Intraoperative Acupuncture as Part of a Multimodal Analgesic Regimen to Reduce Opioid Usage After Total Knee Arthroplasty: A Prospective Cohort Trial.

Objective: Given the U.S. opioid crisis, surgeons and anesthesiologists must collaborate to optimize nonopioid analgesics perioperatively. A common surgical procedure, total knee arthroplasty (TKA) is a critical target for opioid reduction and development of enhanced recovery protocols. Auricular therapy can help reduce pain and opioid analgesic use in the perioperative timeperiod, but intraoperative use for TKA has yet to be explored. The aim of the present study was to investigate the effect of integrating intraoperative auricular therapy as part of an opioid-sparing protocol for TKA. Materials and Methods: In this prospective cohort study, 41 patients undergoing primary unilateral TKA under neuraxial anesthesia received a standardized, opioid-free intraoperative protocol including electroauricular acupuncture. The primary outcome was the number of patients able to remain on a low-dose opioid regimen: ≤112.5 oral morphine equivalents. Additional outcomes included patient-reported pain scores, side-effects, and prior experience with acupuncture. Results: Of the 40 patients who completed the study, 26 (65%) maintained a low-dose opioid regimen, with 3 (7%) remaining opioid-free for 30 days. No subjects used opioids beyond 30 days. Mean pain scores were low at rest (Day 0: 3.4, standard deviation [SD] 2.4; Day 1: 2.4, SD 1.8) and moderate with movement (Day 0: 4.8, SD 2.6; Day 1: 5.1, SD 2.1). The most-common side-effects were dry mouth (43.2%), drowsiness (24.3%), and lightheadedness (24.3%). Conclusions: Incorporating intraoperative electroauricular acupuncture into an existing multimodal analgesia regimen is a feasible way to maintain a low-dose opioid regimen after TKA. This research was registered at clinicaltrials.gov as Clinical Trial Number: NCT#04084288.

The Feasibility of Blinding Intraoperative Electro-Auricular Acupuncture Under Neuraxial Anesthesia.

Objective: Demand for complementary medicine, in particular, acupuncture, has increased over the past few years but widespread acceptance has been limited, in part, by the lack of high-quality studies, including lack of blinding. Acupuncture studies traditionally have difficulty with blinding as sham acupuncture can have up to a 40%-50% analgesic effect. This study randomized patients between Acupuncture and No Acupuncture (standard of care) without using sham needles. The primary outcome was adequate blinding of electro-auricular acupuncture in the intraoperative setting with secondary outcomes of pain/nausea control. Materials and Methods: Forty patients undergoing anterior cruciate ligament reconstruction were enrolled. Subjects were randomly assigned to receive acupuncture (Enhanced Electro-Auricular Trauma Protocol) or No Acupuncture during their surgeries. All patients received spinal anesthesia and intravenous midazolam, ketamine, and propofol for sedation. 1000 mg of intravenous (IV) acetaminophen and up to 30 mg of IV ketorolac were given at closure. No opioids or peripheral nerve blocks were administered intraoperatively. Results: Bang's Blinding indices were 0.2 (95% confidence interval [CI]: -0.02, 0.42) in the Acupuncture group, and 0.11 (95% CI: -0.10, 0.31) in the No Acupuncture group on postoperative day 1. Both groups had adequate blinding. There were no differences in pain scores, nausea/vomiting incidence, opioid consumption 0-24 hours, or patient satisfaction. Five patients in the No Acupuncture group received rescue blocks, while no patients in the Acupuncture group needed a rescue block (Fisher's exact test: p = 0.047). Conclusions: This study proved the primary hypothesis that adequate blinding of intraoperative acupuncture can be performed when patients are under sedation and neuraxial anesthesia. This research is registered at ClinicalTrials.gov as Clinical Trial Registration #: NCT03711734.

Anterior Quadratus Lumborum Block Does Not Provide Superior Pain Control after Hip Arthroscopy: A Double-blinded Randomized Controlled Trial.

BACKGROUND: Hip arthroscopy is associated with moderate to severe postoperative pain. This prospective, randomized, double-blinded study investigates the clinically analgesic effect of anterior quadratus lumborum block with multimodal analgesia compared to multimodal analgesia alone. The authors hypothesized that an anterior quadratus lumborum block with multimodal analgesia would be superior for pain control. METHODS: Ninety-six adult patients undergoing ambulatory hip arthroscopy were enrolled. Patients were randomized to either a single-shot anterior quadratus lumborum block (30 ml bupivacaine 0.5% with 2 mg preservative-free dexamethasone) or no block. All patients received neuraxial anesthesia, IV sedation, and multimodal analgesia (IV acetaminophen and ketorolac). The primary outcome was numerical rating scale pain scores at rest and movement at 30 min and 1, 2, 3, and 24 h. RESULTS: Ninety-six patients were enrolled and included in the analysis. Anterior quadratus lumborum block with multimodal analgesia (overall treatment effect, marginal mean [standard error]: 4.4 [0.3]) was not superior to multimodal analgesia alone (overall treatment effect, marginal mean [standard error]: 3.7 [0.3]) in pain scores over the study period (treatment differences between no block and anterior quadratus lumborum block, 0.7 [95% CI, -0.1 to 1.5]; P = 0.059). Postanesthesia care unit antiemetic use, patient satisfaction, and opioid consumption for 0 to 24 h were not significantly different. There was no difference in quadriceps strength on the operative side between groups (differences in means, 1.9 [95% CI, -1.5 to 5.3]; P = 0.268). CONCLUSIONS: Anterior quadratus lumborum block may not add to the benefits provided by multimodal analgesia alone after hip arthroscopy. Anterior quadratus lumborum block did not cause a motor deficit. The lack of treatment effect in this study demonstrates a surgical procedure without benefit from this novel block.

Medical Acupuncture as a Treatment for Novel COVID-19-Related Respiratory Distress: Personal Experience from a Frontline Anesthesiologist.

Background: COVID-19 leads to significant respiratory distress among many other multiorgan dysfunctions. Depending on severity of symptoms, current treatment in the United States for COVID-19 consists of supportive care, including, but not limited to, supplemental oxygen, antipyretic drugs, pain killers, and mechanical ventilation. Case Description: This case reports a previously healthy anesthesiologist and medical acupuncturist working in a New York City COVID intensive care unit who contracted and was diagnosed with COVID-19 virus. She subsequently developed self-diagnosed acutely symptomatic COVID pneumonia, including symptoms of pleuritic chest pain, hypoxia with shortness of breath, increased respiratory rate, dry cough, orthostatic hypotension, and headache. She self-treated with cupping therapy at the onset of symptoms and medical acupuncture at the onset of pulmonary symptoms to full recovery. Conclusions: Acupuncture should be considered as a viable adjunct in supportive care for patients with symptomatic COVID-19 pneumonia.

Integrating complementary medicine in the perioperative period: a simple, opioid-sparing addition to your multimodal analgesia strategy?

The current US opioid health-related crisis underscores the importance for perioperative physicians to optimize various approaches to pain management. Multimodal techniques and enhanced recovery after surgery (ERAS) protocols are frequently cited as the most effective strategies for improving the experience of pain and reducing opioid exposure. Complementary medicine (CM) techniques, while frequently shown to be effective at reducing opioid and other pharmacologic agent use, are rarely discussed as part of these multimodal strategies. In general, CM therapies are low-cost with minimal associated risk, making them an ideal choice for incorporation into ERAS and other opioid-sparing protocols. In this Daring Discourse, we discuss the benefits and challenges of incorporating CM therapy into anesthetic practice. We hope that anesthesiologists can become more familiar with the current evidence regarding perioperative CM therapy, and begin incorporating these therapies as part of their comprehensive multimodal approach to perioperative pain management.