Journal of Acupuncture and Meridian Studies 2022;15(5):314-321

pISSN 2005-2901 • eISSN 2093-8152

https://doi.org/10.51507/j.jams.2022.15.5.314 RESEARCH ARTICLE

Sedative Effect of Ketamin-Midazolam Administered at

Acupoint GV20 Compared to Intramuscular Route in
Blue-Fronted Amazon (Amazona aestiva ): a Pilot Study
Aricia Noelli Brega Monteiro1,*, Bruno Simões Sérgio Petri2, Haroldo Furuya2, Liliane Milanelo2,
Márcia Valéria Rizzo Scognamillo3, Ayne Murata Hayashi4
1
Private Veterinary Acupuncture Practitioner, Cosmopolis, Sao Paulo, Brazil
2
Centro de Recuperacao de Animais Silvestres (CRAS PET-TIETÊ) Parque Ecológico do Tiete, Sao Paulo, Brazil
3
Private Veterinary Acupuncture Practitioner, Uberlândia, Minas Gerais, Brazil
4
Department of Surgery, School of Veterinary Medicine, University of Sao Paulo, Sao Paulo, Brazil

Received February 1, 2022
Revised February 21, 2022
Accepted July 11, 2022
Correspondence to
Aricia Noelli Brega Monteiro
Private Veterinary Acupuncture
Practitioner, Cosmopolis, Sao Paulo,
Brazil
E-mail aricia_monteiro@hotmail.com
Background: The growth of exotic pet medicine is leading to fast developments in clinical
investigations on birds. Acupuncture, specifically pharmacopuncture, offers safe chemical
restraint options.
Objectives: To investigate pharmacopuncture at acupoint GV20 in blue-fronted Amazon
parrots (Amazona aestiva ) using ketamine and midazolam.
Methods: Sixteen healthy birds were distributed into four groups (C: intramuscular
control; 1/2 C: 1/2 dose intramuscular control; 1/2 GV20: 1/2 dose at acupoint GV20;
1/5 GV20: 1/5 dose at acupoint GV20). Degree of sedation, latency, recuperation time,
heart and respiratory rate, and body temperature were measured. Quantitative data were
analyzed by a Student’s t-test.
Results: The C, 1/2 C, and 1/2 GV20 groups showed the same degree of sedation. The
1/2 GV20 group showed longer latency times (6 ± 2.1) than the 1/2 C (2.5 ± 0.5) group.
Sedation time did not differ between the C (28 ± 9.8), 1/2 C (30.5 ± 8.6), and 1/2 GV20 (41
± 22.24) groups. The 1/2 GV20 group recuperated faster (13.7 ± 3.7) than the C group
(64.2 ± 3.5). The C and 1/2 C groups showed tremors and slow and unstable recovery.
Two animals in the C group showed mild hypothermia (38°C).
Conclusion: The use of 1/2 GV20 was effective and safe to sedate blue-fronted Amazon
parrots without side effects, providing easy, stable, and fast recovery. The use of 1/5 GV20
had a shorter sedation time. These findings show that the combination of acupuncture and
drugs provides new possibilities for efficient anesthetic protocols with fewer side effects in
birds.
Keywords: Acupuncture, Pharmacopuncture, Traditional chinese medicine, Parrot,
Anesthesiology

INTRODUCTION
The increasing growth of exotic pet medicine, with its
economic and ecological impact, is leading to fast develop­
ments in wildlife clinical investigation, especially on birds.
The urban environment can cause stress in birds and increase
admission rates to wildlife rescues and rehabilitation centers
[1,2].
Therefore, anesthetic procedures for birds have become
more important in veterinary practice. In this sense, it is
important to have safe chemical restraint options, enabling
physical and auxiliary tests and minimizing stress factors [3].
The combination of acupuncture and drugs provides new
possibilities for efficient anesthetic protocols with fewer side
effects.
Acupuncture is a noninvasive and safe treatment option,
as well as a widely accepted technique for alleviating pain and
inflammation. Reports on domestic animals and, recently, in
south tortoises, penguins, toucans, and raptors, have observed
that acupuncture can normalize appetite and digestion,
modulate the immune system function, treat musculoskeletal
and neurological diseases, and reduce behavior problems [4-10].

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This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/
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Sedative Effect of Ap GV20 in A . aestiva

Acupoint injection is a modern acupuncture method. A deviation body weight of 0.358 ± 0.615 kg (Fig. 1).
saline solution, distilled water, autologous blood, vitamins, The parrots were temporarily housed at the wild animal
homeopathic drugs, ozone, bee venom, and herbal medicine center of “Parque Ecológico do Tietê” (CRAS-PET) in São
extracts are injected at acupoints, providing a prolonged Paulo, SP, Brazil, before release. All the parrots underwent
mechanical stimulus [11-16]. Recently, pharmacopuncture, routine physical examinations and were considered in good
i.e., the injection of subclinical doses of drugs at acupoints, health. The parrots were maintained in f locks of 16-20
has been implemented with successful results in veterinary enclosed birds. During the study, the parrots were individually
practice. Pharmacopuncture in animals has been shown to housed in plastic cages for visual evaluation (Fig. 2).
produce similar effects as conventional doses of drugs in
horses, pigs, dogs, and cats [17-21]. In mammals, the main Study design
acupoints used for drug injections are YinTang, GV16 and All the birds were randomly assigned to one of four
GV20 [12,18,19,21-27]. The sedative effect at GV20 can be treatments: 1) Drug Control (C), ketamine (15 mg/kg) and
associated with alpha-2-adrenergic system activation [18]. The midazolam (1 mg/kg) injected into the pectoral muscle mass;
GV20 anatomic location is at the intersection of the sagittal 2) Half dose control (1/2 C), 50% ketamine (7.5 mg/kg) and
dorsal line and the line connecting the ears [28]. GV20 is midazolam (0.5 mg/kg) injected into the pectoral muscle
called the Guan Ji Point in birds, “the meeting point of all
Yang channels,” and its stimulation has been shown to treat
mental distress [28].
To the best of our knowledge, there are currently no reports
on avian pharmacopuncture. Therefore, this pilot study aims
to investigate pharmacopuncture at acupoint GV20 in blue-
fronted Amazon parrots (Amazona aestiva) using ketamine
and midazolam as a low-cost anesthesia alternative for birds.
This pilot study involves a small number of animals to test
the logistics of a larger study and gain some preliminary
information.

MATERIALS AND METHODS

Sixteen healthy adult blue-fronted Amazon parrots of
unknown sex were included in this study. The birds were Fig. 2. Blue-fronted Amazon parrots (Amazona aestiva ) indi­
ringed for individual identification with a mean ± standard vidually housed in plastic cages for visual evaluation.

Fig. 1. Slight physical restraint for weighing at blue-fronted Fig. 3. Pharmacopuncture in at acupoint GV20 in a blue-
Amazon parrot (Amazona aestiva ). fronted Amazon parrot (Amazona aestiva ).

www.journal-jams.org 315
 Aricia Noelli Brega Monteiro, et al.

mass; 3) Pharmacopuncture half dose (1/2 GV20), 50%
ketamine (7.5 mg/kg) and midazolam (0.5 mg/kg) injected
subcutaneously at acupoint GV20; 4) Pharmacopuncture 20%
dose (1/5 GV20), 20% ketamine (3 mg/kg) and midazolam (0.2
mg/kg) injected subcutaneously at acupoint GV20 located
at the intersection of the sagittal dorsal line and the line
connecting the two ears (Fig. 3).
The chosen dose is commonly used in clinical avian
veterinary practice. The injections were performed using 6
mm × 0.25 mm (13G) hypodermic needles. Total experimental
time was defined as the recuperation time for each animal to
stay upright. In each set of experiments, four animals were
Table 1. Alertness score for sedation evaluation
Sedation Parameters
Satisfactory Closed eyes, decubitus, no
movement, and muscle relaxation.
Moderate Light signs of tranquilization, possible
decubitus, open eyes, responsive to
stimulus.
Absent Standing position, open eyes,
responsive to stimulus.
observed by four blind evaluators. All behavioral responses
were recorded in a behavior form (Appendix 1). The degree
of sedation, latency, recuperation time, heart and respiratory
rate, and body temperature were measured. The quantitative
data were analyzed using a Student’s t-test. The degree of
sedation was evaluated according to an adapted descriptive
numeric scale (Table 1) [29].
RESULTS
The C, 1/2 C, and 1/2 GV20 groups showed the same
sedation degree (Fig. 4). In each group, three animals
presented satisfactory sedation, and one had moderate
sedation (Fig. 5A and 5B). Only one animal in the 1/5 GV20
group had satisfactory sedation, one had moderate sedation,
and two had no sedation (Fig. 5C).
Grade
The C and 1/2 GV20 groups showed the same latency time
0 (Table 2 and Fig. 6). The 1/2 GV20 group showed a longer
latency time than the 1/2 C group, although both received the
1
2
Table 2. Mean and standard deviation of latency time,
sedation time, and recuperation time (in minutes) in blue-
fronted Amazon parrots (Amazona aestiva )

Mean and standard

Parameter Group
deviation
Degree of sedation
Latency time C 4 ± 2.70
C 1/2 C 2.5* ± 0.57
1/2 GV20 6* ± 2.16
1/2 C 1/5 GV20 5 ± 5.83
Groups

Sedation time C 28 ± 9.83

1/2 GV20 1/2 C 30.5 ± 8.69
1/2 GV20 41 ± 22.24
Satisfactory
Moderate 1/5 GV20 6.25 ± 7.32
1/5 GV20
Absence Recuperation time C 64.25* ± 3.59
0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 1/2 C 27.5 ± 21.29
Individuals number 1/2 GV20 13.75* ± 3.77
1/5 GV20 7.5 ± 10.37
Fig. 4. Pharmacopuncture-induced degree of sedation in
blue-fronted Amazon parrots (Amazona aestiva ). *p < 0.05.

A B C

Fig. 5. Degree of sedation in blue-fronted Amazon parrots (Amazona aestiva ). (A) Satisfactory sedation. (B) Moderate sedation.
(C) Mixed sedation in Group 1/5 GV20: satisfactory sedation.

316 www.journal-jams.org
Sedative Effect of Ap GV20 in A . aestiva
Mean values
125 C
1/2 C 64.25
1/2 GV20 41
1/5 GV20
28 30.5 27.5
25
13.75
7.5
6 6.5
5
5 4
2.5
1
Latency time Sedation time Recuperation time
Fig. 6. Pharmacopuncture mean values of latency, sedation,
and recuperation time in blue-fronted Amazon parrots
(Amazona aestiva ).
same dose of ketamine and midazolam (Table 2 and Fig. 6).
The sedation time did not differ between the C, 1/2 C, and 1/2
GV20 groups (Table 2 and Fig. 6).
The 1/2 GV20 group showed a faster recuperation time
than the C group (Table 2 and Fig. 6). All animals from
the C and 1/2 C groups showed tremors and had a slow
and unstable recovery (Fig. 7). The 1/2 GV20 group had no
adverse effects.
DISCUSSION
The first evidence of veterinary acupuncture in China
came from the Zhou Dynasty (1027 to 221 BC) when General
Sun-Yang wrote the “Canon of Veterinary Medicine” (650
BC). However, it was not until 1825 that acupuncture was
first used on a paralytic female dog at the Veterinary School
of Alford [30-33]. Regardless of the abundant reports on the
effect of acupuncture on domestic or experimental animals
and humans, reports involving wild animals are rare [4-6,34-
37]. Acupuncture is also not often described in birds and
is mainly published as meeting abstracts and in a few case
reports [7-10,38].
The sedative effects of pharmacopuncture are described
in dogs, cats, and horses using several drugs and different
acupoints. Xylazine pharmacopuncture at Yin Tang (10% of
clinical doses) has been shown to induce sedation without
bradycardia, cardiac arrhythmia, or emesis in dogs [24].
Acepromazine pharmacopuncture at GV1 (10% of clinical
doses) has been shown to produce mild [12] to significant
sedation in horses and reduce the mean heart rate and
transport-induced increased heart rate at unloading during
road transport [25].
Bird sedation is a routine technique and provides easier
restraint, increasing the safety of clinical procedures [1,3].
Fig. 7. Unstable recuperation in a blue-fronted Amazon
parrot (Amazona aestiva ) after intramuscular administration
of ketamine and midazolam.
Ketamine is one of the most used injectable anesthetics for
most avian species [39]. The recommended dose for parrots
is 10 to 50 mg/kg, requiring higher doses in smaller birds
and longer recovery time in larger birds [40]. Ketamine
injected intramuscularly has a latency period of three to five
minutes and a duration of ten minutes. Complications, such
as prolonged recovery, tremors, and poor muscle relaxation,
are reported [39] Therefore, the combination of ketamine and
sedatives, such as benzodiazepines (midazolam), is essential
[41]. In turn, midazolam can cause muscle relaxation, though
its duration is considered short [3]. When combined with
ketamine, a dose of 0.2 to 4 mg/kg is recommended [40].
The combination of ketamine and midazolam is widely used
in birds and recommended for short, minimally painful
procedures or for anesthetic induction [42]. However, its
application is questionable since its sedation period is short,
and recovery is prolonged [43]. Thus, the present pilot study
evaluated pharmacopuncture sedation effects in blue-fronted
Amazon parrots using ketamine and midazolam. The C, 1/2
C, and 1/2 GV20 groups showed the same sedation degree,
validating the use of half the recommended ketamine and
midazolam dose at GV20 as an efficient anesthetic option
with fewer side effects than traditional administration routes
in blue-fronted Amazon parrots. Cost reduction is also an
important aspect, as the most diverse birdlife resides in third
world countries, mainly South America [44], where financial
funds are scarce.
For mammals, 10 to 20% of the clinical dose for pharmaco­
puncture shows effective sedation [12,22-27]. In the present
study, a 50% dose was needed to achieve the same sedation
degree as in the control group. These results corroborate the
sedative pharmacokinetics of birds, leading to the need for
higher drug doses for traditional drug administration [1].
These results also corroborate the acupuncture theory in
www.journal-jams.org 317

which birds are classified as warm and hyperactive species
[5]. Indeed, mild sedation using pharmacopuncture (1/5
GV20) can be the first option for minor procedures like
wing clipping and physical and imaging tests. As a clinical
technique, a 20% clinical dose could be increased to 50% of
the clinical dose if necessary. Therefore, there is a need for
further studies to evaluate different drugs and acupoints for
avian pharmacopuncture.
Systematic reviews show the use of pharmacopuncture on
cervical pain, cancer-related symptoms (pain, ileus, hiccup,
fever), and gastrointestinal signs. These reviews also show
improved quality of life in human cancer patients [16,45,46].
However, few data are available on clinical indications for
pharmacopuncture in animals [12,17-27].
Pharmacopuncture effects are directly related to acupoint
specificity, i.e., correct acupoint selection and anatomical
localization [17]. In this study, the easy access to GV20
facilitated injection and lessened the chance of error. GV20
pharmacopuncture is thus a new feasible adjuvant technique,
executable even by non-acupuncturists for bird sedation.
The 1/2 GV20 group had a significantly higher latency time
than the 1/2 C group (2.5 ± 0.57). This result was expected,
as intramuscular absorption is faster than subcutaneous
absorption, the pharmacopuncture route [17,24]. Despite
the longer latency, the sedation degree was similar in both
groups. The C (mean 4 ± 2.70 minutes) and 1/2 GV20 (6 ±
2.16 minutes) groups showed the same latency time, counter­
signing the acupoint action on drug effect [26]. Surprisingly,
both the C and 1/2 C groups had the same sedation time.
This pilot study is limited by the small sample size. How­
ever, it was useful to obtain preliminary conclusions about
the feasibility, cost, and outcome of pharmacopuncture in
birds. The 1/2 GV20 group had a faster, calmer, and quicker
anesthetic recovery (> 17 minutes), while the C and 1/2 C
groups showed difficult and slow recuperation, with tremors
and struggle [42,47]. Pharmacopuncture avoided these
recovery complications and the risk of severe life‐threatening
injuries in birds. Thus, pharmacopuncture is an effective
route for blue-fronted Amazon parrot sedation, with fewer
adverse effects than traditional drug administration routes.
Due to the multiplying and optimization effects of pharma­
copuncture, it is necessary to reduce the dose to prevent the
incidence of undesirable effects. For instance, the injection
of total doses of dexmedetomidine at the GV20 of dogs was
shown to increase the duration, degree of sedation, and
analgesic effects. However, as expected, bradycardia was more
significant in the acupuncture group [17].
In this study, all groups showed normal heart and respi­
ratory rates. Two animals (50%) in the C group showed mild
hypothermia (38℃), as expected. Hypothermia in birds
leads to several changes in physiological parameters, such as
318 www.journal-jams.org
Aricia Noelli Brega Monteiro, et al.
bradycardia, low respiratory rate, bleeding, and death. Thus,
GV20 pharmacopuncture is safe, reducing hypothermia
risks, and is feasible in birds due to its easy access with usual
physical restraint.
To our knowledge, this is the first study on pharmaco­
puncture at GV20 for sedation in birds. Further pharmaco­
puncture studies are needed to determine the optimal drug
concentration and acupoint for maximal sedation without
undesirable effects in blue-fronted Amazon parrots.
In conclusion, half the recommended dose of ketamine
and midazolam at GV20 (1/2 GV20) was effective and safe
to sedate blue-fronted Amazon parrots without side effects,
providing easy, stable, and fast recovery. Twenty percent of the
recommended dose at GV20 was also effective and safe and
had a shorter sedation time in blue-fronted Amazon parrots
without side effects. Therefore, these pharmacopuncture tech­
niques can be useful for quick procedures, such as auxiliary
tests. These findings are motivating, despite the small sample
size, showing the need for further studies with larger sample
sizes and different acupoints. Also, other bird species must
be subjected to pharmacopuncture to evaluate the quality of
sedation across all avians.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
ORCID
Aricia Noelli Brega Monteiro,
https://orcid.org/0000-0002-1329-4007
Bruno Simões Sérgio Petri,
https://orcid.org/0000-0002-9662-9289
Haroldo Furuya, https://orcid.org/0000-0002-0494-3888
Liliane Milanelo, https://orcid.org/0000-0001-9966-4410
Márcia Valéria Rizzo Scognamillo,
https://orcid.org/0000-0003-4149-5217
Ayne Murata Hayashi,
https://orcid.org/0000-0002-7360-5911
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Sedative Effect of Ap GV20 in A . aestiva

Appendix 1. Individual file group X

Identification: Weight:
Ketamin (xx mg/kg) =
Midazolam (xx mg/kg) =

Behavior Time
Application time
Presence of clinical effects (decubitus and decreased reflexes)
Return of the first reflexes
First reflexes until standing positionand carrying out their activities

Parameters
Heart rate
Respiratory rate
Body temperature

Degree of sedation

Sedation Parameters Grade

Satisfactory Closed eyes, decubitus, no movement, and muscle relaxation. 0
Moderate Light signs of tranquilization, possible decubitus, open eyes, responsive to stimulus. 1
Absent Standing position, open eyes, responsive to stimulus. 2

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