg, and room air oxygen saturation was 98%. Chest auscultation
was clear with bilateral equal breath sound. Her heart had regular rate
and rhythm. A surgical scar was noted in her mid-sternum area. The patient's
abdomen was soft and her extremities were cold with adequate peripheral
circulation. The temperature in her lower extremities was lower than
in the upper extremities. She had poor intravenous access. Two palpable
solid aneurysms were noted in the right axilla (5x5 cm) and right leg
(3x3 cm). Oral examination revealed a bluish-purple tongue with a split
tip. Pulse diagnosis was as follows (Figure 1).
|Figure 1. Pulse Diagnosis
||Weak and thin
||Slightly rapid (90/min)
||Deficiency syndrome, Liver Yin deficiency, Liver Fire hyperactivity,
Kidney deficiency, Qi and Blood deficiency, and obstruction of the
A complete medical assessment was performed prior to the procedure.
The patient's informed consent was obtained regarding acupuncture-assisted
anesthesia and possible general anesthesia as a back-up plan. She was
brought to the operating room 30 minutes after application of 5 g of
EMLA cream (a eutectic mixture of lidocaine and prilocaine) to each
ear canal. Non-invasive monitors were placed, which included dinamap
for blood pressure, electrocardiogram, and pulse oximeter.
POINTS AND TECHNIQUES
LI 4 (ho gu), TH 5 (wai guan), and ST 36 (zu san li) were stimulated;
ITO No. 3 (0.2x40) acupuncture needles (ITO Co Ltd, Tokyo, Japan) were
used for acupuncture. Initial acupuncture with De Qi, then constant
needle manipulation on LI 4, TH 5, and ST 36 points were performed throughout
the surgery. The surgeon entered 40 minutes later and the old myringotomy
tubes were removed and replaced with new ones. The patient tolerated
the procedure well, without complication (Figures 2 and 3). She was
then observed in the recovery room for an additional 30 minutes prior
to discharge home with a parent. The day after the surgery, the patient
stated that she had been extremely anxious and apprehensive about the
surgery. After acupuncture began, she reported feeling relaxed as if
she were lying on a beach throughout the surgical procedure.
Otitis media is a common problem in children.1 It is thought to be due
to heat, cold, or dampness entering the ear canals, i.e., Gallbladder
and Triple Heater, and obstructing the flow of Qi in the ear. Acupuncture
analgesia is addressed at the channels around the ear, and distal acupuncture
points are commonly used. Three acupuncture points were chosen for this
case: TH 5 (wai guan) is a luo point, which expels wind and regulates
Qi circulation; LI 4 (ho gu) is a source-yuan point of hand Yang-Ming
and the command point of the face and mouth; ST 36 (zu san li) is a
uniting-he point, which regulates and tonifies Qi.
Acupuncture is used for anesthesia and analgesia during various operations.2
It has been used for surgery on the brain, head, teeth, ear, nose, throat,
neck, thyroid gland, chest, abdomen, limbs, and in various obstetric
and gynecological surgeries.3-7 The use of acupuncture anesthesia and
analgesia in the operating room depends on the availability of properly
trained personnel. The team should be composed of those who have expertise
in the use of anesthetic agents and are familiar with acupuncture analgesia.
The surgeon must be skilled, alert, and capable.8 A comprehensive pre-operative
assessment is essential to evaluate the patient as a whole, focusing
on the surgery site as well as any co-existing diseases. Optimizing
the patient's condition will allow the patient to tolerate surgery safely
and facilitate recovery.
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Acupuncture-assisted anesthesia. Medical Acupuncture. 2000; 12(1):28-31.
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Chin Med J. 1995;108:870-871.
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Dr Yuan-Chi Lin is a Pediatrician, Anesthesiologist, Pain Specialist,
and Medical Acupuncturist. Dr Lin is the Director of the Medical Acupuncture
Service at Children's Hospital Boston, Harvard Medical School, Boston,
Yuan-Chi Lin, MD, MPH, FAAP
Medical Acupuncture Service, Department of Anesthesia
Children's Hospital Boston
300 Longwood Ave
Boston, MA 02115
Phone: 617-355-4158 Fax: 617-355-4924