J Acupunct Meridian Stud 2012;5(1):11e14

- RESEARCH ARTICLE -

Electro-acupuncture Stimulation at Acupoints

Reduced the Severity of Hypotension During
Anesthesia in Patients Undergoing Liver
Transplantation*
Mohammad Ali Sahmeddini, Mohammad Hossein Eghbal*,
Mohammad Bagher Khosravi, Sina Ghaffaripour, Farahzad Janatmakan,
Sakine Shokrizade

Shiraz Anesthesiology and Intensive Care Research Center, Shiraz University of Medical Science, Shiraz, Iran

Available online Dec 7, 2011

Received: May 22, 2011 Abstract

Revised: Aug 21, 2011
Accepted: Aug 29, 2011
KEYWORDS
electro-acupuncture;
hypotension;
liver transplantation
Background: Patients with end-stage liver diseases who undergo liver transplantation may suffer
from hypotension related to the liver disease itself or related to the surgical procedure. Because
electro-acupuncture (EA) at the Neiguan (PC-6) and the Jianshi (PC-5) points influences hemody-
namics, we hypothesize that electro-acupuncture at the traditionally used acupuncture points
will reduce the severity of hypotension in patients who undergo liver transplantation.
Methods: Forty patients with end-stage liver disease who underwent orthotropic deceased donor
liver transplantation were randomized into two groups. The norepinephrine (NE) group received
norepinephrine as a vasoconstrictor, and the electro-acupuncture group received EA at the PC-5
and the PC-6 points for treatment of hypotension during anesthesia for the liver transplantation.
The patients were monitored, during the three stages of liver transplantation by using hemody-
namic parameters.
Results: During the three stages of liver transplantation, there were no significant differences in
the hemodynamic measurements including the mean arterial pressure, heart rate and central
venous pressure between the two groups (p > 0.05).
Conclusions: Electro-acupuncture at the acupuncture points reduced the severity and the inci-
dence of hypotension during anesthesia for liver transplantation.

1. Introduction output and arteriolar vasodilation [1, 2]. Nitric oxide and
guanosine cyclic monophosphate (cGMP) have been impli-
Up to 70% of patients with end-stage liver disease develop cated as the causes of hypotension [3]. Liver trans-
a hyperdynamic state characterized by increased cardiac plantation represents the sole definitive treatment for

*
Disclosure statement: We do not have any commercial associations that might create a conflict of interest in connection with this
research.
* Corresponding author. Shiraz Anesthesiology and Intensive Care Research Center, Namazi Hospital, Namazi Sq, Shiraz, Fars, Iran.
E-mail: mheghbal@sums.ac.ir

Copyright ª 2012, International Pharmacopuncture Institute

doi:10.1016/j.jams.2011.11.001
12
end-stage liver disease, and patients who undergo liver
transplantation may suffer from hypotension related to the
liver disease itself, or related to the surgical procedure.
Furthermore, liver transplantation is one of the most
stressful cardiovascular events that a patient with cirrhosis
may undergo [4].
Acupuncture-based techniques have been used for
treatment of postoperative nausea and vomiting [5], post-
operative analgesia [6], and preoperative management
of anxiety [7]. In animal studies, electro-acupuncture at
the Neiguan (PC-6) and the Jianshi (PC-5) points influences
vascular pressure responses and the cardiovascular sympa-
thetic system [8,9].
We hypothesize that electro-acupuncture (EA) stimula-
tion at the traditionally used acupuncture points will
reduce the severity of hypotension during anesthesia in
patients undergoing liver transplantation. Thus, the
purpose of the present preliminary study is to test the
effect of electro- acupuncture at the PC-6 and the PC-5
points on hypotension during anesthesia in patients who
undergo liver transplantation.
2. Methods
From May 2010 to December 2010, a prospective, random-
ized study was performed on 40 patients with end-stage
liver disease who underwent orthotropic deceased donor
liver transplantation. After obtaining written informed
consent, the patients were randomly and evenly allocated
to two groups: the norepinephrine (NE) group and the
electro-acupuncture group. Patients in the norepinephrine
(NE) group received norepinephrine as a vasoconstrictor,
while patients in the electro-acupuncture group received
electro-acupuncture treatment during anesthesia.
The induction of anesthesia was accomplished with thio-
pental, fentanyl, and midazolam. Pancurronium or atracu-
rium was used for neuromuscular blockade. Ventilation was
maintained with an air-oxygen mixture plus isoflurane. Fluids
and packed cells were administrated to maintain the central
venous pressure at about 10 cm H2O and the hematocrits at
about 30%. Calcium gluconate was used to correct for a low
calcium (Caþ) level. Cardiovascular function was monitored
using an electrocardiogram, a radial artery catheter, and the
central venous pressure via the right internal jugular vein.
Transplantation of the graft was performed using the piggy-
back technique. The total ischemic time was defined as the
period from the aortic cross-clamping and perfusion with
preservation solution in donor to the completion of the
anastomoses with portal reperfusion.
During the surgery, the patients in NE group whose mean
blood pressure dropped to less than 60 mmHg, were given
norepinephrin as vasoconstrictor with an initial dose of 0.05
mcg/kg/min; the dosage was increased until the mean arte-
rial pressure (MAP) was maintained at more than 60 mmHg.
For the EA group, we inserted sterile disposable acupuncture
needles (diameter 0.25 mm and length 30 mm) in acupunc-
ture points Neiguan (PC-6) and Jianshi (PC-5), as shown in
Fig. 1. These points were selected based on the previous the
studies and protocols of acupuncture therapy and are found
to be 2 cun proximal to the crease of the wrist on the palmar
side of the arm, between the tendon of the long palmar
M.A. Sahmeddini et al.
Figure 1 The locations of acupuncture points Neiguan (PC-6)
and Jianshi (PC-5).
muscle and the radial flexor muscle of the wrist. Two needles
were then connected to the EA system (model WQ-IOD1
multiple electronic acupunctoscope, Beijing, China) and
stimulation started with a dense-disperse frequency (f1:10
and f2:40) at an intensity of 4 mA, for all of the patients in this
group. The intensity was then increased to 10 mA in some
patients in order to maintain the mean arterial pressure
above 60 mmHg. Because these patients were under general
anesthesia, intensity of 10 mA did not hurt these patients.
After that, the patients’ hands were covered by an operating
room drape. In the NE group, the same needles were inserted
at two nonacupoints of the patients’ shoulder, the wire of the
EA system was connected to these needles without any
stimulation, and then the area was covered with an operating
room drape to ensure the blindness of the study.
3. Statistics
All values were presented as means  SD and p < 0.05 was
considered significant in all statistical tests. A group size of
at least 20 patients was needed to show a difference of 15
(SD 10) mmHg in the mean arterial pressure (MAP) with
a significance level of 0.05 (a < 0.05) and a power of 80%
(b < 0.20). The statistical analysis was performed using the
Kruskal-Wallis test for discrete variables and continuous
variables were compared by using the one-way analysis of
variance (ANOVA) test.
4. Results
No significant differences were noted in the demographic
data of the donors and the recipients (p > 0.05) (Tables 1
and 2) or in the graft factors between the acupuncture
group and the NE group (p > 0.05) (Table 2).
Table 1 Demographics data in recipients group.
NE (n Z 20) EA (n Z 20) p-Value
Sex(M/F) 13/7 12/8 0.09
Age(year) 28  5 30  5 0.72
MELD Score 20  5 21  3 0.59
Body Weight(kg) 51  7 63  2 0.08
All values reported represent the mean  standard deviation.
NE, Norepinephrin. EA, Eletcroacupuncture.
Electro-acupuncture stimulation at acupoints 13

patients with end-stage liver disease during the adminis-

Table 2 Demographic data in donor group.
tration liver transplantation anesthesia. Patients with end-
NE(n Z 20) EA(n Z 20) p-Value stage liver disease develop a hyperdynamic state charac-
Sex(M/F) 16/4 17/3 0.08 terized by increased cardiac output and arteriolar vasodi-
Donor Age(year) 28  7 30  6 0.3 lation [1,2]. The primary cause of low blood pressure in the
Fatty change liver(%) 61 51 0.6 patients with end-stage liver disease is vasoactive
Graft weigh/recipient 1.15  0.18 1.20  0.25 0.4 substances, such as nitric oxide and guanosine 3 V,5 V-cyclic
weight monophosphate (cGMP) which bypass the normal hepatic
Total ischemic 9.5  1.8 8.8  2.4 0.10 metabolism [3].
time(Hour) During anesthesia for liver transplantation, many other
factors add to the primary vasodilation as causes of hypo-
All values reported represent the mean  standard deviation.
tension. In the preanhepatic stage, in addition to the
NE,Norepinephrin. EA, Electroacupuncture.
primary vasodilation, bleeding and drainage of ascites are
major causes of hypotension. Moreover mobilization of the
liver sometimes causes short duration hypotension [10]. In
Also, no significant differences in the baseline mean
the anhepatic stage, cross-clamping of the suprahepatic
arterial pressure, the baseline heart rate and the baseline
and infrahepatic vena cava (IVC) which decreases venous
central venous pressure were noted between the two
return by as much as 50%, is a cause of hypotension [11,12].
groups (p > 0.05) (Table 3).
Furthermore, in the neohepatic stage, reperfusion of the
During the hepatectomy phase, the central venous
new liver through the portal vein is associated with an
pressures were similar between the two groups (p > 0.05)
increase in preload but abrupt increases in the potassium
(Table 3). In this phase no significant differences in the
and the hydrogen ion concentrations can cause decreases in
mean arterial pressures, and the heart rates between the
the systemic vascular resistance and the blood pressure
two groups (p > 0.05) (Table 3).
[13,14].
In the anhepatic phase, the central venous pressures
During anesthesia for liver transplantation, vasocon-
were similar between the two groups and there were no
strictors like vasopressin, and norepinephrine are usually
significant differences in the mean arterial pressures and
used in order to treat the hypotension resulting from the
heart rates were noted between the two groups (p > 0.05)
primary vasodilation; however, they have some complica-
(Table 3).
tions [15]. Norepinephrine seriously lowers the splanchnic
In the neohepatic phase, the mean arterial pressures
blood flow, but in some cases, it may reverse hepatorenal
and heart rates were similar between the acupuncture and
syndrome [16]. Vasopressin sometimes causes severe
the NE group (p > 0.05) (Table 3). In this phase, the central
cardiac complications sometimes, and can be fatal in 5% of
venous pressures were kept similar between the two groups
the patients [17].
(p > 0.05) (Table 3).
In the present study, other causes of hypotension that
resulted from the primary vasodilation were controlled
5. Discussion during anesthesia. Hypotension that resulted from
bleeding, drainage of ascites and cross-clamping of the
The present study showed that the electro-acupuncture at suprahepatic and infrahepatic vena cava (IVC) was cor-
acupuncture points reduced the severity of hypotension in rected by maintaining the central venous pressure (CVP) at

Table 3 Hemodynamic data in both groups.

Base line Hepatectomy phase Anhepatic phase Neohepatic phase
EA group 91  3 70  6 67  2 60  3
MAP(mm Hg)
NEgroup 88  4 69  2 68  1 61  1
MAP(mm Hg)
p-Value 0.098 0.23 0.34 0.29
EA group 110  5 87  3 90  2 80  5
HR(beats/min)
NEgroup 115  2 90  1 89  1 82  3
HR(beats/min)
p-Value 0.069 0.098 0.120 0.20
EA group 7.1  1 9.8  2 10.1  1 14.5  1
CVP(cmH2O)
NEgroup 6.9  1 9.6  2 9.8  2 13.9  2
CVP(cmH2O)
p-Value 0.38 0.21 0.43 0.16
All values reported represent the mean  standard deviation. NE, Norepinephrin. EA, Electroacupuncture. MAP, Mean arterial pressure.
HR, Heart rate. CVP, Central venous pressure.
14
about 10 cm H2O. Also, prior to the reperfusion, acidosis
(excess hydrogen ion concentrations) and hyperkalemia as
probable causes of hypotension during reperfusion, were
corrected.
Electro-acupuncture at acupuncture point is known to
influence hemodynamics and cardiovascular sym-
pathoexcitatory responses [18,19]. In addition, electro-
acupuncture at the PC-6 point is known to increase the
stroke volume and the cardiac output, to alleviate hemor-
rhagic hypotension [20]. Electro-acupuncture at the PC-6
point also augments sympathetic tone and improves the
inhibited cardiovascular function [21]. Based on a study by
Syuu et al [20], the mechanism for the antihypotension
effect of PC-6 EA seems to be due to increased vasomotor
and venomotor tones. As Arai et al [22] showed in their
study, transcutaneous electrical nerve stimulation (TENS)
at the traditional acupuncture points reduced the severity
and the incidence of hypotension after spinal anesthesia in
parturient. By this Arai et al [22] meant that TENS applied
on the PC-6 and the PC-5 points might have augmented
sympathetic tone, thereby increasing the cardiac function,
as well as the vascular tone.
One of the limitations of the present study was the
failure to clarify the effect of PC-6 EA on venomotor tone
because of the risk of severe hypotension resulting from the
clamping of inferior vena cava, the drainage of huge
ascetics and sometimes severe bleeding, the central venous
pressure being kept at about 10 cm H2O by transfusion of
adequate amount of colloids and blood products. Thus, in
the present study as in previous clinical studies, we
postulate that the electro-acupuncture applied on the PC-6
and the PC-5 acupoints might have increased the vascular
tone and alleviated the hypotension that resulted from
vasodilation during anesthesia for liver transplantation.
In conclusion, electro-acupuncture on acupuncture
points reduced the severity and incidence of hypotension
during anesthesia for liver transplantation.
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