TMR Non-Drug Therapy Doi: 10.12032/TMRND20210416028

TMR Non-Drug Therapy doi: 10.12032/TMRND20210416028

Electroacupuncture in perioperative anesthesia and analgesia management: a non-invasive adjuvant treatment

Cheng-Yun Hu1 #, Lai Jiang2 #, Zhe-Tao Zhang3 *, Chao-Liang Tang4 *

1Department of Anesthesiology, Anhui Provincial Hospital, Wannan Medical College, Hefei 230001, China. 2Department of Obstetrics and Gynecology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, China. 3Department of Pharmacy, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230036, China. 4Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, China.

#Cheng-Yun Hu and Lai Jiang are the co-first authors of this paper.

*Corresponding to: Zhe-Tao Zhang. Department of Pharmacy, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, No.1 Swan Lake Road, Hefei 230036, China. Email: [email protected]; Chao-Liang Tang. Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, No. 17, Lujiang Road, Hefei 230001, China. Email: [email protected].

Abstract Anesthesia is mainly a kind of reversible functional inhibition of the central nervous system and (or) peripheral nervous system through drugs or other methods. In modern clinical medicine, modern anesthesiology is a comprehensive subject, which mainly includes clinical anesthesia, pain diagnosis and treatment, intensive care treatment, first aid and resuscitation, etc. Electroacupuncture is developed based on acupuncture therapy which is an important part of traditional Chinese medicine. It uses the comprehensive efficacy of acupuncture and electrical stimulation to deliver electrical energy through acupoints to achieve therapeutic effects. It has been widely used in recent years in clinical. This article summarizes the analgesic mechanism of electroacupuncture and its application in different anesthesia methods, so that clinicians have a deeper understanding of the clinical application of electroacupuncture and promote its clinical application. Keywords: Electroacupuncture, Anesthesia, Analgesia, Cognitive dysfunction, Perioperative period

Competing interests: The authors declare no conflicts of interest. Acknowledgments: This study was supported by grants from the National Natural Science Foundation of China (No. 81801175), the China Postdoctoral Science Foundation (No. 2019M662179), the Anhui Province Postdoctoral Science Foundation (No. 2019B324), and the Fundamental Research Funds for the Central Universities (No. WK9110000044). Abbreviations: PONV, postoperative nausea vomiting; POCD, postoperative cognitive dysfunction. Citation: Hu CY, Jiang L, Zhang ZT, Tang CL. Electroacupuncture in perioperative anesthesia and analgesia management: a non-invasive adjuvant treatment. TMR Non-Drug Ther. 2021;4(2):7. doi: 10.12032/TMRND20210416028. Executive editor: Shan-Shan Lin.

Submitted: 08 April 2021, Accepted: 16 April 2021, Online: 23 April 2021.

Submit a manuscript: https://www.tmrjournals.com/ndt 1 doi: 10.12032/TMRND20210416028 REVIEW and mental effects to the patient, but may also cause Clinical anesthesiology has shown great changes in pathological changes in the nervous, circulatory, and terms of the anesthetic drugs, anesthesia equipment endocrine systems, affecting the quality of life of the and anesthesia concepts and methods in a history of patient. In our country, electroacupuncture has been more than 150 years. However, various anesthesia widely used in the treatment of various diseases and methods have some shortcomings. For example, accepted by the public because of its remarkable general anesthesia requires multiple medications or analgesic effect [5], it activates a variety of combined with multiple anesthesia techniques, which biologically active substances through multiple has the disadvantages of large and complex medication signaling pathways around and on the spinal cord to and strong stress response when extubating. Combined produce analgesic effects [6]. Electroacupuncture spinal-epidural anesthesia has the higher incidence of analgesia is produced by releasing endogenous opioid headache, not only brings pain to the patient, but also peptides or activating the endogenous pain suppression increases the patient’s body stress response, affects system [7]. Different causes of pain also involve postoperative wound healing, and prolongs the different signaling pathways and molecular levels. In postoperative recovery time. In recent years, enhanced inflammatory pain, electroacupuncture has the dual recovery after surgery has been promoted, which effects of analgesia and anti-inflammatory, requires us to further optimize the anesthesia method cyclooxygenase 2 mainly regulates the release of during the perioperative period to provide patients with inflammatory mediators, which can lead to the comfortable medical treatment. production of inflammatory pain, and vanilloid Acupuncture therapy has a history of more than receptor plays an important role in neuropathic pain [8]. 2,500 years in China [1]. With the development of Fang et al. found that electroacupuncture may act science and technology, acupuncture technology is through the p38 mitogen activated protein kinase constantly evolving, from the initial hand-twisted /activated transcription factor 2/vanilloid receptor 1 acupuncture to the current electric acupuncture and pathway that regulates the duration of inflammatory transcutaneous electrical acupoint stimulation. pain rather than regulating p38 mitogen activated Originated in 1958, acupuncture anesthesia is based on protein kinase /activated transcription factor different types of operations and surgical sites, 2/cyclooxygenase 2 pathway [9]. Researchers according to the principles of meridian, syndrome established a rat model of acute gouty arthritis and by differentiation, local or symptomatic acupoint selection using electroacupuncture, they found that through [2]. It is a method of anesthesia for surgical operations peripheral κ and μ opioid receptors, it upregulated the after which the patient remains awake but reaching a expression of β-endorphin in inflamed skin tissues and certain anesthetic effect. Acupuncture anesthesia needs effectively relieved pain [10]. In neuropathic pain, to be operated at specific acupoints and is electroacupuncture can regulate neurotransmitters and time-consuming, so it is difficult to popularize in related receptors, reduce hippocampal excitatory today’s operating rooms. With the same theoretical neurotransmitter glutamate content, and increase the basis, using electric current instead of acupuncture, content of inhibitory neurotransmitter γ-amino-butyric electroacupuncture can achieve the effect of standard acid to reduce neuropathic pain in higher brain areas acupuncture in a short time [3]. Electroacupuncture [11]. In addition, electroacupuncture can also stimulate can be used as an effective means of auxiliary the expression of interleukin 10 in microglia, and anesthesia in the perioperative period and has shown inhibit neuropathic pain by interleukin 10 mediating many benefits such as relieving anxiety and the expression of β-endorphin in spinal microglia [12]. preemptive analgesia before surgery; reducing the use of anesthetics during surgery; effectively reducing the Electroacupuncture in perioperative incidence of postoperative nausea vomiting (PONV) anesthesia management after surgery, relief of postoperative pain, prevention of postoperative stress and postoperative cognitive Electroacupuncture combined with local anesthesia dysfunction (POCD). The use of electroacupuncture is Local anesthesia is the application of local anesthetics relatively simple and easy and can provide a stable and to block the nerve conduction temporarily, completely effective acupuncture effect without a professional and reversibly in a certain area of the body, so that this acupuncturist, which provides the feasibility and area has an anesthetic effect. Clinically, generalized practicability for the application of electroacupuncture local anesthesia includes surface anesthesia, local in clinical anesthesia. infiltration anesthesia, regional anesthesia, nerve block, and intraspinal anesthesia. Although local anesthesia The analgesic mechanism of electroacupuncture can preserve the patient’s consciousness and maintain Pain, listed as the “fifth vital sign” in 1995, is the the protective reflex, its analgesic effect is often not subjective feeling of the patient, the unpleasant feeling ideal [13]. The pain of the surgical operation may and emotional experience caused by tissue damage or stimulate the body to cause violent fluctuations in potential tissue damage [4]. It not only brings physical circulation, and the traction on the peritoneum makes

2 Submit a manuscript: https://www.tmrjournals.com/ndt TMR Non-Drug Therapy doi: 10.12032/TMRND20210416028 the patient feel uncomfortable. The need for multiple prolonged recovery time still often occur, the stress administrations during the operation has a certain response generated by the operation can last for many impact on the quality of the operation and the recovery days after surgery, affecting the treatment effect and of the patient after the operation. In addition, even if postoperative recovery of patients [21–23]. Animal the block level of intraspinal anesthesia is higher, it experiments have confirmed that electro-acupuncture cannot completely eliminate the discomfort or nausea analgesia can be used in various animal operations and and vomiting caused by intra-abdominal operation, and has the advantages of safety, less physiological it can easily cause postoperative chills, headaches, and interference, fewer complications, and quicker urinary retention, which is not conducive to recovery after surgery although there are also postoperative recovery which will reduce the quality of unsatisfactory muscle relaxation and insufficient life [14, 15]. Modern medicine has confirmed that after analgesia have also occurred during the operation [24, electrical acupuncture stimulation, the brain releases 25]. Jin et al. compared the anesthesia effects of simple neuroactive substances such as endorphins, serotonin, general anesthesia and electroacupuncture combined and other cytokines, which affect the transmission of with general anesthesia, and found that the pain signals and thereby produce analgesic effects [16]. perioperative blood pressure, heart rate, Xiao et al. conducted a study on the complications adrenocorticotrophic hormone, cortisol, epinephrine related to labor pain and anesthesia during labor and blood sugar in the electroacupuncture combined analgesia with electroacupuncture, and found that group are more stable, and the cardiovascular stress electroacupuncture combined with combined response is also smaller [26]. In an analysis evaluating spinal-epidural analgesia and patient-controlled the efficacy of electroacupuncture combined with epidural analgesia could reduce the visual analogue general anesthesia in patients undergoing cardiac score of labor pain by 1 to 2 points, and reduce the surgery, it was found that compared with the general incidence of urinary retention [17]. After subarachnoid anesthesia group, the vasoactive drugs required by the block (spinal anesthesia for short), due to the inhibition electroacupuncture combined with general anesthesia of the lumbosacral spinal cord and the dysfunction of group were significantly reduced, and the the detrusor, the bladder is overfilled, and urinary intraoperative myocardial cell damage was retention is formed. Gao et al. showed that significantly reduced. The need for intraoperative electroacupuncture combined with spinal anesthesia anesthetics is also reduced, which significantly can reduce postoperative urinary retention and shorten shortens the time of mechanical ventilation and the the spontaneous urination time of patients [18]. time spent in the intensive care unit, and reduces the Shivering is also a common complication after level of pro-inflammatory mediators [1]. regional anesthesia. The use of electroacupuncture at Electroacupuncture combined with general anesthesia specific points can maintain the body’s core body has significant advantages, has a significant regulatory temperature, thereby reducing the incidence of effect on the body’s circulatory function, can promote shivering after anesthesia [19], but this is closely hemodynamic stability, and has a good application related to the effective duration of electroacupuncture prospect. stimulation which needs to overcome technical difficulties [15]. In total knee arthroplasty, Effect of electroacupuncture on perioperative electroacupuncture combined with continuous femoral anxiety nerve block can provide effective anesthesia, and can also relieve postoperative pain [20]. Preoperative anxiety is as high as 20%–80% of Electroacupuncture combined with local anesthesia patients undergoing elective surgery [27, 28]. can increase the analgesic effect of anesthesia, which is Traditional Chinese medicine believes that anxiety is superior to local anesthesia alone, and can reduce mainly caused by the stasis of Qi, which leads to postoperative complications and benefit patients’ imbalance of Qi and blood in the viscera, dysfunction. postoperative functional recovery. Preoperative anxiety increases the sensitivity of the patient’s pain response, the demand for postoperative Electroacupuncture combined with general analgesics, prolongs the postoperative recovery time, anesthesia and is detrimental to the patient’s postoperative General anesthesia refers to the inhalational, recovery and physical and mental health [29]. At intravenous or intramuscular injection of anesthetics present, the effects of drugs in the treatment of anxiety into the body, resulting in temporary depression of the are average and have certain side effects, such as central nervous system throughout the body. With the hypotension, lethargy, and drug addiction [30]. Clinical development of medical technology, general anesthesia studies have shown that both body acupuncture and can be safely and effectively applied to surgical electroacupuncture are an effective method for treating operations, but a series of adverse reactions such as anxiety disorders, and there are no obvious adverse reduced perioperative respiratory function, unstable reactions. Bae et al. compared preoperative hemodynamics, large dosage of anesthesia, and acupuncture treatment with placebo treatment and

Submit a manuscript: https://www.tmrjournals.com/ndt 3 doi: 10.12032/TMRND20210416028 REVIEW found that acupuncture treatment can significantly pain after total knee replacement found that improve the patient’s preoperative anxiety and meet postoperative use of electroacupuncture to stimulate the preoperative sedation requirements [31]. In Futu (ST32), Yanglingquan (GB34), Zusanli (ST36), addition, some scholars use a more objective bispectral Xuehai (SP10) and Yinlingquan (SP9) can effectively index of the electroencephalography to observe the alleviate the pain response after total knee replacement effect of electroacupuncture in alleviating anxiety and [37]. Electroacupuncture, as a non-drug auxiliary found that low frequency electroacupuncture to analgesic method, has fewer side effects and its clinical stimulate the 7 heart’s acupoints significantly reduced effect is significantly better than that of pure drug bispectral index of the electroencephalography and the analgesia. However, electro-acupuncture during effect was more significant than using a single dose of perioperative analgesia needs to select different 10 mg of diazepam, which may be related to acupuncture points according to different surgical sites stimulating the release of endogenous opioids [32]. In to achieve the most satisfactory results. Therefore, fact, different types of acupuncture and moxibustion, clinical use requires professional systemic acupoint acupoints, and duration can alleviate anxiety to a analgesia guidance. certain extent [30]. At present, there are few studies on electroacupuncture in preoperative anxiety, more Effect of electroacupuncture on PONV clinical studies are still needed to prove its clinical effect. Follow-up studies can focus on stimulation PONV is one of the common complications after frequency, timing, and intensity. surgery, usually with an incidence of 20%–30%, and the incidence of patients with high-risk factors can be Effect of electroacupuncture on as high as 70%–80% [38]. PONV not only increases intraoperative and postoperative pain the patient’s hospital stay but also increases the medical expenses, causes water and electrolyte In daily clinical anesthesia, intraoperative and disturbances, aspiration pneumonia, aggravate wound postoperative pain caused by surgery not only affects pain, and affect wound healing. Although with the the operation and effect, but also brings physical and development of the medical level, a variety of psychological trauma to the patient, and affects the interventions have been used clinically to reduce postoperative functional recovery and quality of life of PONV, and the incidence has dropped to < 10% [39], the patient. At present, the clinical methods used to but the side effects brought by it still cannot be ignored. treat pain are mainly opioids, local anesthetics, Clinically, drugs are mainly used for antiemetics, non-steroidal drugs and N-methyl-D-aspartic acid which may cause adverse reactions such as sedation, receptor antagonists [33]. Studies have shown that headache, drowsiness, and dizziness [39]. In recent electroacupuncture can replace opioids as an important years, electroacupuncture, used as a physical therapy method for pain relief, which can not only reduce the to prevent and treat PONV, has been found that it has dosage of opioids during and after surgery, but also better curative effect and fewer side effects, and is reduce the incidence of respiratory depression, heart worthy of popularization. At present, the main points rate reduction, nausea and vomiting and other adverse used to relieve the symptoms of PONV are Neiguan events [34]. Electroacupuncture-assisted analgesia has (PC6), Hegu (LI4) and Zusanli. Neiguan is the been widely studied by scholars, and it has been collateral point of the pericardium meridian of proven to be used for the treatment of perioperative Hand-Jueyin, which can calm the mind and nerves, pain in various operations. β-endorphin is one of the regulate Qi and relieve pain; Hegu is the original point three family members of human endogenous opioid of the large intestine meridian, which can rise and fall peptides and plays a role in the regulation of pain and the energy and unblock the blood [40] ； Zusanli is a immunity. Electroacupuncture stimulation can increase combined point under the Stomach Meridian of plasma β-endorphin concentration, reduce Foot-Yangming, which generates stomach Qi and postoperative pain and reduce the use of postoperative dampens spleen [41]. Tian studied the effects of analgesics [35]. Zhang et al. divided thyroid surgery electroacupuncture at different times on PONV. The patients into two groups, cervical plexus block alone as experimental group chose Neiguan, Hegu, Zhigou (SJ6) control group and cervical plexus block combined with and Quchi (LI11) points to retain needles for 30 electroacupuncture stimulation as observation group, minutes, and the control group used patients in the and found that the observation group had a lower granisetron group that received intravenous injection visual analogue score. Electroacupuncture inhibited the 30 minutes before surgery. It was found that the levels of adrenocorticotropic hormone and C-reactive incidence of nausea and vomiting at 24 hours protein at various time points after the operation, and postoperatively in the control group was significantly promoted the release of β-endorphin, thereby higher than that in the test group [40]. Li et al. elected producing analgesic effects during the perioperative Neiguan and Zusanli acupoints during the study and period and reducing the body’s fatigue [36]. A kept the needles for 30 minutes, turns out that meta-analysis of electroacupuncture intervention for electroacupuncture treatment one day before surgery

4 Submit a manuscript: https://www.tmrjournals.com/ndt TMR Non-Drug Therapy doi: 10.12032/TMRND20210416028 can effectively prevent PONV [42]. However, Park et anesthesia significantly reduces the dosage of opioids al. used electroacupuncture to stimulate Zusanli and used in the operation and significantly improves Neiguan 1 hour before and 6 hours after thyroidectomy POCD in elderly patients, which may attributed to in an experiment to study electroacupuncture to reducing inflammation [50]. Acupuncture has a certain prevent nausea and vomiting after thyroidectomy. The curative effect in preventing POCD, and has no toxic results showed that electroacupuncture did not affect side effects, and has high clinical application value. the incidence of PONV within 36 hours after surgery Many studies have proved that electroacupuncture can [43]. Therefore, the timing of stimulation with improve POCD in a variety of ways, but the specific electroacupuncture to prevent PONV is still unclear. mechanism needs further research. There are different results of stimulation before, during and after surgery. Further research is needed to Limitations determine the best timing of stimulation, and the experimental results may differ from individual Although the role of electroacupuncture in anesthesia patients, electrical acupuncture stimulation frequency has been recognized by many scholars, the specific and other factors. mechanism of electroacupuncture analgesia has not yet been elucidated. The current research only suggests Effect of electroacupuncture on POCD that electroacupuncture stimulation may exert analgesic effect by regulating the function of the POCD is a central nervous system complication that immune system, however, the specific regulatory often occurs after surgical anesthesia in elderly patients pathways are still lacking, further research is needed to which clinical manifestations are cognitive clarify the role of electroacupuncture analgesia in impairments such as memory, attention, orientation, different causes and different parts, and to expand its and understanding after surgery, and can last for scope of use. The use of electroacupuncture will several weeks, months or even more. A large number produce fatigue effects and the stability of acupuncture, of studies have shown that POCD in the elderly after the selection of acupoint optimization will affect its general anesthesia is closely related to the occurrence therapeutic effect. At present, there is still no unified and development of Alzheimer’s disease [44]. At standard for the time, frequency, and intensity of present, the pathogenesis of POCD is not yet clear [45], electroacupuncture during perioperative period, which but neuroinflammation and oxidative stress play a key may affect its wide application. role in the progression of POCD, especially hippocampal neuroinflammation [46, 47]. Conclusion and prospects A large number of animal experiments have proved that electroacupuncture can improve POCD and brain Electroacupuncture is an effective analgesic method, protection by reducing neuroinflammation or which can increase the pain perception threshold and inhibiting oxidative stress. α7-nicotinic acetylcholine tolerance threshold. After combined anesthesia, the receptors lays a regulatory role in the cognitive process, dosage of intraoperative anesthetics is reduced, which Liu et al. established a POCD rat model in the study is more conducive to the stability of the circulatory and found that electroacupuncture can enhance the system, and the recovery time of patients after surgery cognitive function of rats by increasing the expression is shortened, and anesthesia-related complications are of α7-nicotinic acetylcholine receptors and inhibiting reduced. With the promotion of comfort medicine, neuroinflammation [46]. Some scholars believe that electroacupuncture combined with anesthesia electroacupuncture can reduce POCD through the conforms to the new concept of enhanced recovery microglia/ toll-like receptor 4/2 signaling pathway and after surgery in recent years. In the future, more improve the spatial memory of rats after surgery [47]. multi-center randomized controlled studies of Yuan et al. studied the effects of electroacupuncture on electroacupuncture anesthesia are needed to provide the cognitive function of elderly rats after acute more convincing evidence-based evidence to further myocardial ischemia reperfusion by observing the promote its application. pathological examination, oxidative stress level and systemic inflammatory response in the hippocampal References CA1 area, and found that electroacupuncture may be a neuroprotective therapy, which reduces brain damage 1. Asmussen S, Przkora R, Maybauer DM, et al. and POCD [48]. In addition, electroacupuncture can Meta-analysis of electroacupuncture in cardiac also significantly reduce cognitive impairment in anesthesia and intensive care. J Intensive Care POCD rats by inhibiting astrocyte activation and Med. 2019;34(8):652–661. oxidative stress [49]. These animal experiments 2. Yuan W, Wang Q. Perioperative acupuncture provide theoretical support for the clinical application medicine: a novel concept instead of acupuncture of electroacupuncture. Clinically, pretreatment with anesthesia. Chin Med J (Engl). electroacupuncture 30 minutes before induction of 2019;132(6):707–715.

Submit a manuscript: https://www.tmrjournals.com/ndt 5 doi: 10.12032/TMRND20210416028 REVIEW 3. Rosen DA, Unger K, Gustafson RA, et al. 579–586. Electroacupuncture addition to the anesthesia care 16. Zhang R, Lao L, Ren K, et al. Mechanisms of of pediatric patients for congenital heart surgery. acupuncture–electroacupuncture on persistent J Cardiothorac Vasc Anesth. 2017;31(4): pain. Anesthesiology. 2014;120(2):482–503. 1497–1504. 17. Xiao J, Yi W, Wu L. Effects of electroacupuncture 4. Walid MS, Donahue SN, Darmohray DM, et al. on reducing labor pain and complications in the The fifth vital sign--what does it mean? Pain labor analgesia process of combined Pract. 2008;8(6):417–422. spinal-epidural analgesia with patient-controlled 5. Lv Q, Wu F, Gan X, et al. The involvement of epidural analgesia. Arch Gynecol Obstet. descending pain inhibitory system in 2019;299(1):123–128. electroacupuncture-induced analgesia. Front 18. Gao Y, Zhou X, Dong X, et al. Integr Neurosci. 2019;13:38. Electroacupuncture for bladder function recovery 6. Zhang R, Lao L, Ren K, et al. Mechanisms of in patients undergoing spinal anesthesia. Evid acupuncture–electroacupuncture on persistent Based Complement Alternat Med. 2014;2014: pain. Anesthesiology. 2014;120(2):482–503. 892619. 7. Choi JW, Kang SY, Choi JG, et al. Analgesic 19. Yeh BY, Hsu YC, Huang JY, et al. Effect of effect of electroacupuncture on electroacupuncture in postanesthetic shivering paclitaxel-induced neuropathic pain via spinal during regional anesthesia: a randomized opioidergic and adrenergic mechanisms in mice. controlled trial. BMC Complement Altern Med. Am J Chin Med. 2015;43(1):57–70. 2012;12(1):233. 8. Guo A, Vulchanova L, Wang J, et al. 20. Guo X, Gui F, Guo M, et al. The preventive effect Immunocytochemical localization of the vanilloid of CT image-guided electroacupuncture receptor 1 (VR1): relationship to neuropeptides, combined with continuous femoral nerve block the P2X3purinoceptor and IB4 binding sites. Eur on deep vein thrombosis after total knee J Neurosci. 1999;11(3):946–958. arthroplasty based on an adaptive algorithm. 9. Fang JQ, Du JY, Liang Y, et al. Intervention of World Neurosurg. 2020;S1878–8750(20): electroacupuncture on spinal p38 32361–32365. MAPK/ATF-2/VR-1 pathway in treating 21. Kahveci K, Ornek D, Doger C, et al. The effect of inflammatory pain induced by CFA in rats. Mol anesthesia type on stress hormone response: Pain. 2013;9(1):13. comparison of general versus epidural anesthesia. 10. Chai W, Tai Y, Shao X, et al. Electroacupuncture Niger J Clin Pract. 2014;17(4):523–527. alleviates pain responses and inflammation in a 22. Brown EN, Pavone KJ, Naranjo M. Multimodal rat model of acute gout arthritis. Evid Based General Anesthesia: Theory and Practice. Anesth Complement Alternat Med. 2018;2018:2598975. Analg. 2018;127(5):1246–1258. 11. Huang CP, Lin YW, Lee DY, et al. 23. Wang Y, Kong L, Liu X. Effect of epidural block Electroacupuncture relieves CCI-induced anesthesia combined with general anesthesia on neuropathic pain involving excitatory and postoperative cognitive ability of elderly patients inhibitory neurotransmitters. Evid Based undergoing thoracoscopic surgery. Int J Clin Exp Complement Alternat Med. 2019;2019:6784735. Pathol. 2020;13(10):2447–2454. 12. Ali U, Apryani E, Wu HY, et al. Low frequency 24. Sheta E, Ragab S, Farghali H, et al. Successful electroacupuncture alleviates neuropathic pain by practice of electroacupuncture analgesia in equine activation of spinal microglial surgery. J Acupunct Meridian Stud. 2015;8(1): IL-10/beta-endorphin pathway. Biomed 30–39. Pharmacother. 2020;125:109898. 25. Kim DH, Cho SH, Song KH, et al. 13. Fang G, Ding Z, Song Z. Comparison of the Electroacupuncture analgesia for surgery in cattle. effects of epidural anesthesia and local anesthesia Am J Chin Med. 2004;32(1):131–140. in lumbar transforaminal endoscopic surgery. 26. Jin S, Zhang M, Liang D, et al. Effect of general Pain Physician. 2016;19(7):E1001–1004. anesthesia combined electro -acupuncture on 14. Bordlee JW, Beakley BD, Mody R, et al. A case stress response in patients undergoing thyroid of paradoxical presentation of a postural surgery. China Mod Doctor. 2018;56(25): postdural puncture headache after combined 124–127. spinal-epidural anesthesia. J Clin Anesth. 27. Fathi M, Alavi SM, Joudi M, et al. Preoperative 2017;38:156–157. anxiety in candidates for heart surgery. Iran J 15. Hong JH, Kim SJ, Hwang MS. Comparison of Psychiatry Behav Sci. 2014;8(2):90–96. effect of electroacupuncture and nefopam for 28. Roomruangwong C, Tangwongchai S, prevention of postanesthetic shivering in patients Chokchainon A. Preoperative anxiety among undergoing urologic operation under spinal patients who were about to receive uterine anesthesia. Korean J Anesthesiol. 2016;69(6): dilatation and curettage. J Med Assoc Thai.

6 Submit a manuscript: https://www.tmrjournals.com/ndt TMR Non-Drug Therapy doi: 10.12032/TMRND20210416028 2012;95(10):1344–1351. chemotherapy-induced nausea and vomiting: 29. Luo J, Liang J, Zhang H, et al. The effects of study protocol for a randomized controlled trial. preoperative anxiety on postoperative pain and Trials. 2017;18(1):477. opioid consumption in patients undergoing 42. Li S, Yang G, Zheng M, et al. Identifying the laparoscopic hysterectomy. J Clin Anesth. optimal timing of preoperative 2016;32:543–546. electroacupuncture for postoperative nausea and 30. Amorim D, Amado J, Brito I, et al. Acupuncture vomiting and pain in patients undergoing and electroacupuncture for anxiety disorders: A laparoscopic gynecologic surgery: Study protocol systematic review of the clinical research. for a randomized controlled trial. Eur J Integr Complement Ther Clin Pract. 2018;31:31–37. Med. 2019;30:100951. 31. Bae H, Bae H, Min BI, et al. Efficacy of 43. Park MS, Park WS, Nam D, et al. Efficacy of acupuncture in reducing preoperative anxiety: a electroacupuncture in preventing nausea and meta-analysis. Evid Based Complement Alternat vomiting after thyroidectomy: a prospective Med. 2014;2014:850367. randomized controlled trial. Trial. 2020. Doi: 32. Rodrigues-Silva N, Coelho R, Liça N, et al. 10.21203/rs.3.rs-62887/v1. P-150 - Effects of low-frequency 44. Isik B. Postoperative cognitive dysfunction and electroacupuncture on the BIS and anxiety in Alzheimer disease. Turk J Med Sci. anxious volunteers: a prospective, randomized, 2015;45(5):1015–1019. blinded study. Eur Psychiat. 2012;27(supp-S1): 45. Czyz-Szypenbejl K, Medrzycka-Dabrowska W, 1-1. Kwiecien-Jagus K, et al. The occurrence of 33. Long JB, Bevil K, Giles DL. Preemptive postoperative cognitive dysfunction (POCD) - analgesia in minimally invasive gynecologic systematic review. Psychiatr Pol. surgery. J Minim Invasive Gynecol. 2019;26(2): 2019;53(1):145–160. 198–218. 46. Liu PR, Zhou Y, Zhang Y, et al. 34. Ali U, Apryani E, Ahsan MZ, et al. Electroacupuncture alleviates surgery-induced Acupuncture/Electroacupuncture as an cognitive dysfunction by increasing Alternative in Current Opioid Crisis. Chin J alpha7-nAChR expression and inhibiting Integr Med. 2020;26(9):643–647. inflammatory pathway in aged rats. Neurosci Lett. 35. Chen T, Wang K, Xu J, et al. Electroacupuncture 2017;659:1–6. reduces postoperative pain and analgesic 47. Feng PP, Deng P, Liu LH, et al. consumption in patients undergoing thoracic Electroacupuncture alleviates postoperative surgery: a randomized study. Evid Based cognitive dysfunction in aged rats by inhibiting Complement Alternat Med. 2016;2016:2126416. hippocampal neuroinflammation activated via 36. Zhang C, Zhou M, Li M. Clinical study of microglia/TLRs pathway. Evid Based electroacupuncture on perioperative analgesia in Complement Alternat Med. 2017;2017:6421260. patients with thyroid surgery under cervical 48. Yuan S, Zhang X, Bo Y, et al. The effects of plexus block. Chin Acup Moxib. electroacupuncture treatment on the postoperative 2018;38(12):1261–1265.. cognitive function in aged rats with acute 37. Li Y, Wang P, Deng D, et al. Electroacupuncture myocardial ischemia-reperfusion. Brain Res. for pain control after total knee arthroplasty: a 2014;1593:19–29. meta-analysis. CJTER. 2021;25(6):957–963. 49. Liu PR, Cao F, Zhang Y, et al. Electroacupuncture 38. Apfel CC, Laara E, Koivuranta M, et al. A reduces astrocyte number and oxidative stress in simplified risk score for predicting postoperative aged rats with surgery-induced cognitive nausea and vomiting: conclusions from dysfunction. J Int Med Res. 2019;47(8): cross-validations between two centers. 3860–3873. Anesthesiology. 1999;91(3):693–700. 50. Zhang Q, Li YN, Guo YY, et al. Effects of 39. McCaul C, Buckley M, Hegarty A. Ambulatory preconditioning of electro-acupuncture on anesthesia and postoperative nausea and vomiting: postoperative cognitive dysfunction in elderly: A predicting the probability. Ambul Anesth. prospective, randomized, controlled trial. 2016;3:27–35. Medicine (Baltimore). 2017;96(26):e7375. 40. Tian Q. Effect of electroacupuncture on postoperative cognition, dosage of anesthetics and postoperative nausea and vomiting in patients undergoing general anesthesia for lumbar spine surgery. Ningxia Medical University;2019. 41. Chen B, Guo Y, Zhao X, et al. Efficacy differences of electroacupuncture with single acupoint or matching acupoints for

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