Effects of perioperative transcutaneous electrical acupoint stimulation on monocytic HLA-DR expression in patients undergoing coronary artery bypass grafting with cardiopulmonary bypass: study protocol for a double-blind randomized controlled trial.

BACKGROUND: Cardiac surgery involving cardiopulmonary bypass (CPB) is known to be associated with a transient postoperative immunosuppression. When severe and persistent, this immune dysfunction predisposes patients to infectious complications, which contributes to a prolonged stay in the intensive care unit (ICU), and even mortality. Effective prevention and treatment methods are still lacking. Recent studies revealed that acupuncture-related techniques, such as electroacupuncture and transcutaneous electrical acupoint stimulation (TEAS), are able to produce effective cardioprotection and immunomodulation in adult and pediatric patients undergoing cardiac surgery with CPB, which leads to enhanced recovery. However, whether perioperative application of TEAS, a non-invasive technique, is able to improve immunosuppression of the patients with post-cardiosurgical conditions is unknown. Thus, as a preliminary study, the main objective is to evaluate the effects of TEAS on the postoperative expression of monocytic human leukocyte antigen (-D related) (mHLA-DR), a standardized "global" biomarker of injury or sepsis-associated immunosuppression, in patients receiving on-pump coronary artery bypass grafting (CABG). METHODS: This study is a single-center clinical trial. The 88 patients scheduled to receive CABG under CPB will be randomized into two groups: the group receiving TEAS, and the group receiving transcutaneous acupoint pseudo-electric stimulation (Sham TEAS). Expression of mHLA-DR serves as a primary endpoint, and other laboratory parameters (e.g., interleukin [IL]-6, IL-10) and clinical outcomes (e.g., postoperative infectious complications, ICU stay time, and mortality) as the secondary endpoints. In addition, immune indicators, such as high mobility group box 1 protein and regulatory T cells will also be measured. DISCUSSION: The current study is a preliminary monocentric clinical trial with a non-clinical primary endpoint, expression of mHLA-DR, aiming at determining whether perioperative application of TEAS has a potential to reverse CABG-associated immunosuppression. Although the immediate clinical impact of this study is limited, its results would inform further large-sample clinical trials using relevant patient-centered clinical outcomes as primary endpoints. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02933996. Registered on 13 October 2016.

[Protection of Electro-acupuncture for Gastric Mucosa of Patients Undergoing Endoscopic Sinus Surgery].

OBJECTIVE: To evaluate the effect of electro-acupuncture (EA) on gastric mucosal oxygenation and systemic inflammatory response in patients undergoing endoscopic sinus surgery with controlled hypotension (CH), and to explore its protective effect on gastric mucosa. METHODS: Fifty-four patients, 18-65 years old, grade I-II of American Society of Anesthesiology (ASA), who were scheduled for endoscopic sinus surgery were randomly assigned to two groups, group A (general anesthesia group) and group B (general anesthesia combined EA anesthesia group), 27 in each group. Conrolled hypotension was executed during operation, and mean arterial pressure (MAP) was maintained at 55-65 mmHg. After tracheal intubation gastric tesiometer catheter was indwelled through nasal cavity or oral cavity. After successful indwelling, it was connected with gastric mucosa monitoring mode of multifunctional parameters monitor. Patients' MAP and heart rate (HR), pHi, partial pressure of carbon dioxide (PgCO2), arterial partial pressure of carbon dioxide (Pg-aCO2) and endtidal pressure of carbon dioxide (Pg-etCO2) were measured and recorded at T, (immediately before induced hypotension), T, (20 min following induced hypotension to target MAP), T2 (40 min following induced hypotension to target MAP), T3 (20 min after ending induced hypotension), and T4(40 min after ending induced hypotension). Blood samples were intravenously collected, TNF-alpha, IL-1, and IL-6 were detected by ELISA 24 h before operation, during operation (T3), and 24 h after operation. RESULTS: After hypotension was induced, Pg-CO2, Pg-aCO2 and Pg-etCO2 increased significantly (P < 0.01, P < 0.05), while pHi decreased significantly (P < 0.01) in both groups at T1-T4 than those at T0. During T1-T4, PgCO2, Pg-aCO2, and Pg-etCO2 were higher (P < 0.01, P < 0.05), while pHi was lower in group A than in group B (P < 0.01). Furthermore, TNF-alpha, IL-1, and IL-6 increased significantly in both groups during operation and 24 h after operation, when compared with those 24 h before operation (P < 0.01, P < 0.05). TNF-alpha and IL-1 in group A were higher than those in group B (P < 0.05) during operation and 24 h after operation, but with no significant difference in the plasma concentration of IL-6 (P > 0.05). CONCLUSION: EA exerted obvious protective effect of gastric mucosal injury in endoscopic sinus surgery with controlled hypotension, which might be achieved by increasing gastric mucosal blood flow, maintaining oxygen supply and demand, inhibiting inflammatory response, and alleviating injury of gastric mucosal barrier.

Combining interscalene brachial plexus block with intravenous-inhalation combined anesthesia for upper extremity fractures surgery: a randomized controlled trial.

BACKGROUND: A parallel-group randomized controlled trial (RCT) was conducted to evaluate the effect of combining the interscalene brachial plexus block (IBPB) with Intravenous-inhalation combined anesthesia to isolated Intravenous-inhalation anesthesia in the upper extremity fractures surgery of elderly patients. METHODS: One hundred elderly patients who underwent upper extremity surgery were randomly assigned to received isolated Intravenous-inhalation combined anesthesia (group CI, n = 50) and IBPB associated with Intravenous-inhalation combined anesthesia (group NB, n = 50). Associated side effects, recovery time after operation, as well as the dose of intraoperative vasoactive agents and auxiliary drugs were noted. RESULTS: The two groups were not significantly different in gender (P = 0.539), ages (P = 0.683) and weight (P = 0.212). Five patients (10%) in the group NB and 17 patients (34%) in the group CI suffered from preoperative hypotension (P = 0.004). Besides, lower incidence of other adverse effects such as mental stress, incision pain and hypertension were also found in the group NB; however, the differences were not statistically significant (P > 0.05). The consumption of general anesthetics in the group NB was significantly less than that of the group CI (propofol, P = 0.004; lsoflurane, P < 0.001), and the recovery time of the group NB was significantly shorter than that of the group CI (P = 0.020). CONCLUSION: Combining IBPB with Intravenous-inhalation combined anesthesia in elderly patients hold a greater potential for upper extremity fractures surgery due to its improved clinical effectiveness and fewer side effects.

[Effect of dexmedetomidine and midazolam on respiration and circulation functions in patients undergoing open heart surgery under acupuncture-assisted general anesthesia].

OBJECTIVE: To evaluate the effect of Dexmedetomidine and Midazolam on respiratory and circulation in patients experiencing open heart surgery under acupuncture-assisted general anesthesia. METHODS: Sixty patients undergoing open heart surgery (cardiac valve replacement surgery and aortic valve replacement surgery) were randomly and equally divided into Dexmedetomidine (D) and Midazolam (M) groups. Electroacupuncture (EA) was applied to bilateral Yunmen (LU 2), Zhongfu (LU1), Lieque (LU7) and Neiguan (PC6). For patients of group D, Dexmedetomidine (i.v., loading dose: 1 microg/kg, and succedent dose: 0.2-1 microg x kg(-1) x h(-1)) was given. For patients of group M, Midazolam (i.v., loading dose: 0.05 mg/kg, succedent dose: 0.01-0.03 mg x kg(-1) x h(-1)) was given. Arterial oxygen pressure (PaO2), arterial carbondioxide tension (PaCO2), O2 saturation (SPO2), mean arterial pressure (MAP), heart rate (HR), anesthetic effect, time of spontaneous breathing recovery, and time of resuscitation were recorded before operation (T0), immediately after skin incision (T1), immediately after sternotomy (T2), before suspension of cardiopulmonary bypass (CPB, T3), immediately after cardiac re-beating (T4), immediately after CPB cessation (T5), and at the end of surgery (T6). RESULTS: Before operation, no significant differences were found between the group D and M in the levels of PaO2, PaCO2 and SPO2 (P > 0.05). The PaO2 and SPO2 levels after skin incision, sternotomy, before suspension of CPB and at the end of surgery were significantly lower in group M than in group D (P < 0.05), while the le- vels of PaCO2 after skin incision, sternotomy, before suspension of CPB and at the end of surgery, and HR after skin incision, sternotomy, before suspension of CPB, after heart re-beating,after CPB cessation and at the end of surgery in group M were considerably higher than those in group D (P < 0.05). In addition, the time of spontaneous breathing recovery of group M was significantly later than that of group D (P < 0.05). No significant differences were found between the two groups in MAP levels at the 6 time-points during surgery, in the PaO2, PaCO2 and SPO2 levels at the time-points of post-cardiac re-beating, and after CPB cessation (P > 0.05). It suggested that the respiration and circulation states in group D were more smoothly than those in group M. There was no significant difference between the two groups in the time of resuscitation (P > 0.05). CONCLUSION: Dexmedetomidine is superior to Midazolam in analgesia, and improving respiration and circulation functions for open heart surgery patients under acupuncture-assisted general anesthesia.

[Efficacy on analgesia with electric stimulation of long-term retaining needle after laparoscopic cholecystectomy].

OBJECTIVE: To observe the clinical effect of electric stimulation of long-term retaining needle on analgesia after laparoscopic cholecystectomy (LC) and the impacts on the post-surgical flatus time. METHODS: Under static absorptive composite general anesthesia, 90 cases of LC were randomized into three groups, 30 cases in each one. In the control group, the analgesia was not applied after LC. In the analgesia-pumper group, the patient controlled intravenous analgesia (PCIA) was used. In the needle-retaining group, the electric acupuncture stimulator was used. The needles were inserted transversely at Riyue (GB 24), Qichong (ST 30) and Yanglingquan (GB 34) and fixed with sterile sticker. Separately, in 8 h and 24 h after surgery, the electric acupuncture stimulation with disperse-dense wave, 2 Hz/100 Hz frequency was applied continuously for 30 min. Visual analogue scale (VAS), adverse reactions such as vomiting and nausea and the postoperative flatus time in 2, 4, 8, 12, 24 and 36 h after surgery were observed and recorded in the three groups. RESULTS: In 2, 4, 8, 12 and 24 h after surgery, VAS scores in the needle-retaining group and the analgesia-pumper group were all lower than those in the control group (P < 0.05, P < 0.01). The analgesia effect at the above time points in the needle-retaining group was better than that in the analgesia-pumper group (all P < 0.05). There was not adverse reaction in the needle-retaining group. But there were 3 cases of somnolence, 6 cases of nausea and 3 cases of vomiting in the analgesia-pumper group, and 2 cases of nausea and 1 case of vomiting in the control group. The flatus time was quite earlier in the needle-retaining group as compared with the other two groups [(14.77 +/- 4.99) h vs (18.50 +/- 4.22) h, P < 0.01; (14.77 +/- 4.99) h vs (18.17 +/- 4.69) h, P < 0.05]. CONCLUSION: The electric stimulation of long-term retaining needle is safe and effective in analgesia after LC. It avoids the adverse reactions of analgesics and promotes postoperative flatus.

[Effects of transcutaneous electrical acupoint stimulation combined with general anesthesia on cerebral oxygen metabolism in elderly hip replacement patients during controlled hypotension].

OBJECTIVE: To observe the protective effect of transcutaneous electrical acupoint stimulation (TEAS) on cerebral tissue in elderly hip replacement operation patients during general anesthesia under controlled hypotension. METHODS: Forty hip replacement operation patients were randomly divided into general anesthesia (GA) control group and TEAS + GA group (n = 20 in each group). Patients of the two groups during operation were treated with controlled hypotension for reducing blood loss. TEAS (2 Hz/100 Hz, 8-12 mA) was applied to bilateral Yuyao (EX-HN 4) and Fengchi (GB 20) and began 30 min before GA. General anesthesia was performed by intravenous injection of Midazolam, Diprivan, Fentanyl and Cis-atracurium, sevoflurane-inhaling, Remifentanil, etc., and the patient's mean arterial pressure was maintained to be about 70% of the normal level (controlled hypotension) by using venous administration of Remifentanil about 10 min after the operation. GEM Premier 3000 blood gas analyzer was used to analyze levels of the arterial oxygen (CaO2), internal jugular venous oxygen (CjvO2), arterio-venous oxygen content difference (Da-jvO2) and cerebral oxygen (CERO2) uptake rates of blood samples before controlled hypotension (T0), 20 min after controlled hypotension (T ). 40 min after controlled hypotension (T2) and 20 min after the end of controlled hypotension (T3). RESULTS: Self-comparison of each group showed that in comparison with pre-controlled hypotension, CjvO2 levels at the time-points of T, T2 and T3 were significantly increased in both GA control and TEAS+GA groups (P < 0.05), while Da-jvO2 and CERO2 uptake rate levels at the time-points of T,. T2 and T3 in these two groups were significantly decreased (P < 0.05). Comparison between two groups showed that CivO2 levels at the time-points of T2 and T3 were significantly higher in the TEAS + GA group than in the GA control group (P<0. 05). while Da-jvO2 and CERO2 uptake rate levels at the time-point of T2 were obviously lower in the TEAS + GA group than in the GA control group(P<0. 05), suggesting a reduction of cerebral oxygen consumption after TEAS. No significant differences were found between these two groups in blood CjvO2, Da-jvO2 and CERO2 uptake rate levels at the time-points of T0 and T1 (P > 0.05). CONCLUSION: TEAS can reduce cerebral oxygen uptake rate in elderly patients undergoing hip replacement during controlled hypotension, suggesting a protective effect of TEAS on patient's cerebral tissue.

[Progresses of studies on acupuncture analgesia for postoperative reaction].

A large number of clinical trials and animal experiments have been carried out to focus on neurochemical mechanisms of acupuncture analgesia including postoperation pain relief, which may provide guidance for developing a novel clinical approach for postoperative analgesia. In the present paper, the authors review new progresses of researches on acupuncture analgesia for postoperative pain and side effects in the past few years from thyroidectomy, chest surgery, abdominal surgery, five sense organs (ear, nose, eye and throat) surgery, and others. Regarding the mechanism of acupuncture, central neurotransmitters (including the endop endorphin, 5-HT, gamma-aminobutyric acid, etc.), immune cytokines, cytokines from the spinal glia cells are complicated in the process of acupuncture analgesia. A lot of findings of researches demonstrated that acupuncture therapy is effective in reducing postoperative pain and adverse reactions as nausea, vomiting, etc. As a common technique widely used in the field of clinical medicine, the underlying mechanisms of acupuncture therapy for relieving post-surgery pain and side-effects should be studied profoundly in the future.

[Impacts of electroacupuncture at different frequencies on the postoperative nausea and vomiting of patients with laparoscopic surgery].

OBJECTIVE: To assess the impacts on postoperative nausea and vomiting of the patients with laparoscopic surgery undergoing the general anesthesia by electroacupuncture (EA) at different frequencies at bilateral Neiguan (PC 6). METHODS: One hundred and twenty female patients with laparoscopic surgery undergoing the general anesthesia were randomized into 4 groups: 2 Hz EA treatment group (group A), 2 Hz/100 Hz EA treatment group (group B), 100 Hz EA treatment group (group C) and a control group (group D), 30 cases in each one. The same anesthetic program was adopted in each group. For the patients in A, B and C groups, in the first half a hour undergoing the conventional drug anesthesia, acupuncture was applied to bilateral Neiguan (PC 6). After arrival of qi, HANS-200A electroacupuncture apparatus was connected, at the frequency as 2 Hz, 2 Hz/100 Hz and 100 Hz separately. The electric stimulation was discontinued at the end of surgery. The life physical signs after surgery, the occurrence of postoperative nausea and vomiting and the severity grades of postoperative nausea and vomiting were observed and recorded for the patients in each group. RESULTS: The differences in the postoperative 1 h heart rate, mean arterial pressure (MAP), finger pulse oxygen saturation and respiratory frequency were not significant statistically in comparison of the patients among groups (all P > 0.05). The incidence of postoperative nausea and vomiting of the patients in group B was lower apparently than that in A, C and D groups [10.0% (3/30) vs 30.0% (9/30), 36.7% (11/30), 53.3% (16/30), all P < 0.01]. The severity of postoperative nausea and vomiting of the patients in group B was lower apparently than that in the rest three groups (all P < 0.01). CONCLUSION: The electroacupuncture at 2 Hz/100 Hz reduces effectively the incidence and the severity of postopera tive nausea and vomiting of the patients with laparoscopic surgery undergoing the general anesthesia.

[Protecting action of acupuncture-drug compound anesthesia with different frequency electroacupuncture on stress reaction in pneumonectomy].

OBJECTIVE: To observe the protective effect of acupuncture-drug compound anesthesia with different frequency electroacupuncture on stress reaction in pneumonectomy and to explore potential mechanisms. METHODS: Eighty patients scheduled for pneumonectomy were randomly divided into four groups, named group A, B, C and D, 20 cases in each group. General anesthesia and single lung protective mechanical ventilation were produced in all the groups. They were treated with acupuncture at Houxi (SI 3), Zhigou (TE 6), Neiguan (PC 6), and Hegu (Li 4) 30 min before general anesthesia, and then with Han's acupoint nerve stimulator (HANS-200). The acupuncture needles without needle bodies were pasted on the acupoints and the electroacupuncture were not turned on in group A, and the 2 Hz continuous wave were produced in group B, and 100 Hz continuous wave were produced in group C and the 2 Hz/100 Hz were produced in group D. The supplementary anesthesia medicine during pneumonectomy, heart rate (HR), mean arterial pressure (MAP), CD4+ /CD/ in venous blood before and after the surgery, and the contents of epinephrine (E) and cortisol (Cor) in plasma at the time of inter-room and outer-room were detected. RESULTS: (1) The supplementary fentanyl in group B and C were lower than those in group A and D (P < 0.05, P < 0.01). (2) The MAP in the four groups at intratracheal intubation (T1) were all higher than those at before anesthesia (T0) (all P < 0.01), and the ascending extent in group B, C and D were lower than that in group A (all P < 0.01). The HR at T in group A was higher than that at T0 (P < 0.05) and there were no significant differences in the other groups (all P > 0.05), and the ascending extent in group B and D were lower than that in group A (both P < 0.05). The MAP and HR at the other moment in all the groups were maintained stable. (3) CD4+ /CD8+ in group A after pneumonectomy was lower than that before the surgery (P < 0.05), and there were no significant differences in the other groups (all P > 0.05). (4) The content of E and Cor after the surgery were all increased (all P < 0.01), and the ascending extent of E in group D was lower than that in group A (P < 0.05), and the ascending level of Cor in group B and D were lower than that in group A (P < 0.01) and group B compared with group C and D were got the same result. CONCLUSION: Acupuncture-drug compound anesthesia can attenuate the stress reaction so as to protect organs under the condition of less drug and can alleviates the undulate phenomenon of MAP and HR at intubation and stabilize CD4+ /CD8+ after pneumonectomy. Among them, the 2 Hz and 2 Hz/100 Hz electroacupuncture groups have the comparatively better effects.

[Observation on the anti-stress effect of acupuncture-assisted anesthesia for puhnlmonary lobectomy patients].

OBJECTIVE: To observe the anti-stress effect of acupuncture-assisted anesthesia in patients undergoing pulmonary lobectomy. METHODS: A randomized, controlled, single-blind clinical trial was conducted in the present study. A total of 48 patients undergoing pulmonary lobectomy were randomized into regular general anesthesia (RGA), general anesthesia combined with 2 Hz electroacupuncture (EA) (GA+2 Hz-EA), general anesthesia combined with 2 Hz/100 Hz EA (GA+2 Hz/100 Hz-EA), and GA + 100 Hz-EA groups (n=12). EA (1-3 mA) was applied to bilateral Houxi (SI 3), Zhigou (SJ 6), Neiguan (PC 6) and Hegu (LI 4) for 30 min, followed by general anesthesia with midazolam (0.05 mg/kg), fentanyl (5 microg/kg), propofol (2 mg/kg), and vecuronium (0.1 mg/kg). The dosages of the anesthetics, heart rate (HR), systolic blood pressure (SBP), and bispectral index (BIS) of electroencephalogam during general anesthesia were recorded. Plasma adrenaline and cortisol concentrations were assayed by radioimmunoassay. RESULTS: In comparison with the RGA group, the dosages of supplementary propofol and fentanyl in both GA + 2 Hz-EA and GA + 100 Hz-EA groups,and that of propofol in the GA+2 Hz/100 Hz-EA group were decreased significantly (P < 0.05, P < 0.01). Compared to the RGA group, both HR and SBP values during trachea extubation in the GA+ 2 Hz/100 Hz-EA and GA + 100 Hz-EA groups were significantly lower (P < 0.01, P < 0.05). No significant differences were found between the GA+2 Hz/100 Hz-EA and RGA groups in the supplementary dose of fentanyl, between the GA+2 Hz-EA and RGA groups in HR and SBP values during trachea extubation, among the 4 groups in HR and SBP values before trachea extubation and in plasma adrenaline and cortisol levels (P > 0.05). CONCLUSION: Acupuncture-assisted anesthesia can decrease the dosage of general anesthetics, and effectively restrain cardiovascular stress reaction during trachea extubation in pulmonery lobectomy patients.