MEDICAL ACUPUNCTURE APPLICATIONS IN SURGICAL ANESTHESIA

PATRICK Y.P. MOK, M.D.

ABSTRACT -- Numerous reports have been published during the last twenty years regarding medical acupuncture applications in surgical and obstetrical anesthesia. According to the available literature, acupuncture anesthesia appears to have originated in mainland China. There are sporadic reports of successful application of medical acupuncture in Anesthesia in the United States, Hong-Kong, Japan, and various countries in Europe. This report is based on the observation of a limited number of cases at a community hospital in Ohio, during a period between 1989 and 1990.

     "Complete anesthesia" is defined as consisting of amnesia, unconsciousness, analgesia, and complete muscle relaxation. There is ongoing controversy regarding whether regional anesthetics and epidural morphine applications should be considered as complete anesthesia under this definition. Medical acupuncture application in surgery is even further from satisfying this stringent definition of complete anesthesia. Therefore, it seems best not to use the term "acupuncture anesthesia'' to describe the application of medical acupuncture to anesthetic procedures. Rather, "acupuncture analgesia" may more accurately describe such applications of medical acupuncture.
     Medical journals in the United States have repeatedly reported the use of acupuncture. It appears that the role of medical acupuncture in pain management is well defined. The advantage of acupuncture in controlling post operative nausea has also been reported recently in the anesthesia literature.
     In 1989, after extensive review of the available literature regarding acupuncture applications in anesthesia, a protocol was created at our institute. The sources of information included data from China, Hong-Kong, Japan, the U.S. Journal of Regional Anesthesia, as well as reports from experiences in veterinarian surgery. Also, discussions were held with the department of surgery regarding the required modifications in surgical techniques that would be necessary in cases where surgical analgesia were to be provided with medical acupuncture. In March 1989, an article appeared in the Journal of Regional Anesthesia reporting the successful use of medical acupuncture in microsurgery. This report afforded further encouragement to begin a series of cases in a community hospital setting.
     Information was also obtained from the "U.C.L.A. Research on Auricular Acupuncture" monograph, which described in detail auricular points used in anesthesia and postsurgical pain control.

CASE REPORT # 1
     In May of 1989, the first appropriate candidate for this approach came to our attention. He was a 64-year-old white male who suffered from chronic intestinal adhesions, abdominal distention and severe chronic obstructive lung disease. The patient required 24-hour oxygen for his survival. He had developed a large incarcerated inguinal hernia with constant and excruciating pain for which surgery was indicated. On physical examination, the patient was found to have a barrel chest that provided him with very little movement for adequate ventilation. His primary ventilatory effort was through his abdominal muscles. The patient also had a history of congestive heart failure, hypertension, cardiac dysrrhythmias, and peptic ulcers with recurrent bleeding. He had to be on corticosteroids and antidepressants in addition to the standard cardiopulmonary medications for his condition. Two months prior to this episode, the patient suffered from a severe case of herpes zoster that was successfully controlled with medical acupuncture, giving the patient confidence in this therapeutic modality. A lengthy discussion was conducted with the patient and his wife explaining that, given his condition, general anesthesia was contraindicated. Furthermore, a spinal or epidural anesthetic could potentially abolish his abdominal muscle function, thereby causing respiratory embarrassment. It was explained that, although there were other choices available, medical acupuncture was a most logical technique to help him through the surgical procedure. It was emphasized that this was an experimental procedure in our institution. The patient and his wife consented to the use of acupuncture analgesia.
     Preoperative preparation was conducted by a cardiologist and a pulmonologist, in an effort to optimize the patient's physical condition. A detailed preoperative discussion was held with the surgeon. Approximately 30 minutes prior to the surgery, the patient received midazolam 3 mg intramuscularly. This is a benzodiazepine which is commonly used parenterally (IM or IV) as a short-acting sedative in the premedication phase before surgery. No narcotics were ordered at this time, in an effort to avoid respiratory suppression. Following administration of the preoperative medication, the patient was placed on cardiac monitoring and pulse oximetry. Two liters per minute of nasal oxygen were provided. Acupuncture was then applied to selected points on both lower extremities, as well as on the left upper extremity and the auricles, bilaterally. Within ten minutes the patient became very relaxed and his respiration was noted to be smooth and comfortable. Pulse oximetry indicated a satisfactory level of oxygen saturation (greater or equal to 95%). The patient was also able to tolerate a supine position following the application of acupuncture, which he had been entirely unable to do previously, due to his chronic obstructive pulmonary disease. This may have been the result of either acupuncture alone or in combination with the anxiolytic effect of IM midazolam. After twenty minutes of acupuncture application, the patient was transferred to the operating room. At this time he received 12.5 mg meperidine intravenously. Verbal contact was maintained with the patient to insure that he remained comfortable and ventilating adequately. Following skin preparation and surgical draping, a 12 cm. surgical incision was made. No local anesthetic was used. The patient did experience some pain as the incision was made, but it was transient and he requested no medication. All through the soft tissue dissection and closure of the hernia ring, the patient did not complain of pain. A small amount of local anesthetic was employed around the major nerves to be resected. The patient appeared relaxed and comfortable throughout the procedure. He complained of some pain during the suturing of the muscle layer. A small dose of meperidine was given intravenously again. A mesh insertion was also conducted, along with resection of part of the omentum, which allowed complete closure of the wound. Muscle relaxation for this procedure was not entirely satisfactory, but it was improved by verbal coaching which led the patient to relax his abdominal musculature. The surgery was successfully completed in one hour and fifteen minutes. The total dose of meperidine used during surgery was 37.5 mg, and a total of 15 cc of 0.5% lidocaine was employed (normally, 50-60 cc of lidocaine are used on similar procedures).
     Postoperatively, the patient continued to feel comfortable. He did not request any analgesics while in the recovery room. He was able to drink some fluids immediately after surgery without difficulty. His cardiopulmonary status remained stable throughout. The patient's chronic sinus tachycardia was also attenuated, decreasing from an average of 100-110/min. to 90-95/min. The surgical incision and manipulations never raised the patient's blood pressure or pulse. Even while complaining, the patient's vital signs were stable. Pulse oximetry readings were maintained at 95-97% saturation. Given the patient's remarkably stable postoperative condition, he was discharged from the hospital to his home within two hours after the surgery. Communication by telephone was maintained with him during the evening and following day. The patient reported no difficulties and did not require any pain medication. Indeed, the only analgesic medication taken by the patient throughout his entire postoperative week was one tablet of oxycodone 5 mg and acetaminophen 325 mg, prescribed by an anesthesiologist just prior to his discharge from the recovery room. The surgeon reported that the patient did not complain of any significant pain during the week following his discharge.

CASE REPORT # 2
     In July of 1989, an 80-year-old male patient was admitted for a left inguinal hernia repair. The patient had a history of unstable angina, bifascicular block, cardiac arrhythmia and dilated cardiomyopathy. This patient also consented to the experimental application of medical acupuncture for anesthesia. Preoperatively he received an intramuscular injection of meperidine 25 mg and 3.5 mg of midazolam. Acupuncture application was the same as in the first case. The surgical procedure lasted approximately 40 minutes. The patient's vital signs remained stable and he did not complain of pain during the surgery, except at the skin incision. This complaint was transient. Nevertheless, he was given 6 mg of morphine sulfate IV, along with 5 cc of plain 1% lidocaine injected subcutaneously along the incision. The patient's cardiopulmonary status remained stable throughout the procedure and postoperative period. He was discharged two and a half hours after surgery without any complications.
     The same patient returned in six weeks for a fight inguinal repair. He again requested acupuncture as his anesthetic procedure for the surgery. The same amount of medication was given along with medical acupuncture, and the patient completed the second surgery satisfactorily. He took three doses of oral analgesics at home within a 24-hour period following surgery, but no further pain medication was necessary thereafter.
     Two other cases were conducted in the same manner with equal success. This small collection of inguinal hernia repairs performed under medical acupuncture, confirm the positive results of previous reports. It also provides a model for employing such techniques in a community hospital setting.
     In addition, there was one case of a laparoscopic tubal ligation performed primarily under medical acupuncture in combination with hypnosis and a small amount of local anesthetic. The results were successful. The patient was discharged in less than one hour after surgery. She required only one tablet of propoxiphene napsylate 100 mg with 650 mg of acetaminophen. She took no other analgesics during her entire postoperative period.
     Finally, an attempt was made to perform a cholecystectomy with medical acupuncture for anesthesia/analgesia. The initial stages of the operation were performed successfully with no complaints from the patient. The skin incision as well as the exposure of the gallbladder provided the patient with no significant discomfort. However, when the surgeon began to explore the bowel, the patient complained of pain due to visceral traction. Further exploratory efforts precipitated restlessness in the patient, and general anesthesia had to be induced.

DISCUSSION
     Based on previous reports and the observations of this limited number of cases, the following conclusion can be drawn:

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