The Effect of TEAS on the Quality of Early Recovery
Condition: C.Delivery; Surgery (Previous), Gynecological; Inappropriate Device Stimulation of Tissue; Delayed Emergence From Anesthesia
MeSH terms: Delayed Emergence from Anesthesia
Study type: Interventional

Summary: 
      During the past four decades, gynecologic laparoscopy has evolved from a limited method to an
      advanced operative approach that frequently serves as a substitute for laparotomy. The
      advantages of laparoscopy over laparotomy include less postoperative pain, shorter hospital
      stays, and reduced blood loss. However, in the surgery CO2 increases the intra-abdominal and
      intrathoracic pressure, which leads to cardiac output decrease and increases sympathetic
      activity in a reflex. On the other hand, CO2 accumulation in the body leads to hypercapnia,
      which indirectly stimulates aortic body chemosensory organs and carotid sinus, increasing the
      concentration of plasma catecholamines, cortisol and vasopressin , these responses have an
      important impact on patient recovery after surgery.

      Acupuncture is an ancient Chinese method to treat diseases and relieve pain. Transcutaneous
      electrical acupoint stimulation (TEAS), a noninvasive adjunctive intervention based on
      acupuncture, has been widely accepted and used worldwide. To date, multiple studies have
      demonstrated TEAS could reduce intra-operative opioid drugs consumption, reduce the incidence
      of postoperative nausea and vomiting (PONV) and improve postoperative cognitive function.
      However, whether TEAS could improve the quality of early recovery after gynecologic
      laparoscopy is unknown. In this study we therefore investigated the effects of TEAS at the
      acupoints of Baihui (GV20), Yingtang (EX-HN3), Zusanli (ST36) and Neiguan (PC6) on the
      quality of early recovery in the patients undergoing gynecological laparoscopic surgery.
    

Detailed description: 
      Patient population Sixty patients undergoing elective gynecological laparoscopic surgery at
      Guizhou province people's hospital with an ASA physical status of I-II were recruited between
      November 2013 and November 2014. Their ages ranged from 29-60 yr. Exclusion criteria were
      recent use of TEAS or acupuncture, neural damage or infection along the meridian at which the
      acupoints lay, use of antiemetic in the previous week, regular use of opioids, hepatic
      dysfunction, confirmed renal impairment, diabetes mellitus, cognitive dysfunction and
      conversion to laparotomy during gynecologic laparoscopy.

      Randomization and blinding Patients were assigned to either TEAS stimulus (TEAS group) or
      control group (Con group) on the basis of random numbers generated by a computer. Only the
      acupuncturist was informed the randomization allocation, just before the onset of TEAS. None
      of the anesthesiologists, surgeons, physicians in the post-anesthesia care unit (PACU), or
      participants were aware of the allocation. Blinding of the patients was ensured by using gel
      electrodes in the same therapeutic setting, which has previously been proved to be a
      successful strategy.

      TEAS protocol An experienced acupuncturist performed TEAS for 30 min before anesthesia.
      According to the theory of traditional Chinese medicine, bilateral Baihui (GV20), Yingtang
      (EX-HN3), Zusanli (ST36) and Neiguan (PC6) were chosen as the acupuncture points. These
      acupoints were identified according to the traditional anatomic localization. Gel electrodes
      were applied to the skin after it had been cleaned with ethyl alcohol. The acupoints were
      then stimulated electrically with an intensity of 12-15 mA and dense-disperse frequency of
      2/100 Hz for 30 min, using the Hwato electronic acupuncture treatment instrument (model No.
      SDZ-V, Suzhou Medical Appliances Co., Ltd, Suzhou, China). The intensity was adjusted to
      maintain a slight twitching of local muscles according to individual maximum tolerance,
      indicating a satisfactory of De-Qi phenomenon and thus adequate stimulation. The patients in
      the control group had the electrodes applied but received no stimulation.

      Anesthesia and perioperative management One surgeon conducted all surgeries according to a
      standard protocol; surgery commenced between 8:30 and 1:00 p.m. Anesthesia was induced i.v.
      with propofol and remifentanil using a target-controlled infusion (TCI) system. After loss of
      consciousness, vecuronium (0.1 mg kg-1) was administered i.v., and patients were
      orotracheally intubed 5 min later. Anesthesia was maintained with TCI of propofol and
      remifentanil. The depth of anesthesia was monitored using index (BIS). Effect site
      concentrations of propofol and remifentanil were adjusted to the hemodynamic and BIS.
      Patients' lungs were mechanically ventilated in a volume-controlled mode with a tidal volume
      of 8ml kg-1 body weight during the operation. In both groups, remifentanil and propofol
      infusions were stopped 5 min before the end of surgery. Patients were extubated and
      transferred to the PACU after surgery.

      Data collection Baseline data included demographics, body mass index (BMI), and ASA physical
      status. Surgical information recorded included anesthesia duration, surgery duration,
      estimated blood loss, and all other intraoperative medications. Postoperative data were
      collected regarding the incidence of nausea and vomiting, postoperative pain medications and
      antiemetics.

      The Quality of Recovery-40 (QoR-40) is a validated scale with 5 domains 10-12. These measure
      physical comfort, emotional state, physical independence, psychological support, and pain.
      Each domain is scored to a maximum global score of 200. QoR-40 scores have been found to be
      associated with both quality-of-life scales and patient satisfaction indices 13 as well as
      postoperative pain 14. In the present study, QoR-40 evaluation was performed on preoperative
      day 1(T0), postoperative day 1 (T1) and postoperative day 2 (T2).

      Visual analog scales (VAS) are widely used in behavioral science and previous studies
      reported their usefulness and validity 15, 16. VAS scores at rest queried about their level
      of pain on postoperative day 1 (T1) and postoperative day 2 (T2).

      The Mini-Mental State Examination (MMSE) is one of the most widely used assessment
      instruments of cognitive functioning postoperatively, which screens domains of orientation to
      time and place, attention and memory, concentration, language and praxis 17. Patient
      cognitive function was assessed using the MMSE on preoperative day 1(T0), postoperative day 1
      (T1) and postoperative day 2 (T2).

      Statistical analysis All statistical analyses were performed using SPSS 13.0 (SPSS, Inc.,
      Chicago, IL, USA). Continuous variables are presented as mean (SD) and compared using the
      unpaired Student's-test. Dichotomus variables were presented as the number of patients
      (percent) and analyzed using the X2 test. The level of significance for all statistical tests
      was set at 0.05.
    

Intervention name(s): TEAS; Con; propofol, remifentanil, vecuronium; mechanical ventilation
Intervention type(s): Other; Other; Drug; Other
Intervention description(s): According to the theory of traditional Chinese medicine, bilateral Baihui (GV20), Yingtang (EX-HN3), Zusanli (ST36) and Neiguan (PC6) were chosen as the acupuncture points. These acupoints were identified according to the traditional anatomic localization . Gel electrodes were applied to the skin after it had been cleaned with ethyl alcohol. The acupoints were then stimulated electrically with an intensity of 12-15 mA and dense-disperse frequency of 2/100 Hz for 30 min, using the Hwato electronic acupuncture treatment instrument (model No. SDZ-V, Suzhou Medical Appliances Co., Ltd, Suzhou, China). The intensity was adjusted to maintain a slight twitching of local muscles according to individual maximum tolerance, indicating a satisfactory of De-Qi phenomenon and thus adequate stimulation.; The patients in the Con group had the electrodes applied at the same acupoints, but received no stimulation.; Anesthesia was induced i.v. with propofol (2 mg kg-1) and remifentanil (1 μg kg-1) using a target-controlled infusion (TCI) system. After loss of consciousness, vecuronium (0.1 mg kg-1) was administered i.v.; Patients' lungs were mechanically ventilated in a volume-controlled mode with a tidal volume of 8ml kg-1 body weight during the operation.
Intervention MeSH terms: Remifentanil; Propofol; Vecuronium Bromide
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Investigator, Outcomes Assessor)
Primary purpose: Supportive Care
Keywords: Transcutaneous electric acupoint stimulation (TEAS); gynecological laparoscopic surgery; QoQ-40; MMSE; VAS