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Battlefield Acupuncture and Its Use In Multimodal Perioperative Anesthesia Care
Session: MP-01a
Thurs, April 19, 8-9:45 am
Shubert (Shubert Complex), 6th floor

Please note, medically challenging cases are removed three months after the meeting and scientific abstracts after three years.


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Michael Weber DO, Aashish Jay Kumar MD, Hazem M Alahwal MD, Vijval Patel, and Padmavathi Patel MD
John D Dingell VA Medical Center/ Detroit Medical Center, Detroit, Michigan.

 Battlefield acupuncture (BFA) is an auricular therapy (Figure 1) originating from Eastern Asian medicine centuries ago. Ease of application, low cost, and minimal side effects make battlefield acupuncture a perioperative modality that has been linked to decreased morbidity and mortality in patients undergoing surgical procedures and anesthesia (1). In the United States there is pressure by the government and the medical community to decrease opioid use, especially in the perioperative time period. Opioid use due to postoperative pain, postoperative nausea and vomiting (PONV), as well as perioperative anxiety have all been linked to increased hospital stays, increased morbidity and mortality, and ultimately higher healthcare costs (2). Anesthesia providers can be trained in the application of acupuncture in the perioperative time period to minimize adverse health outcomes. Through analyses of rates of postoperative opioid use, postoperative nausea and vomiting, and perioperative anxiety, the efficacy and utility of battlefield acupuncture has shown to be an effective adjunct to multimodal anesthesia care.   This study hypothesizes that perioperative battlefield acupuncture for general surgery and urology cases undergoing general anesthesia will decrease opioid requirements, postoperative pain, the incidence of PONV, and the incidence of perioperative anxiety in comparison to simulated (placebo controls) perioperative battlefield acupuncture. 
 This study was IRB and VA approved. Upon consent, patients were randomly assigned to the BFA (n=19) or Control group (patients who underwent similar surgeries but did not receive BFA; n=20). Inclusion criteria for patients were ages 18-100, ASA 1 to 4, scheduled to undergo general surgery and urology cases under general anesthesia in an inpatient setting.  Measured variables included opioid requirements, postoperative pain, the incidence of PONV, and the incidence of perioperative anxiety. Statistical analyses included Student’s t-test (unpaired), repeated measures ANOVA and Chi-Squared tests for categorical variables. Statistical significance was defined as p<0.05.
 BFA patients consumed a significantly lower 24-hr PO (oral) Milligram Morphine equivalent (MME) of 35.4 mg compared to that of control patients (70.0 mg; p<0.05; Figure 2). VAS scores in the 24-hr post-operative period were significantly reduced in the BFA group (p<0.005) across all of the measured post-operative time periods (6,12,18, 24 hours) compared to controls (Figure 3). Although there was no significant difference between cases and controls, a 15% reduction in the incidence of PONV was observed in BFA patients (Table 1). No statistically significant difference between the two groups was observed in the incidence of post-operative anxiety. 

 In this study, we observed a significant reduction in post-operative opioid use and post-operative pain levels in patients who underwent BFA compared to controls who received the standard of care opioid administered for postoperative pain relief.  Opioid analgesics are frequently used to treat pain in the perioperative period, however, it is commonly known that opioids are associated with multiple adverse effects which can delay recovery and increase the length of hospital stay (3). Most of the adverse effects of opioids are dose-dependent, thus, minimizing opioid use will help decrease these adverse effects (4). In reported studies, it was observed that acupuncture via different techniques provided patients increased pain relief compared to control patients receiving conventional care. Intradermal acupuncture along the bladder meridian showed a 50% decrease in intravenous morphine as well as a 20-30% decrease in PONV during general surgery (5) which was similar to results observed in our study. In the perioperative period and on post-operative day 1, plasma epinephrine and cortisol levels were observed to be decreased 3050% in acupuncture patients compared to controls (5). This suggests that acupuncture can decrease the post-operative stress response which is detrimental to the healing process. The simplicity and ease of BFA application is an ideal technique to apply for post-operative analgesia compared to other acupuncture techniques.   In current anesthesia and critical care practices, Enhanced Recovery Programs (ERP) are broadly implemented across surgical specialties and have decreased complications and lengths of stay. One of the pillars of ERP is the promotion of opioid-sparing analgesic techniques with an emphasis on multimodal approaches (6). BFA can provide a novel ERP modality that is low cost, effective, safe, and easy to implement. Further trials of BFA should be conducted as an integral part of ERP multimodal post-operative pain management. 
REFERENCES: 1) Lu, Z, Dong, H, Wang, Q, and Xiong, L. Br. J. Anaesth. 2015 Aug;  115(2):183-93.  2) Fleckenstein, J, et al. Trials. 2014 Jul; 15(1):292. 3) Wu, MS, et al. PLoS One. 2016 Mar; 11(3):e0150367.doi:10.1371/journal.pone.015036 4) Luo, J and Min, Su. J Pain Res. 2017 Nov; 10:2687-2698.  5) Fahey, R. Integrative Medicine Alert. 2018 Jan; 21(1).  6) Kim, BJ and Aloia, TA. J Gastrointest Surg. 2018 Jan; 22(1):164-171.  7) Teresa M. Kerge et al 2013. Practical Pain Management  http://www.practicalpainmanagement. com/pain/spine/trauma/us-service-members-polytrauma 

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