Incorporating acupuncture into enhanced recovery after surgery (ERAS) for ambulatory total hip replacement surgery

Stephanie I. Cheng MD, DABMA, FAAMA^1,2, Marko Popovic BS¹, Junying Wang PhD¹, Maya Tailor BA¹, Mia Zonies BA¹, Angela Puglisi BS¹, Miriam Sheetz BS¹, Christopher J Li MD, DABMA^1,2, William P. Qiao MD^1,2, Elizabeth B. Gausden MD, MPH³, Eytan M Debbi MD, PhD³, Jonathan M. Vigdorchik MD³, Brian P. Chalmers MD³, Cynthia A. Kahlenberg MD³, David J. Mayman MD³, Seth A. Jerabek MD³, Michael P. Ast MD³

¹Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA

²Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA

³Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA

Introduction:

 

Nonpharmacologic analgesic adjuncts like acupuncture remain underutilized in the perioperative period. Although opioids are effective, they have undesirable side-effects like nausea, vomiting, pruritis, sedation, and decreased gut motility, delaying discharge readiness. This is essential in orthopedic surgeries like total joint arthroplasty (TJA), where recovery times are substantially different depending on opioid consumption. Given the move towards ambulatory TJA, exploring potential effectiveness of non-opioid approaches like acupuncture in treating post-operative pain should be prioritized.

Methods:

This triple-blind randomized controlled trial (IRB approval #2021-1496) enrolled 484 patients (242/group) aged 18-80 with ASA 1-2 undergoing total hip replacement. Exclusions included chronic opioid use, contraindication to neuraxial anesthesia, allergic to NSAIDS/opioids, implanted cardiac device, chronic kidney disease, diabetes or BMI>40. Both groups received standard mepivacaine spinal anesthetic with propofol sedation. The intraoperative acupuncture group received the CHENG Protocol - auricular acupuncture with 30Hz electrostimulation after induction but before incision. Follow-ups were conducted during post-anesthesia care unit (PACU), and on Days 1, 2, 14, and 30. Sample size estimation used a two-sided T-test with mean difference 42.9, standard deviation 160, significance level 0.05, 80% power and 10% dropout. Group differences were examined using Wilcoxon rank sum or Chi-squared tests.

Results:

Acupuncture patients showed lower total opioid consumption at 14/30 days (p>0.05) and reported significantly lower PACU NRS scores (median+/-IQR: 4+/-3 vs 5+/-3, p=0.002). Other outcomes (hours-to-discharge, patient satisfaction, NRS scores at additional times, and Day 1 nausea/vomiting) were not statistically significant.

Discussion/Conclusion:

Significant progress has been made toward making ambulatory TJA feasible and attractive for select patients without compromising safety or satisfaction. Patient perception and pain scores, especially during initial recovery, are very important for discharge and cumulative opioid consumption. Although the decrease in opioid consumption was not statistically significant, it may be still clinically meaningful. As we refine approaches to reduce opioid use and recovery time after joint surgery, it is important to consider acupuncture as part of a multimodal fast-track protocol.