Use of alternative medical therapies in the perioperative period: is it time to get on board?

Paul F. White, MD, PhD, FANZCA* Acustimulation has been shown to produce sedation and to reduce preoperative anxiety levels and postoperative pain, nausea and vomiting in a variety of clinical settings. For example, Kober et al. (1) found auricular acupressure to be effective in reducing anxiety in patients being transported to the hospital. In elderly patients with hip fractures, this technique was recently reported to reduce both anxiety and pain during emergency transportation (2). Wang et al. reported that auricular acupressure decreased maternal anxiety during induction of anesthesia in their children (3), and also reduced preoperative anxiety in adult patients undergoing ambulatory surgery (4). In this issue of Anesthesia & Analgesia, Karst et al. (5) compared the anxiolytic effects of auricular acupressure to a wellknown pharmacologic anxiolytic drug (midazolam) in patients undergoing dental procedures. Although the authors’ decision to use the intranasal route for administering midazolam is a valid criticism of this study, the investigation is still a useful addition to the literature because the authors compared this nontraditional approach to reducing preoperative anxiety with a well-known anxiolytic drug. Clearly, there is a need for additional studies comparing this acustimulation technique to a more widely used premedication technique (e.g., midazolam 20 g/kg IV). The major challenge in performing these much needed comparative studies is the difficulty in avoiding bias due to inadequate “blinding” of the investigators and the patients (6,7). The study by Fassoulaki et al. (8) illustrates some of the difficulties in conducting clinical investigations into the possible mechanism(s) of acupressure’s sedative and anxiolytic effects. These investigators previously reported that acupressure reduces the bispectral index (BIS) value and the “verbal stress score” in volunteers (9). In their recent investigation (8), these researchers examined the relationship between acupressure stimulation, stress levels, BIS values, and blood concentrations of melatonin and -endorphin. The authors minimized the placebo effect by including both a “no treatment” (control) and a “sham acupoint” group. This cross-over study confirmed that acupressure reduced the volunteers’ stress level and BIS values; however, sedation and stress levels failed to correlate with changes in melatonin and -endorphin blood concentrations. The authors’ inability to detect a change in their primary end points suggests that the clinical effects of acupuncture are unrelated to changes in these surrogate end points (i.e., hormone levels). Alternatively, the study may simply be inadequately powered (i.e., the group sizes were too small) to detect meaningful changes in these variables. A variety of acustimulation techniques have been used to control emetic symptoms in the postoperative period, including acupressure, acupuncture, and transcutaneous electrical stimulation (10). Acustimulation appears to be comparable to the popular 5-HT3 antagonist, ondansetron, in the prevention of PONV when used as part of a multimodal antiemetic regimen (11,12). However, the efficacy of this technique varies markedly depending on the clinical setting (e.g., surgical population (13,14), timing of its administration (15,16)). Interestingly, the study by Gan et al. (12) From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas. Accepted for publication October 27, 2006. Supported by the endowment funds from the Margaret Milam McDermott Distinguished Chair of Anesthesiology, and the White Mountain Institute. Address correspondence and reprint requests to P. F. White, MD, PhD, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9068. Address e-mail to paul.white@ utsouthwestern.edu. Copyright © 2007 International Anesthesia Research Society DOI: 10.1213/01.ane. 0000253081.07841. 01