THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE

Volume 13, Number 2, 2007, pp. 241–246

© Mary Ann Liebert, Inc.
DOI: 10.1089/acm.2006.6262

Acupuncture as an Adjunct for Sedation During Lithotripsy

SHU-MING WANG, M.D.,1 MAMATHA PUNJALA, M.D.,2 DANA WEISS, B.S.,3

KEVIN ANDERSON, M.D.,4 and ZEEV N. KAIN, M.D.5

ABSTRACT

Objective: To determine whether a combination of auricular and body acupuncture is effective as an adjunct
for the preprocedural anxiety and pain management in patients undergoing lithotripsy procedures.
Design: Randomized controlled study.
Setting and Location: Lithotripsy suite located at the Yale New Haven Hospital, New Haven CT.
Subjects: Adult patients who were scheduled to receive elective lithotripsy procedures.
Interventions: Acupuncture group: Preprocedural auricular acupuncture intervention combined with in-
traprocedural electroacupuncture stimulation (n  29); Sham control group: Preprocedural sham auricular
acupuncture intervention combined with intraprocedural sham electroacupuncture stimulation (n  27).
Outcomes measurement: Preprocedural anxiety, intraprocedural alfentanil consumption, visual analogue
scale for pain.
Results: Patients in the acupuncture group were less anxious preprocedure than those in the Sham Control
Group 32 (29–34) versus 40 (35–45) (p  0.029). Similarly, patients in the Acupuncture Group used a lesser
amount of alfentanil than those in the sham control group (p  0.040). The adjustable alfentanil consumption
as expressed by median rate of alfentanil consumption of 1 (0.6–1.6) g kg1minute1 in the acupuncture
group was lower than that of 1.5 (0.9–2.3) g kg1minute1 in the sham control group. Patients in the Acupunc-
ture group also reported lower pain scores on admission to the recovery room (p  0.014).
Conclusions: A combination of auricular and body acupuncture can be used as an adjunct treatment to de-
crease preprocedural anxiety and intraprocedural analgesia in patients undergoing lithotripsy.

INTRODUCTION quire sedatives or analgesics such as intravenous opioids.3–5

Because avoidance or minimization of opioids is generally

S hock-wave lithotripsy (SWL) is a technique that uses

shockwaves to fragment small renal and upper ureteral
calculi.1,2 Although SWL is a noninvasive technique, it can
lead to significant discomfort during and after the proce-
dure. In fact, the majority of patients who undergo SWL re-
desirable, other treatment modalities that can provide the
analgesic effect are currently being explored.
Acupuncture and related techniques have been used as a
treatment for many medical conditions. Indeed, acupuncture
is reported to be effective in the management of periopera-

1Department of Anesthesiology, Center for the Advancement of Perioperative Health® and Yale University School of Medicine, New
Haven, CT.
2Department of Anesthesiology, Yale School of Medicine, New Haven, CT.
3Yale School of Medicine, New Haven, CT.
4Department of Urology, Yale School of Medicine, New Haven, CT.
5Department of Anesthesiology, Pediatrics, and Child Psychology, Center for the Advancement of Perioperative Health® and Yale

University School of Medicine, New Haven, CT.

241
242
tive conditions such as preoperative anxiety,6 postoperative
nausea and vomiting,7–9 and postoperative pain.10–12 A lit-
erature search revealed two reports that describe the use of
acupuncture as an analgesic modality during SWL.13,14 The
first report is a case series of 3 individuals who received
acupuncture during SWL,13 and the second report is a non-
randomized, uncontrolled, cohort study that examined the
analgesic effect of acupuncture during SWL.14
Previous studies conducted by our laboratory have
demonstrated that auricular acupuncture at the valium, mas-
ter cerebral, and relaxation points can reduce preoperative
anxiety of adults undergoing ambulatory surgery.6,15 Also,
a Chinese acupuncture textbook16 and several other recent
studies report that body acupuncture stimulation applied to
the Liver 3 and Large Intestinal 4 acupuncture points can
decrease back and visceral pain.17,18 Based on these previ-
ous studies, we hypothesized that the application of retained
auricular acupuncture would reduce preprocedural anxiety
and, when combined with electroacupuncture stimulation,
will decrease the intraprocedural alfentanil consumption
during SWL.
MATERIALS AND METHODS
A double-blinded, sham-controlled, randomized study was
conducted in a group of patients who were scheduled to re-
ceive elective lithotripsy (compact Donier 4 lithotriptor) for
either renal or upper ureteral calculi at Yale-New Haven Hos-
pital. The institutional ethics committee approved the study
protocol, and all patients provided informed written consent
prior to participating in the study. The American Society of
Anesthesiologists’ Physical Status I-III English-speaking pa-
tients, ages 18–65 years who had no previous experience of
acupuncture were enrolled in this study. Exclusion criteria
for participation included a history of psychiatric problems,
previous experience in acupuncture treatment, and analgesic
use within 1 week before the procedure.
Potential patients were identified from the schedule sev-
eral days in advance from the operating room scheduling
system. An investigator called eligible patients the night be-
fore surgery and provided study information; explained the
participation required, and obtained a verbal informed con-
sent over the telephone. On the day of procedure, scheduled
patients arrived at the Yale-New Haven Hospital and un-
derwent routine admitting procedures. When the routine ad-
mission procedures were completed, a research assistant ob-
tained a written informed consent as instructed by the
institutional review board. Next, patients completed a de-
mographic questionnaire and the baseline State-Trait Anxi-
ety Inventory (STAI).19 This instrument is a 40-item, self-
report measure that contains 20 items measuring state
anxiety and 20 items measuring trait anxiety. Once baseline
measures were obtained, patient allocation was stored in a
WANG ET AL.
sealed envelope (the group assignment was generated by a
computer-generated randomized number), available only to
the acupuncturist. It is important to note that the acupunc-
turist did not participate in any of the clinical care of the pa-
tient, data collection, or statistical analysis. In addition, the
communication between the acupuncturist and patients or
research assistant and patients was limited to scripted
speech. All acupuncture interventions were performed by
the first author (S.M.W.), who is a board certified anesthe-
siologist and registered acupuncturist.
While in the holding area, the acupuncturist performed
the appropriate auricular acupuncture intervention, ipsilat-
eral to the patient’s dominant hand, without the presence of
the research assistant. Patients in the acupuncture group re-
ceived auricular acupuncture at the Relaxation, Master Cere-
bral, and Valium points of the Ear and patients in the sham
group received auricular acupuncture at the Wrist, Shoul-
der, and Extraauricular sham points of the Ear (Fig. 1A). All
auricular acupuncture interventions (both acupuncture and
sham groups) were achieved using sterile, single-use, sticker
press needles (retainable needles), which are 0.25 mm  2
mm (Seirin Pyonex,® SaiShui, Japan). The press needle has
a circular base (2 mm2 in diameter) that is directly attached
to self-adhesive tape and once positioned, it remains in
place. Both ears were then covered with a surgical hat to
conceal the needle locations and thus blind the observers.
Thirty (30) minutes after the initiation of auricular acupunc-
ture, all patients (both Acupuncture and Sham Groups) com-
pleted a second self-assessment of state anxiety (STAI).
A
B
FIG. 1. A. Auricular acupuncture points for “True acupuncture”
and “Sham control” groups. B. Acupuncture points for “four gates.”
ACUPUNCTURE AS AN ADJUNCT DURING LITHOTRIPSY
Patients were next brought to the lithotripsy suite and af-
ter patients were situated on the lithotripsy table, electro-
cardiogram, noninvasive arterial blood pressure, arterial
oxygen saturation, and end-tidal carbon dioxide tension
monitors were placed. The anesthesiologist connected the
patient to an alfentanil patient-controlled analgesia (PCA)
pump (3 g kg1 bolus of alfentanil with a 5-minute lock-
out interval). Patients were told to use the PCA pump when-
ever they experienced pain and were asked to indicate any
pain during the procedure if the self-administered alfentanil
was not adequate. The anesthesiologist was instructed to
give supplemental alfentanil boluses (3 g kg1) only if the
patient complained of pain while the PCA pump was in a
lockout period. Next, the anesthesiologist administered an
intravenous dose of 20 g kg1 of midazolam, 10 g kg1
of alfentanil, and 10 mg of metoclopramide over 5 minutes
to all study patients. Then, the acupuncturist was called to
the lithotripsy suite and placed the body acupuncture nee-
dles according to group assignment.
Patients in the acupuncture group received body acupunc-
ture at bilateral Liver 3 and Large Intestine 4 points. Liver 3
is located on the dorsum of the foot in the depression distal
to the junctions of the first and second metatarsals, and Large
Intestine 4 is located on the radial side of the middle of the
second metacarpal (Fig. 1B). Body acupuncture interventions
were performed using 0.3  50 mm needles (Addiqui,® Ito
Co., Ltd., Shanghai, China). After the body acupuncture in-
sertion process, these needles were attached to a Patheon®
Electro Stimulator 4-C (Venice, CA) (Fig. 2). This electrical
stimulator has four isolate microcurrent output channels,
which deliver symmetrical biphasic waveform, with spike-
shaped waves on the top and bottom. The positive and neg-
ative aspects of the waveform are equal in voltage amplitude,
and the net DC bias of the waveform is zero. The pulse width
is 4 milliseconds. The acupuncturist adjusted the frequency
to 2 Hz and 25 V.
Patients in the sham group received body acupuncture us-
ing 0.3  50-mm needles (Addiqui) at the Bilateral Liver 3
and Large Intestine 4 points. Although the location of the
body acupuncture needles was identical in both study groups,
the depth of needle insertion varied significantly. That is, the
acupuncture group received the traditional Chinese needle in-
sertion, whereas the sham group received only a very super-
ficial insertion (1–2 mm).20,21 After the insertion process, the
needles were attached to the same Patheon Electro Stimula-
tor 4-C, but no electrical stimulation was delivered. All pa-
tients were told that they might or might not experience vi-
bration when the electrodes were applied and during the
adjustment of output. It is important to note that the stimula-
tor was encased in a sealed box to conceal output settings in
order to ensure blindness of the research assistant, anesthesi-
ologist, nursing staff, and urologist during the procedure. This
sealed box containing the stimulator was then placed at the
foot of the bed so the patient was not able to see the box while
lying in the supine position needed for SWL. All patients then
243
received a standardized shockwave protocol treatment (2500
shocks for renal calculi and 3000 shocks for ureteral calculi)
to a maximum level of 6. At the conclusion of the lithotripsy,
the acupuncturist was called to the lithotripsy suite to remove
the auricular and body acupuncture needles. Patients were
then transported to the Recovery Room.
Pain was assessed using a visual analogue scale (VAS) on
admission to the recovery room and every 15 minutes through-
out the entire recovery period. The VAS rating system con-
sists of a 100-mm line that represents the two extremes at ei-
ther end of a continuum (i.e., no pain [score of 0] and extremely
painful [score of 10]).22 A bolus of 25 g of intravenous fen-
tanyl was administered by a recovery room nurse if the pa-
tient achieved a score of 3 or higher on the VAS pain scale.
The total dose of fentanyl was administered, and episodes of
nausea and vomiting and postoperative anti-emetic require-
ments were documented. Routine electrocardiogram, nonin-
vasive blood pressure, and arterial oxygen saturation were
monitored throughout the recovery period. To assess the sen-
sory and affective dimension of pain prior to patients’ dis-
charge from the Recovery Room, we used the short-form
McGill questionnaire (SF-MPQ),23 which comprised a total of
15 words (11 words from sensory category and 4 words from
affective category) that allowed us to obtain more information
from the patient than just the intensity of pain.
Finally, upon discharge from the hospital, all patients
were asked to grade their satisfaction with intraprocedural
SWL analgesia using the VAS satisfaction and whether they
believed that they received the true acupuncture treatment.
This rating system consists of a 100-mm line that represents
the two extremes at either end of a continuum (i.e., not sat-
isfied [score of 0] and extremely satisfied [score of 10]).
Statistics
Sample size was based on data obtained from our previ-
ous study of adult patients undergoing lithotripsy using
FIG. 2. The Patheon® Electro Stimulator (Venice, CA).
244 WANG ET AL.

TABLE 1. BASELINE DEMOGRAPHICS

True acupuncture Sham acupuncture

group group
(n  29) (n  27)

Age (yr) 46 (36–56) 44 (34–54)

Weight (kg) 89 (82–96) 84 (77–91)
History of hypertension (no/yes) 83/17 85/15
History of diabetes (no/yes) 86/14 89/11
Ureter/renal calculi (%) 59/41 48/52
Size of renal calculi (cm) 1.1 (0.5–1.8) 1.0 (0.4–1.7)
Handedness, right/left (%) 93/70 92/80
Female/male (%) 62/38 16/90
Previous lithotripsy, no/yes (%) 17/12 16/11
Duration of procedure (min) 24 (22–27) 24 (22–26)
Baseline of STAI-S 37 (33–40) 38 (36–42)
Baseline STAI-T 35 (31–38) 35 (32–39)

Data are presented as mean (95% CI), or percentage. STAI-S, State and Trait Anxiety Inventory (State Anxiety); STAI-T, State and
Trait Anxiety Inventory (Trait Anxiety).

alfentanil sedation.24 In that study, the alfentanil require-
ment of the control group was a mean (standard deviation)
119  16 g min1. Twenty-seven (27) patients are there-
fore required in each group to achieve a 20% effect, with
an alpha of 0.05 and a power of 85%. Normally distributed
data are presented as mean (95% CI) and non-normally dis-
tributed data are presented as median (25%–75%). Contin-
uous variables were analyzed using an independent-sample
two-sided Student’s t test; categorical variables were ana-
lyzed using chi-square tests. The Mann-Whitney test was
used for continuous nonparametric data (alfentanil dose,
VAS pain scores upon arrival in the recovery room and SF-
MPQ pain scores on discharge from the hospital). Adjusted-
alfentanil rate was calculated by dividing the total dose of
alfentanil by patients’ weight (kg) and duration of the pro-
cedure (min). Two-way repeated-measures analysis of vari-
ance (ANOVA) was used to explore the STAI anxiety data
before and after the intervention. Data were analyzed using
SPSS version 10 (SPSS Inc., Chicago, IL). A probability
value of less than 0.05 was considered significant.
RESULTS
One hundred and thirty-four (134) patients were identi-
fied from the operating room schedule. After a chart review,

TABLE 2. OUTCOME VARIABLES

True acupuncture Sham acupuncture

group group
(n  29) (n  27) p value

Preprocedure
Anxiety outcome
Postauricular acupuncture STAI-S, median (25–75%) 32 (29–34) 40 (35–45) p  0.029
Intraprocedure
Analgesic outcome
Alfentanil (g kg1 minute1), median (25–75%) 1 (0.6–1.6) 1.3 (0.9–2.3) p  0.040
Postprocedure (PACU)
Pain outcome
VAS (arrival), median (25–75) 0 (0–1.3). 1.7 (0–3.2),. p  0.014
SF-MPQ (discharge), median (25–75) 0.5 (0–2)00 2 (1–5)0 p  0.047
Analgesic outcome
Fentanyl (g kg1), median (25–75) 0 (0–0). 0 (0–0.5) p  0.221
Other outcomes
Time to oral intake (min), mean (95% CI) 20 (13–27) 37 (30–44). p  0.322
PONV (No/Yes) (%) 96/4 85/15 p  0.412
Patients’ satisfaction, mean (95% CI) 9.9 (9.7–10) 9.8 (9.6–9.9) p  0.781
Believe received true acupuncture (no/yes/uncertain) (%) 24/62/7 12/72/16 p  0.519

STAI-S, State and Trait Anxiety Inventory (State Anxiety); PACU, postanesthesia care unit; VAS, Visual Analogue Scale; SF-MPQ,
short-term McGill Questionnaire; PONV, postoperative nausea and vomiting.
ACUPUNCTURE AS AN ADJUNCT DURING LITHOTRIPSY
we found that 48 patients were not eligible because of con-
sumption of psychiatric medication or chronic analgesics, a
physical status of ASA 4, or the inability to contact the pa-
tient before the procedure date. Of the remaining 86 patients,
28 patients declined participation because of one of the fol-
lowing reasons: preference for general anesthesia, defi-
ciency in English language, fear of acupuncture needles,
prior experience in acupuncture treatment, and no interest
in being a study subject. Thus, a total of 58 patients pro-
vided informed consent for participation in the study and
none of them had preprocedural hydronephrosis. Two pa-
tients, however, did not complete the study because of lo-
gistical issues relating to the availability of study drugs (i.e.,
our pharmacy had a shortage of alfentanil that was needed
for this study).
There were no significant differences between the two
study groups regarding demographic variables, baseline anx-
iety, size of calculi, and the locations of calculi (Table 1).
No additional medication was administered to any of the
participants during the lithotripsy except the list of study
medications. Two-way repeated-measures ANOVA demon-
strated a significant Group  Time interaction for anxiety
before SWL [F (1,72)  6.6, p  0.010]. That is, patients
in the Acupuncture Group reported significantly (p  0.029)
less anxiety at 30 minutes after initiation of auricular
acupuncture as compared with patients in the Sham Group
(Table 2). During SWL, we found that the median rate of
alfentanil consumption of 1.0 (0.6–1.6) g kg1minute1
in the Acupuncture Group was significantly (p  0.040)
lower than that of 1.5 (0.9–2.3) g kg1minute-1 in the
Sham Group.
A VAS pain scale was used to assess the level of the pain
in all patients upon admission to the recovery room. We found
that the median pain scores of 0.0 (0.0–1.3) in the acupunc-
ture group were significantly (p  0.014) lower than those of
1.7 (0–3.2) in the sham group when they arrived to the re-
covery room. Similarly, pain scores at discharge from the hos-
pital as assessed by the SF-MPQ were lower in the Acupunc-
ture Group than those of the Sham Group (p  0.047, Table
2). Fentanyl requirements in the recovery room, however, did
not differ between the two groups (p  0.220) (Table 2).
Finally, there were no statistical significant differences be-
tween the acupuncture group and the sham group in the inci-
dence of nausea and vomiting during the recovery period (7%
vs. 18%), time to oral intake of clear fluids, time to discharge
from the recovery room, satisfaction with the analgesia man-
agement, or the number of patients who believed that they re-
ceived the true acupuncture (p  0.519) (Table 2).
DISCUSSION
Under the conditions of this study, we found that patients
who received auricular acupuncture were less anxious be-
fore undergoing SWL as assessed by STAI-S [32 (29–34)
245
vs. 40 (35–45), p  0.029], and that the combination of au-
ricular acupuncture and body electroacupuncture reduced
the amount of alfentanil needed during SWL. Patients who
received acupuncture also indicated lower levels of pain
upon admission to the Recovery Room as assessed by a VAS
for pain [0.0 (0.0–1.3) vs. 1.7 (0–3.2), p  0.014]. The re-
sults of this randomized, controlled trial are consistent with
previous reports suggesting that acupuncture can be used as
an adjuvant to pharmacologic analgesia for patients under-
going SWL.13,14
We submit that the observed reduction of analgesic re-
quirements may be caused by the release of endogenous en-
dorphins via electroacupuncture stimulation16,25 or a de-
creased perceived pain secondary to reduced anxiety.26,27 A
direct causal explanation for this effect, however, is not yet
clear and further research is needed in this area. We have
previously reported the effectiveness of auricular acupunc-
ture in decreasing preoperative anxiety in adult patients and
parents of children undergoing surgery.6,15 This randomized,
controlled trial has confirmed these previous findings in the
setting of a combined treatment scheme, using two differ-
ent acupuncture-based modalities for the treatment of both
anxiety and pain.
Interestingly, although the amount of alfentanil used dur-
ing lithotripsy was lower in the acupuncture group, this was
not associated with a statistically significant difference in
the incidence of nausea and vomiting in the recovery room.
However, because the study was not powered to detect a dif-
ference in nausea and vomiting, the lack of statistical sig-
nificance may very well be due to a Type II error. Future
studies are needed to clarify this point.
A major limitation of the present study is that we did not
include a control group without any acupuncture interven-
tion or another sham Control Group that consisted of elec-
trical stimulation at sham locations. The readers should note,
however, that the inclusion of a control group without any
acupuncture intervention already unblended the subject and
that several recent studies indicated that electroacupuncture-
induced analgesia does not show strong acupoint speci-
ficity.19,28,29 Lastly, between the two groups, we did not find
any difference in the number of patients who believe they
did receive the true acupuncture intervention throughout the
periprocedural period.
CONCLUSIONS
We found that a combination of auricular and body
acupuncture can affect intraprocedural alfentanil require-
ments during lithotripsy. At present, we are not certain
whether this reduction of analgesic requirement during
lithotripsy is mainly caused by the reduction of anxiety or
the additional body electroacupuncture stimulation or a com-
bination of both. Future studies with more complex design
are needed to clarify this issue.
246
ACKNOWLEDGMENTS
The authors thank all of the patients, urologists, and anes-
thetists who participated in this study. In addition, the au-
thors thank Susan Garwood, M.D., and Ms. Tiffani Wheeler,
M.A. for editing the manuscript.
REFERENCES
1. Chaussy C, Fuchs G. Extracorporeal shock wave lithotripsy
for the treatment of urinary calculi. In: Pollack H, ed. Clini-
cal Urography. Philadelphia: WB Saunders, 1990:2861–2888.
2. Chaussy C, Fuchs G. First clinical experience with extracor-
poreally induced destruction of kidney stones by shock waves.
J Urol 1982;127:417–420.
3. Lehman P, Weber W, Madler C. Anaesthesia and ESWL: Five
years of experience. In: Gravenstein J, Pater K, eds. Extra-
corporeal shockwave lithotripsy for renal stone disease.
Boston: Butterworths, 1986:61–68.
4. Sa Rego M, Inagaki Y, White P. Remifentanil administration
during monitored anaesthesia care: Are intermittent boluses an
effective alternative to a continuous infusion? Anesth Analg
1999;88:518–522.
5. Richardson MG, Dooley JW. The effect of general versus
epidural anesthesia for outpatient extracorporeal shock wave
lithotripsy. Anesth Analg 1998;86:1214–1218.
6. Wang SM, Peloquin C, Kain ZN. The use of auricular acupunc-
ture to reduce preoperative anxiety. Anesth Analg 2001;93:
1178–1180.
7. Rusy L, Hoffman G, Weisman S. Electroacupuncture prophy-
laxis of postoperative nausea and vomiting following pediatric
tonsillectomy with or without adenoidectomy. Anesthesiology
2002;96:300–305.
8. Fan CF, Tanhui E, Joshi S, et al. Acupressure treatment for
prevention of postoperative nausea and vomiting. Anesth Analg
1997;84:821–825.
9. Schlager A. Acupuncture in the prophylaxis of postoperative
nausea and vomiting. Wien Med Wschr 1998;148:454–456.
10. Wang B, Tang J, White PF, et al. Effect of the intensity of
transcutaneous acupoint electrical stimulation on the postop-
erative analgesic requirement. Anesth Analg 1997;85:406–
413.
11. Wang HH, Chang YH, Liu DM, Ho YJ. A clinical study on
physiological response in electroacupuncture analgesia and
meperidine analgesia for colonoscopy. Am J Chin Med
1997;25:13–20.
12. Felhendler D, Lisander B. Pressure on acupoints decreases
postoperative pain. Clin J Pain 1996;12:326–329.
13. Quatan N, Bailey C, Larking A, et al. Stick and stones: Use
of acupuncture in extracorporeal shockwave lithotripsy. J En-
dourol 2003;17:867–870.
14. Rogenhofer S, Wimmer K, Blana A, et al. Acupuncture for
pain in extracorporeal shockwave lithotripsy. J Endourol
2004;18:634–637.
WANG ET AL.
15. Wang S, Maranets I, Weinberg M, et al. Parental auricular
acupuncture as an adjunct for parental presence during
induction of anesthesia. Anesthesiology 2004;100:1399–1404.
16. Helms JM. Acupuncture energetics: A clinical approach for
physicians, 1st ed. Berkeley, CA: Medical Acupuncture Pub-
lishers, 1997.
17. David J, Townsend S, Santhanathan R, et al. The effect of
acupuncture on patients with rheumatoid arthritis: A ran-
domised placebo-controlled cross-over study. Rheumatology
1999;38:864–869.
18. Zaslawski CJ, Cobbin D, Lidunse E, Petocz P. The impact of
site specificity and needle manipulation on changes to pain
pressure threshold following manual acupuncture. A con-
trolled study. Complement Ther Med 2003;11:11–21.
19. Spielberger CD. Manual for State-Trait Anxiety Inventory
(STAI: Form Y). Palo Alto, CA: Consulting Psychologist
Press, 1983.
20. Wu MT, Hsien J, Xiong J, et al. Central nervous pathway for
acupuncture stimulation: Localization of processing with func-
tional MR imaging of the brain—preliminary experience. Ra-
diology 1999;212:133–141.
21. Wang SM, Kain ZN. P6 acupoint injection is an effective
droperidol in preventing early postoperative nausea and vom-
iting. Anesthesiology 2002;97:359–366.
22. Abu-Saas H. Assessing children’s responses to pain. Pain
1984;19:163–171.
23. Melzack R. The short-form McGill pain questionnaire. Pain
1987;30:191–197.
24. Koch M, Kain ZN, Ayoub C, Rosenbaum S. The sedative and
analgesic sparing effect of music. Anesthesiology 1998;89:
300–306.
25. Hans JS. The neurochemical basis of pain relief by acupunc-
ture. Beijing, China: Chinese Medical Science and Technol-
ogy Press, 1987.
26. Kain ZN, Sevarino F, Pincus S, et al. Attenuation of the pre-
operative stress response with midazolam: Effects on postop-
erative outcomes. Anesthesiology 2000;93:141–147.
27. Logan D, Rose J. Is postoperative pain a self-fulfilling
prophecy? Expectancy effects on postoperative pain and pa-
tient-controlled analgesia use among adolescent surgical pa-
tients. J Paediatr Psychol 2005;30:187–196.
28. Hsieh JC, Tu CH, Chen FP, et al. Activation of the hypothal-
amus characterizes the acupuncture stimulation at the anal-
gesic point in human: A positron emission tomography study.
Neurosci Lett 2001;307:105–108.
29. Zhang WT, Jin Z, Huang J, et al. Modulation of cold pain in
human brain by electric acupoint stimulation: Evidence from
fMRI. Neuroreport 2003;14:1591–1596.
Address reprint requests to:
Shu-Ming Wang, M.D.
Department of Anesthesiology
Yale School of Medicine
New Haven, CT 06520-8041
E-mail: shu-ming.wang@yale.edu