Cuban Medical Research
Acupunctural Analgesia in Surgical Cases

INTRODUCTION

Natural and Traditional Medicine, also known as Biological or Alternative Medicine, or Reflex Therapy, has developed internationally in the last few decades.   Scientific research and progress have demonstrated the short and long-term damaging effects pharmaceutical drugs may cause.

One of the principles of anaesthesiology is pain relief.  In well-controlled research, acupuncture, a method of Asian Traditional Medicine, has demonstrated has demonstrated I is a technique that can relieve or eliminate pain by means of virtually innocuous and economical procedures.  This unquestionable reality has inspired anaesthesiologists to develop these techniques, so as to provide an analgesia with a minimum of adverse reactions, little operational complexity and considerable economic benefits.

The word acupuncture comes from acu = needle and puncture = puncture.  It consists of puncturing certain points of the skin, known as acupuncture points.  These points are believed to have less electrical resistance than the rest of the skin around them, and they are connected through a network known as meridians. (1, 2, 3)

This procedure dates back 4000 years.   French missionaroes brought it to Europe in the 17^th Century (3).  Acupuncture was first introduced in the Americas through Argentina in 1948.  Argentinean physician, Dr. Floreal Carballo, lectured on this method in 1962 in Cuba, but it was not until the 1970´s that it became systematic practice in the country. (4, 5, 6)

Acupuncture is known to have multiple effects (analgesic, homeostatic, immunological, and sedative) (1).  This has been substantiated by both traditional and modern scientific therories. 

Traditional theories state that acupuncture regulates the energy flow inside a circulation system in the body.  It influences the state of the meridians, which are an essential part of this system.  This theory cannot be completely demonstrated, but it is difficult for modern science to refute it. (2)

An anatomic-physiological explanation is scientifically sought, and several theories have been put forth, the following being the most widely accepted:

The Neuro-Endocrine Theory, which proves the presence of endogenous morphinomimetical substances such as the following:

This theory has demonstrated that the acupuncture points are found in the meridians, whose trajectory is parallel to important nerve branches, particularly neuro-vegetative.  It can then be inferred that they are the result of functional rather than organic organization.   These points often coincide with the location of the skin’s neuro-tropic centers and neuromuscular plexus, bound to somatic and visceral fibers related to ganglia and higher brain structures, choice places for the secretion of neuro-modulating substances, which explains their local, regional and general action. (7, 8). 

Encephalin acts presynaptically upon the central inhibiting neuron and obstructs stimuli coming from Fiber C, which to a certain extent identifies it with Substance P (Neuro-peptide of 11 amino acids that is believed to be the chemical component of pain).  Under certain conditions, the action of encephalin may not suffice to stop the filtration of the nociceptive stimulus (pain).  In these cases, acupuncture facilitates or stimulates the encephalic inter-neurons to neutralize Substance P. (7, 8).  

Serotonin is directly related with the efficacy of analgesic acupuncture.   The stimulation of 36 stomach points (S36), and 30 gallbladder points (Gb 30) increases the serotonin-adrenalin relationship.  In the tele-encephalon, however, this increase is due to the decrease of noradrenalin.  This effect is caused by the serotoninergic neurons of the nucleus of the dorsal and medium raphe‘s  periacueductal gray matter, which takes a downward inhibiting path. 

Although the specific role of brain serotonin in acupuncture analgesia has not been proved, its compensating effect has been demonstrated after morfinomimetized endogen substances are blocked by naloxone (antagonist of opium-derived drugs). (9, 10, 11).

Atropine, antagonist to cholinergic muscarinic receptors, partly blocks acupuncture analgesia and inversely blocks the enzyme that triggers the endogen release of acetylcholine, and increases acupuncture analgesia in rats. (11).

Another theory that has been put forward is that of Melzack and Wall,  known as the Gate Theory.  This theory states that pain impulses travel on Delta A fibers (thin, with little myelin and low conduction speed), and C fibers (amyelinic and slower than A fibers), which would constitute one or several functional gates, open in normal pain conditions.  With application of acupuncture, this impulse runs along the Beta A fibers (myelinized and thick, with a very high conduction speed), which causes the gates to close, and inhibits or diminishes the sensation of pain (9, 10). 

Acupuncture has been said to cause activation of the autogenous control centers, which act upon circulation (both local and general) and muscular contracture.  The neuro-endocrine control centers are activated, including the hypophysis – suprarenal and the hypophysis – thyroid axes. (11)

The use of electrically stimulated needles is called electro-acupuncture and was first applied in China in 1954 (12).   Some authors argue that the analgesic effect of electro-acupuncture lasts for more than 24 hours after the needles are removed. This effect is used for the benefit of the patient in surgical acupuncture analgesia. (10, 12, 13).

Acupuncture was used in a  Shanghai, China hospital in 1958, for a patient whose tonsils had been surgically removed, and its pain-relieving effect was successful.  Surgeons then considered using acupuncture in such operations.  Ten thousand operations of different sorts had been carried out with acupuncture in China by 1965.   By 1979, acupuncture analgesia had been used in 20 % of the total number of surgeries. (10)

In Cuba, the first operation with acupuncture analgesia was a tonsillectomy conducted in the Comandante Manuel Fajardo Hospital in 1975. Other operations were successfully performed later at the Finlay Hospital (5, 14).   A research paper presented by Dr. Rigol at the National Gynecology and Obstetrics Forum in 1995 refers to 37 abortions performed with acupuncture analgesia, demonstrating 95 % effectiveness.  The needles were removed before the beginning of surgery, and the results obtained were the same as when the electrical stimulus is maintained until the end of the operation. (15)   A 1984 residency thesis in anaesthesiology at the “10 de Octubre” Teaching Clinical Surgical Hospital in Havana, described the successful use of surgical acupuncture analgesia in the limbs and lower abdomen.  In 1996, the use of this type of analgesia was extended at this hospital.   The results were the following:

OBJETIVES

GENERAL OBJECTIVE:

To demonstrate the efficacy of surgical acupuncture analgesia

SPECIFIC OBJECTIVES:

MATERIAL AND METHOD

176 major elective operations were conducted at the “10 de Octubre” Teaching Clinical Surgical Hospital using acupuncture analgesia between November 1997 and April 1999.  The sample was taken from the total of major elective surgical operations carried out in this hospital.

SELECTION CRITERIA

Inclusion criteria

Exclusion criteria

All patients were given Diazepan (0.2 mg/kg of body weight) 30 minutes before the analgesic induction,  and Benadryl (3 mg/kg of body weight) intravenously after a previous channelling of the peripheral vein with a plastic trocar.  Crystalloid solutions were continuously infused until the end of the operation. 

For the induction and permanence of acupuncture analgesia, the specialists used a Chinese Great Wall KWA-808 II multi-purpose stimulator, acupuncture needles of different calibres and stainless steel triangular points previously sterilized in an autoclave, Lidocain 0.5 % for skin infiltrative anaesthesia, except for one case in which Benadryl was used on a patient who was allergic to local anaesthetics.

Selection of points:

Skin asepsis and antisepsis is performed with soap and water, and 90º alcohol, and the needles are placed in the selected points.  

The same steps were followed with all patients during induction.

The degree of acceptance of this method was assessed by means of the following question:  Would you agree to use this method if you had to go through surgery again?

Tables were prepared using data from the protocol of anaesthesia, and an official form was used.  Results were expressed in percentages.

ANALYSIS AND DISCUSSION

176 elective operations were conducted using acupuncture analgesia in the 10 de Octubre Teaching Clinical Surgical Hospital between November 1996 and April 1998.

Male patients were predominant (129 for 73 %), whereas patients older than 51 years of age were a majority (115 patients for 65.38 %).

Associated pathologies that increased surgical risk were found in all cases, hypertension being the most frequent in 95 patients (53.84 %), followed by Diabetes mellitus in 47 patients (26.9 %), and heart disease in 34 patients (19.3 %)  (Table 1).  These pathologies are the most frequent in the Cuban population.

Table 1, Associated Pathologies

PATHOLOGIES	No. PATIENTS	PERCENTAGE
HIGH BLOOD PRESSURE	95	53.84
DIABETES MELLITUS	47	26.92
HEART DISEASE	34	19.3

N = 176

67 patients were classified as ASA II (38 %), whereas 109 (62 %) were classified as ASA III. (Graph 1).

Graph1, Distribution A.S.A

Inguinal herniotomy was the most common operation, with 67 patients (38.46 %).  Mastoplasties were practiced on 46 patients (26.92 %), while another 46 patients (26.92 %) were operated on for hemorrhoids (Table 2).

Table 2, Most Frequent Interventions

TYPE OF INTERVENTION	NUMBER	PERCENTAGE
HERNIOTOMIES	67	38
MASTOPLASTIES	46	26
HEMORRHOIDECTOMIES	46	26
EXTRACAPSULAR  EXTRACTION OF THE CRYSTALLINE	16	9,5
THORACOTOMIES	1	0,5

Assessing the results: trans-operation analgesia was successful in 122 patients (69.23 %), and achieved fair results in another 54 (30.77 %); the latter being found in mastoplasties and minimum thoracotomies, as it was necessary to resort to trans-operation Meperidine (Table 3).  These patients were not considered as failures because a change in anaesthesia technique was not required.

Tabele 3, Relationship Between Pain Scale And The Duration Of Analgesia

	PAIN SCALE
DURATION OF  ANALGESIA	0	1	2	3
TRANS-OPERATION	95	27	54	0
1 HOUR  POST-OPERATIVE	149	27	0	0
24 HOURS  POST-OPERATIVE	176	0	0	0

The Visual Analgesic Scale of 149 patients (84.61 %) in the immediate post-operative stage was 0, while it was 1 in 27 patients (15.39 %).  Results were thus evaluated as GOOD. Twenty four hours into the post-operative stage, all 176 patients (100 %) reported Scale 0, and no post-operative analgesics were necessary (Table 3).  Our results match those obtained by other Cuban authors. (9, 10, 15)

All patients were released from hospital 24 hours after their surgeries.  There were no complications in terms of the surgical technique or the acupunctural analgesia. Blood transfusions, neither in the trans-operation nor the post-operation stages, were necessary for the patients who underwent mastoplasty, as there was minimum bleeding because acupuncture produces vessel constriction.

All patients expressed their willingness to use the same method in case a new operation were necessary. 

Advantages of acupuncture analgesia

Disadvantages

CONCLUSIONS

REFERENCES