preoperative electrical ear acupuncture for postoperative pain following abdominal hysterectomy

1. By:
Mohamed Abuelnaga, MD
Lecturer of anesthesia, SCU
Egypt
Postoperative analgesic efficacy of
ear acupuncture in patients
undergoing abdominal hysterectomy:
a randomized controlled trial

2. Background and
rationale

3.  Acupuncture is considered as a traditional
therapeutic technique with a long history of
4000 years.
 Electro-acupuncture is a new type of hand
acupuncture that can deliver effective
analgesia with a minute physiological
disturbance.
 It was used effectively for pain management
in different disorders including post-surgical
pain following cesarean section, gastrostomy,
and enterectomy.
-Haltrecht H. Veterinary acupuncture: Can Vet J 1999; 40: 401–3.
-Taguchi R. Acupuncture anesthesia and analgesia for clinical acute pain in Japan: Evid Based Complement Alternat
Med 2008; 5: 153-58.

4.  Kitade and Hyodo , investigated the effect of
auricular acupuncture stimulation on the
threshold of somatic pain.
 They found the Shen-Men, lungs,
sympathicus, and kidney points showed a
significant pain threshold rise when compared
to non-acupuncture auricular points.
Kitade T, Hyodo M. The effects of stimulation of ear acupuncture points on the body's pain threshold. Am J Chin Med 1979;
7:241–52.

5.  It is believed that the human body has energy
pathways or channels representing the internal
organs.
 Energy is thought to stream continuously through
these pathways ending to the body surface with
acupuncture points that work as gateways to these
channels.
 Stimulation of these acupoints is claimed
to activate the body’s inherent healing
power

6.  Generally, acupuncture can boost physical and
emotional health through the release of certain
neurochemicals from the nervous system, as well
as affecting cerebral areas responsible for
reducing pain and anxiety.
 Acupuncture can help in postoperative pain
reduction by altering the brain's chemistry,
increasing endorphins and neuropeptide Y levels,
and reducing serotonin levels
-Vadivelu N, Mitra S, Narayan D. Recent advances in postoperative pain management. YJBMAU 2010; 83:
11.
-Rubach, A. Principles of ear acupuncture—microsystem of the auricle, hippokrates. 2001

7. What is well known
about perioperative
acupuncture analgesia ?

8.  Several publications have found the analgesic
effectiveness of body acupuncture in
gynaecologic surgery including hysterectomy
 Study 1: Lin JG, Lo MW, Wen YR, Hsieh CL, Tsai SK, Sun WZ. The
effect of high and low frequency electroacupuncture in pain after
lower abdominal surgery. Pain 2002; 99: 509-14
 Acupoints: Body (ST-36) bilateral
 Type of surgery and anesthesia: Abdominal hysterectomy
under general anesthesia
 Time of stimulation: Electro-stimulation 20 minutes before
induction of anesthesia, needles removed before induction of
anesthesia

9.  Study 2: Kim KS, Nam YM. The analgesic effects of capsicum
plaster at the Zusanli point after abdominal hysterectomy. Anesth
Analg 2006; 103: 709-13
 Acupoints:Body (ST-36) bilateral
 Type of surgery and anesthesia: Abdominal
hysterectomy under general anesthesia
 Time of stimulation: Capsicum Plaster for 30 min
before induction of anesthesia and maintained for
8 h per day for 3 postoperative days.

10.  Study 3: Sim CK, Xu PC, Pua HL, Zhang G, Lee TL. Effects of
electroacu- puncture on intraoperative and postoperative analgesic
require- ment. Acupunct Med 2002; 20: 56 - 65
 Acupoints:Body (ST36 and PC6 ) bilateral
 Type of surgery and anesthesia: Total abdominal
hysterectomy with or without bilateral salpingo-
oophorectomy under general anesthesia
 Time of stimulation: Electro-stimulation for 45
minutes preoperative versus 45 minutes
postoperative

11.  Study 4: Chen L, Tang J, White PF. The effect of location of
transcu- taneous electrical nerve stimulation on postoperative
opioid analgesic requirement: acupoint versus nonacupoint
stimulation. Anesth Analg 1998; 87: 1129-34
 Acupoints:Body (ST 36, abdomen at dermatomal levels of
the incision
 Type of surgery and anesthesia: elective abdominal
hysterectomy or myomectomy under general anesthesia
 Time of stimulation: Electro-stimulation postoperative for
30 minutes, The patient was instructed to use the TENS
device every 2-3 h While awake, as well as at bedtime and
on waking in the morning.

12.  Study 5:Sun Y, Gan TJ, Dubose JW, Habib AS. Acupuncture
and related techniques for postoperative pain: a systematic
review of randomized controlled trials. Br J Anaesth.
2008;101(2):151-160
 15 RCTs:
 12:body acupuncture for different surgeries
including hysterectomy
 3:ear acupuncture for
Ambulatory knee surgery
Hip arthroplasty
Molar tooth extraction

13.  A single study discussed the effect of
postoperative auricular ear acupuncture on
post-hysterectomy pain; acupuncture
stimulation was done 24 hours after surgery.
 TSANG, Hin Cheung, et al. A randomized controlled trial of
auricular transcutaneous electrical nerve stimulation for
managing post-hysterectomy pain. Evidence-based
complementary and alternative medicine, 2011, 2011.

14. what is new in our
study ?

15. The new in our study that we used
preoperative auricular acupuncture, as we
believe that it has a pre-emptive effect.
Also, we decided also to use continuous
postoperative ear acupuncture to enhance the
postoperative analgesic effect.

16. Aim of the
work

17. This study aims to investigate the role of
preoperative electric ear acupuncture in
reducing post-operative pain in patients
undergoing hysterectomy by fine acupuncture
needles for four points of ear acupuncture.
The primary objective:
postoperative analgesic requirement
The Secondary objectives :
Intraoperative hemodynamic parameters, Post-
operative pain scores, and Postoperative 1st
request of analgesia.

18. Patients and
methods

19. Type of the study :single-blinded randomized
controlled clinical trial
Patients:
After Obtaining approval by the Hospital Ethics
Committee,56 patients were randomized into
two equal groups:-
Group I (EEA group): 28 females received electric
ear acupuncture after spinal anesthesia.
Group II (control group): 28 females received
spinal anesthesia without ear acupuncture.

20. Inclusion criteria :
 Age between 21-60 years
 ASA physical status I & II.
Exclusion criteria:
 contraindications for spinal anesthesia or ear
acupuncture
 allergy to morphine, and/or bupivacaine
 morbid obesity .
 psychological disease.
 narcotic abuse,prolonged use of sedatives or
opioid drug use
 patient refusal to participate in the study

21. Methods

22. Preoperative assessment:
 Full clinical examination
 Laboratory investigations
Intra-Operative measures:
 Routine Monitoring equipment was attached to the
patient.
 500 mills of I.V fluid were administrated.
 No premedications were given.
 All patients received spinal anaesthesia with
hyperbaric bupivacaine 0.5% (15-20 mg) according
to the patient’s height, in the L4- L5 intervertebral
space, with no supplementary opioids.
 The level of anaesthesia was assessed by pin-prick
every 5 minutes in the first 20 minutes till it
reached T4-T6 .

23. EEA was done by fine needles (10mm x
30guage) to the anatomically defined 4
auricular points :
 Shen Men Point (point 55) which is a sedative
analgesic anti-inflammatory point.
 Thalamus Point 26 which is an analgesic
point in acute and chronic severe pain,
 Analgesia Point 3
 Uterus Point 58.
Rubach, A. Principles of ear acupuncture—microsystem of the auricle, hippokrates. 2001.

25. Then four pre-sterilized single-use
acupuncture needles were inserted in the
predetermined acupoints and connected to
clamps of electrode cords that were connected
to the electro-acupuncture therapeutic
apparatus (KWD-808I MULTIPURPOSE HEALTH DEVICE, Changzhou
Yingdi Electronic Medical Device Co., China).

27. The EA device was adjusted according to the
instruction manual for use to provide
continuous-wave with a frequency of 2Hz and
output impulse amplitude of 6-10 volts
according to the patient's ability.
At the end of the surgery, the electro-
acupuncture device was switched off and the
fine needles were replaced by press needles in
the same acupoints to be removed after 24
hours.

28. Postoperative analgesic plan:
 At the end of surgery ,Diclofenac potassium
75 mg was administered to all patients by IM
injection.
 When the reported visual analog scale was 3
or more, a loading dose of morphine 0.05
mg/kg was administered via slow I.V. route.
 Then, a PCA was administered. The PCA pump
was loaded with 1mg / ml of morphine and
set to deliver on-demand doses of 2 ml with
10 minutes lockout intervals and 4 hours limit
of 20 mg. No background infusion was
allowed

29. Outcome
measurements

30.  Vital signs were recorded every 5 minutes in the first
20 minutes, then every 20 minutes for the rest of the
surgery, then after 1, 3,6,12, and 24 hours
 Post-operative pain assessment was done by visual
analog scale .
 The 1st 24 hours postoperative morphine
consumption.
 Side effects associated with morphine consumption
as nausea, vomiting, and over sedation.
 Side effects associated with auricular acupuncture-
like bleeding, excessive pain, fainting, broken
needles, and local infection were recorded.

31. Results

37. Conclusion

38. Auricular acupuncture is a useful analgesic
adjuvant as it reduced postoperative analgesic
requirements following abdominal
hysterectomy. It provided more patient
satisfaction regarding postoperative pain
control without any hazard.

39. Study limitations and
recommendations

40.  The analgesic effect found in the current study
can be the result of either preoperative EEA,
continuous post-operative acupoint stimulation
by press needles, or combined effect of both
techniques.
 Comparison between EEA and pressure
acupuncture in the same acupoints is
recommended in future studies.

41.  The other limitation in the current study was
the use of a single postoperative non-opioid
analgesic.
 In future studies, at least two non-opioid
analgesics should be used to determine the
real influence of acupuncture on
postoperative analgesia requirements.

43. Thank
you