Acupuncture as a Complementary Treatment Modality in the Post-Anesthesia Care Setting: A Feasibility Study

Introduction

Postoperative pain management and postoperative nausea and vomiting (PONV) are challenging for both health care providers and patients. Unfortunately, many of the pharmacologic therapies currently used to treat pain and nausea have numerous undesirable and problematic side effects. For example, there is a significant risk for respiratory depression with opioids and gabapentin, or QT interval prolongation and extrapyramidal side effects with common antiemetic drugs. Given the current global opioid use epidemic and crisis, this challenge is heightened as the medical community is tasked with finding nonpharmaceutical methods for postoperative pain relief. ^1,2

Acupuncture is a Traditional Chinese Medicine practice in which needles are placed into the skin at specific points to balance the body's vital energy, called qi. Because acupuncture is effective and safe in the management of many types of pain, it has the potential to play a key role in postoperative pain management. ^3,4 With a notably low-risk profile for adverse events and generally low resource requirement, acupuncture is an optimal candidate for postoperative pain management. ^5,6

A recent study demonstrated improved pain and reduced opioid requirements with the acute use of acupuncture and related therapies in the perioperative setting. ⁴ In addition to treating pain, acupuncture has also been successfully used to relieve anxiety and nausea, both of which are common postoperatively. ⁷ The fact that many opioids cause nausea and vomiting as side effects compounds the benefits provided by acupuncture when its use also reduces opioid requirements. ⁸

In 2016, The American Pain Society could neither recommend nor discourage the use of acupuncture and related interventions in their clinical guidelines for the management of postoperative pain due to insufficient evidence. ⁹ However, since those recommendations, there have been several recent randomized controlled trials demonstrating the efficacy of acupuncture on decreasing postoperative pain for a variety of surgeries, as well as efficacy at reducing perioperative anxiety and PONV. ^{10 –16} Given patients have high interest in perioperative acupuncture, there is a keen interest in finding ways to incorporate acupuncture in this setting. ¹⁷ This study aims to further explore the utility and feasibility of acupuncture in the immediate postoperative setting at a single academic hospital.

Materials and Methods

This study was approved by the Mayo Clinic Institutional Review Board. This is a single center retrospective study evaluating 22 patients who electively received acupuncture in the post-anesthesia care unit (PACU) at Mayo Clinic Arizona between June 2019 and July 2019. These patients underwent a variety of surgical procedures. The PACU nurses could refer patients for acupuncture when they continued to report pain, nausea/vomiting, and/or anxiety despite appropriate treatment with medications.

Notably, patients could have multiple indications for acupuncture. These patients were provided the option to receive acupuncture while in the PACU when they were able to appropriately participate in all elements of a standard informed consent as assessed by the PACU nurse. ¹⁸ A total of 88 control patients, 4 control patients per patient who received acupuncture intervention, were selected. ¹⁹

These patients underwent surgery from January 2019 to December 2020 and were selected from a retrospective chart review to correspond to the intervened patient based on age, gender, surgical procedure, and comorbidities. Acupuncture therapy was administered by a licensed acupuncturist who practices at Mayo Clinic. Acupuncture points were chosen at the discretion of the acupuncturist and tailored to each patient.

A specific uniform acupuncture protocol was not used in this study. Each patient's point prescription was determined by chief complaint, tongue and pulse examination, location of surgery, and location of medical equipment. Distal points were chosen for surgical pain related to the channels affected by the surgery site. For example, treatment for an abdominal surgery would involve the stomach, spleen, and kidney channels; therefore, leg points along these channels were used to address pain.

Common pain points, such as LI4 and LV3, were used on most patients without medical restrictions. Nausea was treated with common nausea points such as ST36 and PC6. Most patients received some anxiety support with points such as Yin Tang and Shen Men. Given the nervous system activation after the surgical procedure, small thin Seirin No.1 (.16 × 15 mm) needles were used with neutral stimulation. Needles were generally retained for 20 min, and two patients had needles added 10 min into treatment due to continued symptoms.

The electronic medical record was used to identify demographic data, surgical procedure, American Society of Anesthesiologists (ASA) physical status class, race, ethnicity, and comorbidities. Dosage of opioid medications, nonopioid pain medications, and antiemetic medications were recorded for the preoperative, intraoperative, and postoperative periods. Morphine milliequivalents (MME) were calculated for the preoperative, intraoperative, postoperative, and total perioperative period. ²⁰

Highest pain score while in the recovery room was obtained for both groups from the chart. While in the PACU, a patient's pain score was recorded every 15 min using the Numeric Rating Scale (0–10), with 0 being no pain and 10 being the worst pain imaginable. For patients who were not able to verbalize pain, the Wong-Baker face scale was used. After acupuncture therapy, patients were provided surveys that queried their reasons for agreeing to have acupuncture, symptom improvement with acupuncture, whether they would pursue acupuncture again, and if they would recommend it to other patients (Supplementary Appendix SA1).

The PACU nurse caring for the patient also received a survey to assess their perspectives on the acupuncture therapy their patient received. The survey was two questions on how helpful the nurse perceived the acupuncture to be for their patient and how disruptive the acupuncture treatment was regarding workflow, both ranked on a 1–5 scale (Supplementary Appendix SA2).

The primary outcome measure was to assess the feasibility of acupuncture therapy by investigating patient and nursing perspective of the therapy. Secondary outcomes included total perioperative opioid consumption in MME, highest numerical pain score in the PACU, incidence of PONV determined by antiemetic medication requirements in recovery period, PACU length of stay, and unintended hospital admissions.

Results

Twenty-two patients elected to receive acupuncture therapy in the PACU during the study period. Eighty-eight control patients, four per each patient that received acupuncture, were selected to correspond to the intervened patient. Acupuncture was tailored to each individual patient. The various acupuncture sites utilized, the indication for acupuncture, and the surgical procedure completed are listed in Supplementary Appendix SA3.

The demographics, ASA physical status class, type of surgery, and risk of procedure of those that received acupuncture compared with those that did not are described in Table 1. The majority of patients were ASA physical status class 2 or 3 (59.1% and 31.8%, respectively). Surgeries performed, risk of surgical procedure, and comorbidities between the groups did not differ.

The satisfaction and assessment survey was completed by 19 out of the 22 patients who received acupuncture. 68.4% (13/19) of patients who received acupuncture were satisfied with their treatment and 77.8% (14/18) would always or often recommend acupuncture to future patients undergoing surgery. All patients who responded to the survey did not perceive a downside to receiving acupuncture in the PACU and 63.2% (12/19) would consider therapy again if covered by insurance. 57.9% (11/19) would consider acupuncture if it was very low cost ($20–$50 per session) and 15.8% (3/19) would consider acupuncture if it was 100% cost to the patient ($175.00).

Of the recovery nurses who cared for the patients who received acupuncture in the PACU, 94.7% (18/19) felt that it was helpful, 78.9% (15/19) did not believe it was disruptive, and 94.7% (18/19) would like to see acupuncture available as a therapy in the postoperative setting.

The most common indications for acupuncture were for treatment of pain (68.2%), anxiety (27.3%), and postoperative nausea or vomiting (27.3%), in addition to other reasons (9.1%). A total of 78.9% (15/19) of patients felt improvement in their symptoms. For specific symptoms, 57.9% (11/19) of patients who responded to the postacupuncture survey reported that acupuncture improved their pain, 21.1% (4/19) reported it improved their nausea, and 36.8% (7/19) reported it improved their anxiety.

There were no significant differences in history of PONV or chronic pain between the two groups (Table 2). Patients who received acupuncture therapy had a statistically significant higher pain score in the PACU with median [IQR] (7.0 [5.2, 9.5] vs. 5.0 [3.0, 7.0], p = 0.009) and higher postoperative opioid consumption (22.5 [9.8, 44.8] vs. 15.0 [0.0, 30.0] MME, p = 0.03) (Table 3). There were no differences between incidence of postoperative nausea and total perioperative opioid consumption between the groups. However, there was a statistically significant longer PACU length of stay in patients who received acupuncture (Table 3).

Discussion

The results of this study show that offering acupuncture therapy is feasible in the immediate postoperative setting and desired by the majority of patients. Almost all nurses who cared for patients who received acupuncture in the recovery room felt it was helpful, not disruptive, and would like to see it utilized in the PACU. The majority of patients who received acupuncture therapy postoperatively were satisfied with their treatment, experienced improvement in their symptoms, and would recommend it to future patients. None of the patients who received acupuncture reported any adverse effects to the therapy and more than half would consider undergoing treatment again, even if payment was required but especially if covered by insurance.

Notably, 77.8% (14/18) of patients who received acupuncture would always or often recommend this therapy to future patients undergoing surgery. This indicates that these patients had a positive experience with acupuncture in the immediate postoperative setting. Patients may be willing to trial acupuncture therapy given its favorable benefit–risk ratio and desire to avoid adverse effects of further opioids or other medications. Of note, the authors did not assess patient's prior experience with acupuncture, which could also have been a deciding factor as to whether they chose to utilize the therapy when offered. In a previous study, a majority of patients were interested in acupuncture in the perioperative setting. That interest increased when the patient would be responsible for only a little to no cost. ¹⁷

In addition to patients' perception, it is also important to elucidate the perspective of health care workers to identify the desire to implement therapy and any barriers in doing so. This can be particularly difficult in the hospital and perioperative setting where administering needle therapy could disrupt a nurse or provider's care to a patient. A meta-analysis performed by Zhang et al. demonstrated that 92% of 26 studies evaluating perception of acupuncture reported a positive attitude toward acupuncture by health care providers, including physicians and nonphysicians. ²¹

Most barriers to implementing therapy were lack of resources such as time, providers, and funding. In this study, the reasoning for one nurse's uncertainty of offering acupuncture in the future was the need to see it performed on more patients to make a conclusive decision. Otherwise, all other nurses responded positively with a desire to have it regularly offered in the PACU.

Of the patients who elected to have acupuncture in the PACU, the most common indication was for treatment of postoperative pain. Patients who received acupuncture were noted to have statistically higher overall pain scores in the PACU, increased postoperative opioid consumption, and longer PACU length of stay compared with those who did not receive acupuncture.

This was an anticipated result as one indication to receive acupuncture was pain suboptimally treated with medication. It is likely that patients who chose to receive acupuncture were already in significantly more pain and utilized more opioids before acupuncture. Having poorly controlled pain, along with refractory nausea/vomiting or anxiety, could additionally account for the longer PACU length of stay, all of which were indications to receive acupuncture.

These findings do not necessarily indicate that acupuncture was not effective in treating postoperative pain and opioid use. Previous studies have shown the effectiveness of acupuncture in reducing postoperative opioid consumption. ²² In this study, the authors were unable to assess the timing of opioid consumption relative to acupuncture treatment to determine if patients required less opioids after treatment.

However, acupuncture treatment would have occurred later in the PACU course once the patient could be consented. Although patients who received acupuncture were compared with controls with similar age, comorbidities, and surgeries, there is a high variability in pain experienced by patients postoperatively. This may also contribute to a lack of reduction in opioid requirements in the acupuncture treatment group.

Of the patients who received acupuncture to treat postoperative anxiety or nausea, most reported improvement in their symptoms. There are several studies to suggest that acupuncture therapy does help with anxiety and PONV. In a Cochrane review, PC6 acupoint stimulation significantly reduced the incidence of nausea, vomiting, and need for rescue antiemetics. ²³

In the fourth consensus guidelines for management of PONV published by the Society for Ambulatory Anesthesia and American Society of Enhanced Recovery, PC6 stimulation was shown to reduce risk of PONV; however, its benefit as an adjunctive treatment remains unclear with different stimulation modalities also needing further investigation. ²⁴ In this study, only a small proportion of the patients received acupuncture for PONV and all received treatment after PONV had already developed and antiemetic therapy failed. Although there was improvement in postoperative nausea, further studies would be helpful to determine timing of acupuncture therapy and whether it is more effective as PONV prophylaxis and/or early treatment.

To the authors' knowledge, this is the first study that evaluated the feasibility and acceptability of administering acupuncture therapy in the PACU, which included the perspectives of both patients and their recovery room nurses. Acupuncture can be utilized in the perioperative period for a multitude of issues and evidence suggests it is efficacious in the preoperative, intraoperative, and postoperative period. ²⁵

Limitations include small sample size, a single institution, and the retrospective nature of the comparison with a control group, which limits the generalizability of this study. Given the retrospective nature of this study, some of the assessment tools used may lack validity. Patient controls were selected through chart review specifically for the same type of surgery, age, gender, major comorbidities, and date of surgery. However, they were not selected by surgeon, due to inadequate numbers of control patients by applying that criterion.

Although selected controls corresponded to those who received acupuncture for the same surgical procedure, this analysis included a wide variety of surgical procedures, which is a potential confounder of the data; however, this also adds to the generalizability of this study to clinical practice. Acupuncture may be more effective for certain types of procedures. Patients were given a choice to receive acupuncture therapy rather than assigned to a treatment group, and the timing of therapy was not recorded.

Thus, they may have elected to receive the therapy after trialing various opioid medications without relief, which could explain the treatment group's statistically higher pain scores and postoperative opioid consumption. Acupuncture was performed by a single acupuncturist; however, there was variety in the treatment points utilized since care was tailored to each individual patient's symptoms and pain.

Another limitation was the use of two pain scales (the use of the Wong-Baker scale if assessment was not possible using the numerical rating scale), which has not been validated; of note, this practice mirrors what is done clinically in the hospital setting. Well-powered prospective randomized controlled studies are needed to evaluate the effectiveness of acupuncture in the PACU setting.

Conclusions

In summary, this study shows that a majority of patients who elected to receive acupuncture therapy in the PACU found it beneficial, were satisfied with their therapy, and would recommend it to future patients undergoing surgery. Recovery room nurses who cared for the patients receiving acupuncture felt it was helpful, not disruptive, and would like to see it utilized in the postoperative setting in the future. These findings highlight the feasibility of offering acupuncture therapy in the postoperative setting from the patient and nursing perspectives.

Pain was the most frequent reason for requesting acupuncture in the PACU, which likely accounts for the higher pain scores and postoperative opioid use in the acupuncture group. Notably, these patients reported an improvement in their symptoms after receiving acupuncture. Although randomized controlled trials are needed to make definitive recommendations on acupuncture therapy postoperatively, its favorable risk–benefit profile and acceptance among patients and nursing staff may suggest benefit in its pre-emptive use as an adjunctive therapy.