- Research
- Open Access
- Published:
Acupuncture-related techniques for postoperative cognitive complications: a systemic review and meta-analysis
Perioperative Medicine volume 12, Article number: 14 (2023)
Abstract
Background
Postoperative cognitive complications are major challenges for postoperative recovery. Acupuncture-related techniques have been used for treating neurocognitive dysfunctions. However, whether they help to prevent postoperative cognitive complicationss remains unclear. We intend to evaluate the effect of acupuncture-related techniques on the incidence of postoperative cognitive complications (PCC) in patients undergoing surgery under general anesthesia.
Methods
Based on PRISMA guidelines, a search of PubMed, EMBASE, Web of Science, and the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov was performed to identify eligible trials published from inception to June 6, 2021. The search was performed in June 2021. The inclusion criteria were prospective, randomized, controlled clinical trials that compared acupuncture-related techniques with other techniques or non-acupuncture treatment in patients undergoing surgery under general anesthesia. Pooled odds ratios (ORs), 95% CIs, and P values were estimated for end points using fixed and random effects statistical models.
Results
The analysis included 12 studies with 1058 patients. Compared with patients not receiving acupuncture, patients treated with acupuncture-related techniques had a lower incidence of PCCs (OR, 0.44; 95% CI, 0.33 to 0.59; P < 0.001; n = 968) and lower levels of biomarkers, including IL-6, TNF-α, and S100β. Acupuncture with needles and without needles showed similar effects on the prevention of PCCs. The effects of acupuncture-related techniques on PCCs were observed in both English and non-English articles. Subgroup analyses showed that both agitation and/or delirium (OR, 0.51; 95% CI, 0.34 to 0.76; P < 0.001; n = 490) and delayed cognitive recovery (OR, 0.33; 95% CI, 0.21 to 0.51; P < 0.001; n = 478) were reduced after treatment with acupuncture-related techniques. In adult studies evaluating MMSE scores, the scores were not different between groups (SMD, − 0.71; 95% CI, − 1.72 to 0.3; P = 0.17; n = 441).
Conclusions
Acupuncture-related techniques, including needle techniques and electrical techniques, are associated with fewer postoperative cognitive complications, suggesting that acupuncture could be considered a potential option in the perioperative setting. Additional research is needed to develop higher-quality evidence and optimal regimens.
Trial registration
PROSPERO (CRD42021258378).
Background
Postoperative cognitive complications consisting of agitation and/or delirium and long-lasting postoperative cognitive dysfunction are great challenges for anesthesiologists. Patients, especially those in the aging population, who suffer from postoperative cognitive complications could be at higher risk of morbidity and mortality (Olotu 2020). Growing evidence suggests a possible role for neuroinflammation, reduced functional connectivity, reduced glucose utilisation, and neurotransmitter imbalances, particularly involving dopamine and acetylcholine, in the processes underlying postoperative cognitive complications (PCCs) (Cibelli et al. 2010; Hu et al. 2018; Subramaniyan and Terrando 2019; Dellen et al. 2014; Vasunilashorn et al. 2015).
Management of postoperative cognitive complications involves a multi-professional approach and consists of pharmacological and nonpharmacological components (Olotu 2020). No single medication or intervention to prevent or treat postoperative cognitive complications is available. Avoiding anesthesia that is too deep, avoiding large swings in hemodynamics, effective pain management, and early mobilization are reported to be of benefit (Guenther et al. 2016; Heinrich et al. 2021; Li et al. 2020a; Zuylen et al. 2021).
Acupuncture-related techniques have been used for the treatment of cognitive disorders such as dementia after stroke and mild cognitive impairment (Du et al. 2020; Li et al. 2019, 2020b; Min and Xu-Feng 2016; Wang et al. 2016; Yang et al. 2016). Furthermore, the role of acupuncture in the perioperative scenario are reported in both animal and clinical studies (Lu et al. 2015; Ho et al. 2020). Possible mechanisms include acupuncture modulating inflammation, oxidative stress, synaptic changes, and other cellular events to mitigate cognitive disorders (Mazidi et al. 2017; Liu et al. 2017; Yuan et al. 2014; Silva et al. 2015; Yang et al. 2018). Perioperative acupuncture reduces not only the consumption of anesthetics and analgesics but also anesthesia-related side effects (Yang et al. 2016). Subsequent studies have assessed the effects of acupuncture-related techniques on postoperative cognitive complications, but there has not been a pooling of their findings (Ho et al. 2020). Therefore, we performed a systematic review and meta-analysis of the efficacy of acupuncture-related techniques to prevent postoperative cognitive complications in patients undergoing general anesthesia. Our primary outcome was the incidence of postoperative cognitive complications, and we reported the severity of postoperative cognitive complications and changes in preinflammatory cytokines.
Material and methods
We adhered to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement for the conduct and reporting of this systematic review. The protocol was registered at PROSPERO (CRD42021258378).
A systematic search with no restriction to language and publication status was performed on June 4, 2021. We searched PubMed, EMBASE, Web of Science, the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov for eligible studies. We reviewed the reference lists of the included publications and previous systematic reviews to identify additional eligible studies. The search strategy is detailed in Additional file 1: Supplemental file 1 (eMethod). We did not search the gray literature.
The inclusion criteria were prospective, randomized, controlled clinical trials that compared acupuncture-related techniques with other techniques or non-acupuncture treatment for postoperative cognitive complications in patients undergoing surgery under general anesthesia. We excluded observational studies and quasi-randomized and nonrandomized controlled trials. We excluded studies without assessment of postoperative cognition. This meta-analysis of readily available literature did not require institutional review board approval, and each respective study detailed their consent procedures.
Our primary outcomes included the incidence of postoperative cognitive complications during the hospital stay. Postoperative cognitive complications include emergence agitation and/or delirium, postoperative cognitive dysfunction, and postoperative delirium. When postoperative cognitive complications were assessed several times after surgery, the highest incidence of a postoperative cognitive complications during the hospital stay was extracted. Our secondary outcomes included the highest mini-mental state examination (MMSE) scores during the hospital stay. and levels of inflammatory cytokines and cerebral injury biomarkers, including interleukin (IL-6), tumor necrosis factor (TNF)-α, and S100β.
Data extraction was independently performed by two authors (M.Z. and J.Z.), with good interobserver agreement (κ = 0.95). These two authors independently screened the articles and extracted the following data from each study: patient characteristics (age, sex, and American Society of Anesthesiologists [ASA] physical status), study characteristics (country, type of surgery and anesthesia, sample size), intervention characteristics (type of acupuncture, timing and comparators), and outcomes of interest (assessment tool, type of PCC).
Z.L. and L.S. independently evaluated the risk of bias for each study included with the Cochrane risk of bias assessment tool (Higgins and Green 2008). We also reviewed conflicts of interest or industry sponsorship. We resolved any inconsistency through discussion (κ = 0.55–1.0). When an email address was available, we contacted the authors of the original study for detailed information. Specifically, we attempted to retrieve information regarding the detailed methodology of each trial and the outcomes of interest that were not presented in the articles. We deemed the authors to be unresponsive if they did not reply after three consecutive attempts, based on a previous study (Kuriyama and Maeda 2019). The overall certainty of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach (Balshem et al. 2011).
We calculated the odds ratios (ORs) and standardized mean differences (SMDs) for dichotomous and continuous outcomes, respectively. Pooled ORs and P values were estimated for the incidence of postoperative cognitive complications using the Mantel–Haenszel method and either a fixed or random effects statistical model. When a study presented the data as the median with interquartile range, we converted the values to the mean and standard deviation. Meta-analyses were conducted with Review Manager software (RevMan; version 5.1 for Windows; Nordic Cochrane Centre). The 95% CIs were calculated and are presented in forest plots. Statistical heterogeneity was evaluated with the χ2 test, and inconsistency was estimated using the I2 statistic. We conducted subgroup analysis based on patient population, type of acupuncture, and type of postoperative cognitive complications. The quality of the selected randomized clinical trials was assessed based on the instrument developed by Jadad et al. (Jadad et al. 1996; Spring et al. 2016) (Additional file 1: Table S1). Sensitivity analyses were conducted to evaluate the effect of acupuncture on postoperative cognitive complications in studies published in English and non-English and in studies using different anesthetic techniques. When a trial had zero events in either arm, we performed sensitivity analyses with continuity corrections by adding 1 to each cell of the 2 × 2 tables from the trial (Kuriyama and Maeda 2019; Sweeting et al. 2004). P values of 0.05 were considered statistically significant.
Egger’s regression test was used to assess publication bias for the primary outcomes of this review. We also created a funnel plot for the assessment of publication bias in situations of low risk of publication bias.
Results
Overview of included studies
Our database search initially produced 106 titles and abstracts. Thirty-four records were finally screened. Twenty-one non-RCT records were excluded. One record was excluded due to lack of assessment of postoperative cognition. We ultimately included 12 randomized controlled trials involving 1058 study participants for the analysis after applying the inclusion and exclusion criteria (Fig. 1). The risk of bias for each study was shown in Additional file 1: Fig. S1.
Eight and four trials included patients older than 65 years old and younger than 10 years old (1.5–8 years old for two trials, 2–10 years for one trial, 1–6 years for one trial), respectively. Eight trials were conducted in China. The types of surgery were listed as follows: ENT surgery (adenoidectomy and/or tonsillectomy, myringotomy tube placement), gastrointestinal surgery, interventional surgery, and orthopedic surgery (spine, knee replacement) (Table 1).
Primary endpoint
In one study (Zhang et al. 2017), only highest MMSE scores were recorded and the incidence of PPC could not be determined. Eleven studies comprising 968 participants provided data on the incidence of postoperative cognitive complications. A low certainty of evidence supported that perioperative administration of acupuncture-related techniques was associated with a lower incidence of postoperative cognitive complications (OR, 0.44; 95% CI, 0.33 to 0.59; P < 0.00001; df = 10; I2 = 26%; Fig. 2 and Additional file 1: Table S2). Egger’s regression test for assessing publication bias showed no significant bias (P = 0.27).
Forest plot for the incidence of PCC during hospital stay. The plot shows decreased incidence in patients treated with acupuncture-related techniques compared with non-acupuncture controls. Fixed-effects odds ratios are calculated using the Mantel–Haenszel test. Error bars represent 95% CI. OR = odds ratio
Postoperative delirium and delayed cognitive recovery
Five trials comprising 490 participants assessed postoperative delirium. Acupuncture was associated with a lower incidence of postoperative delirium (OR, 0.51; 95% CI, 0.34 to 0.76; P < 0.001; df = 4; I2 = 64%; Additional file 1: Fig. S2). Seven trials comprising 478 participants evaluated delayed cognitive recovery. Acupuncture was associated with a lower incidence of delayed cognitive recovery (OR, 0.33; 95% CI, 0.21 to 0.51; P < 0.001; df = 5; I2 = 0%; Additional file 1: Fig. S2).
Acupuncture with needle and acupuncture without needle
Three trials comprising 243 participants compared acupuncture with needles and control conditions. The incidence of postoperative cognitive disorder was not different between the two techniques (OR, 0.56; 95% CI, 0.30 to 1.05; P = 0.07; df = 2; I2 = 59%; Additional file 1: Fig. S3). Eight trials comprising 725 participants compared acupuncture without needles and control conditions. Acupuncture was associated with a lower incidence of postoperative cognitive disorder (OR, 0.38; 95% CI, 0.27 to 0.54; P < 0.001; df = 7; I2 = 16%; Additional file 1: Fig. S3).
Pediatric patients and non-pediatric patients
Subgroup analysis showed that based on the four trials comprising 370 participants compared acupuncture and control conditions in pediatric patients, acupuncture was associated with a lower incidence of postoperative cognitive complications (OR, 0.61; 95% CI, 0.38 to 0.98; P = 0.04; df = 3; I2 = 69%; Additional file 1: Fig. S4). Seven trials comprising 598 participants compared acupuncture and control conditions in non-pediatric patients. Acupuncture was associated with a lower incidence of postoperative cognitive complications (OR, 0.36; 95% CI, 0.24 to 0.53; P < 0.001; df = 6; I2 = 0%; Additional file 1: Fig. S4).
Secondary end points
Five trials in adult patients only comprising 441 participants compared the highest MMSE scores obtained during the hospital stay. No difference was observed between participants treated with acupuncture and those in the control group (SMD, − 0.71; 95% CI, − 1.72 to 0.30; P = 0.17; df = 4; I2 = 96%; Fig. 3).
Five trials comprising 459 participants compared serum IL-6 levels. Acupuncture was associated with a lower level of IL-6 (SMD, − 2.51; 95% CI, − 3.57 to − 0.74; P = 0.003; df = 4; I2 = 98%; Fig. 4). Five trials comprising 329 participants and 385 participants compared the levels of serum TNF-α and S100β, respectively. Acupuncture was associated with lower levels of TNF-α (SMD, − 2.07; 95% CI, − 3.41 to − 0.73; P = 0.003; df = 4; I2 = 96%) and S100β (SMD, − 0.91; 95% CI, − 1.3 to − 0.53; P < 0.00001; df = 4; I2 = 68%; Fig. 4). The certainty of the evidence was very low (Additional file 1: Table S2).
Sensitivity analysis
In one trial reporting the incidence of postoperative cognitive complications, the number of events in the control group was zero. For sensitivity analyses with continuity corrections, 1 was added to each cell of the 2 × 2 tables from the trial. Acupuncture was associated with a lower incidence of postoperative cognitive complications (OR, 0.44; 95% CI, 0.33 to 0.60; P < 0.00001; df = 10; I2 = 30%; Additional file 1: Fig. S5).
Seven trials were published in English, and four trials were published in non-English (all Chinese). The results of trials published in English (n = 594; OR, 0.52; 95% CI, 0.35 to 0.79, P = 0.002) and non-English (n = 394; OR, 0.35; 95% CI, 0.22 to 0.55, P < 0.00001) both showed significantly fewer postoperative cognitive complications in patients who received the acupuncture-related interventions (Additional file 1: Fig. S6).
Six trials used propofol, and five trials used sevoflurane for general anesthesia maintenance. Acupuncture-related techniques were associated with significantly lower rates of PCCs regardless of the type of anesthetics used for general anesthesia (both P < 0.001, Additional file 1: Fig. S7).
Discussion
Our review of acupuncture-related techniques as interventions for postoperative cognitive complications found low-certainty evidence that showed that acupuncture-related techniques, compared with control conditions, were associated with reduced postoperative cognitive complications. Subgroup analyses reported that both acute agitation and/or delirium and delayed cognitive recovery were lower in participants who received acupuncture-related techniques. The incidence of postoperative cognitive complications was lower in participants received acupuncture in both pediatric population and non-pediatric population.
In this study, we used the mesh term ‘postoperative cognitive complications’. Another nomenclature 'perioperative neurocognitive disorders’ was also recommended to be used as an overarching term for cognitive impairment identified in the preoperative or postoperative period (Evered et al. 2018). It includes any form of acute event (postoperative delirium) and cognitive decline diagnosed up to 30 days (delayed neurocognitive recovery) and up to 12 months (postoperative neurocognitive disorder) after the procedure. Based on this definition, the cognitive changes after surgery assessed in the included studies were acute delirium and delayed neurocognitive recovery. In the studies included, MMSE was only undertaken as the primary outcome diagnostic tool in patients older than 65 years The MMSE is reported as the diagnostic tool for agitation and delirium in adults only, adding evidence that there are different pathologies presenting as agitations and/or delirium in older adults and in children. As indicated by the subgroup analysis, in pediatric patients, acupuncture was associated with a lower incidence of agitation and/or delirium, which is in accordance with the less cognitive complications in adults.
Our review found very low-certainty evidence that MMSE scores were higher and the levels of proinflammatory biomarkers, including serum IL-6, TNF-α and S100β, were lower in patients treated with acupuncture. This concurs with a previous report that postoperative cognitive dysfunction is correlated with the concentrations of peripheral inflammatory markers, particularly interleukin-6 and S-100β (Wiberg et al. 2021; Peng et al. 2013). The role of inflammation in perioperative brain function is becoming apparent (Subramaniyan and Terrando 2019). Surgery may induce a systemic inflammatory response via cytokines such as IL-1β (Cibelli et al. 2010), TNF-α (Terrando et al. 2010), and IL-6 (Hu et al. 2018), as well as S100 Ca2+-binding proteins and oxidative stress pathways. Administration of an IL-6 monoclonal antibody and targeting of TNF-α have been reported to prevent postoperative cognitive complications (Cibelli et al. 2010; Hu et al. 2018; Subramaniyan and Terrando 2019; Terrando et al. 2010). There is a potential benefit of acupuncture in terms of inflammatory markers and it requires further investigation.
Regardless of the type of acupuncture technique, the effect of decreasing postoperative cognitive complications could be induced by manual or electrical stimulation (transcutaneous electrical acupoint stimulation, TEAS). The frequency of the stimulation regimen for electroacupuncture was low (1 Hz, 2 Hz, 10 Hz, 15 Hz). Various studies have reported that high-frequency and low-frequency electroacupuncture or TEAS have clinical effects elicit through distinct mechanisms (Yang et al. 2016). For example, the suppressive effects of low-frequency electroacupuncture on carrageenan-induced edema and pain are mediated by sympathetic postganglionic neurons, while the suppressive effects of HF EA are mediated by the sympatho-adrenal medullary axis (Kim et al. 2008). Moreover, an animal study showed that high-frequency electroacupuncture (50 Hz) more effectively exerted a protective effect against Aβ1-42-induced learning and memory deficits and synapse ultrastructure impairments (Yu et al. 2018). The most effective electroacupuncture frequency for postoperative cognitive complications remains to be explored. The comparators were no acupuncture, inactive plaster or no stimulation electrode control (which is called mock TEAS). It was recommended that regardless of the choice of control group, it is valuable to check its adequacy (Vincent and Lewith 1995). Nevertheless, no information about verifying the adequacy of the control conditions was provided in the studies included in our review. The timing of acupuncture varies in enrolled studies. Acupuncture was given before the surgery in eight studies and during the surgery in four studies. It was speculated that acupuncture provided after anesthesia induction may not be as effective as that provided when patients were awake (Yang et al. 2016). Further studies were needed to verify the optimal timing of perioperative acupuncture.
The trials on pediatric patients were mostly performed in countries outside China, and the measured outcomes were agitation and/or delirium, which is likely an emergence delirium. The trials on non-pediatric patients were mostly on patients older than 65Â years old and focused on delayed cognitive recovery. The number of acupoints chosen across interventions varied greatly, and a comparison of the effect of acupuncturing different acupoints was difficult. Baihui, Hegu, and Neiguan were the most frequently used acupoints (Baihui in 6 trials, Hegu in 4 trials, and Neiguan in 6 trials). The timing of acupuncture included preoperative, intraoperative and postoperative and a combination of the three treatment times. Seven trials administered TEAS 30Â min before anesthesia induction, which is a frequently used protocol for many studies on perioperative acupuncture (Lu et al. 2021).
Our review could not adequately assess adverse events associated with acupuncture-related techniques. All studies included in our review were published after the release of the Consolidated Standards of Reporting Trials (CONSORT) statement in 1996 (Begg et al. 1996), which recommended that trial investigators report unintended effects related to interventions. However, no study provided information of adverse events. Whether acupuncture-related techniques are related to significant adverse events still needs further investigation.
The strengths of our study include the comprehensive nature of the literature search, which identified 12 publications, thus permitting sensitivity analyses. In addition, we complied with the Cochrane methodology. We attempted to contact the authors to more accurately evaluate the risk of bias and to obtain necessary unpublished data. We also confirmed the robustness of our findings with sensitivity analysis.
Our review also has limitations. First, age ranges of the participants in the enrolled trials were different. Second, the JADAD score of the eligible studies was relatively low. Seven trials had a JADAD score of 2, and one trial scored 1 (Additional file 1: Table S1). The assessment of evidence grade was low and very low for the measured outcomes (Additional file 1: Table S2). Risk of bias and incomplete reporting were major concerns contributing to the low quality of the evidence. Risk of bias resulted from difficulty in blinding for the acupuncture intervention, though it could be partly overcome by blinded outcome assessment Incomplete reporting was based on the failure to provide values of some effects, including the 95% CI, in some trials. There was a risk of multiple testing bias in our secondary outcomes, as a 95% CI was calculated. In relation to this, methodological bias continues to be a concern, as some trials were characterized by an unclear risk of bias. Third, the surgery type varies in the enrolled studies. Data retrieved from same surgeries may provide more potent evidence. Moreover, no data were available on postoperative cognitive disturbance-related outcomes beyond 30 days after surgery. Whether acupuncture like other non-pharmacological interventions have no effect on long-term cognitive disturbance reported after delirium needs to be verified.
Conclusions
This systemic review and meta-analysis reports that acupuncture-related techniques may decrease post-operative cognitive complication and warrants further investigation. Nevertheless, the inherent limitations of the included studies prevent us from reaching definitive conclusions. Future large, well-design ed RCTs with extensive follow-up are needed to confirm and update the findings of this analysis.
Availability of data and materials
All data generated or analyzed during this study are included in this published article, its supplementary information files, and the primary randomized controlled trials cited for inclusion. A copy of the raw data could be reached by requests for additional analysis. Data will be available when the manuscript published.
Abbreviations
- PCC:
-
Postoperative cognitive complications
- PRISMA:
-
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- MMSE:
-
Mini-mental state examination
- IL:
-
Interleukin
- TNF:
-
Tumor necrosis factor
- ASA:
-
American Society of Anesthesiologists
- GRADE:
-
Grading of Recommendations Assessment, Development and Evaluation
- OR:
-
Odds ratio
- SMD:
-
Standardized mean difference
- CI:
-
Confidence interval
- RCT:
-
Randomized clinical trial
- ENT:
-
Ear, nose and throat
- TEAS:
-
Transcutaneous electrical acupoint stimulation
- CONSORT:
-
Consolidated Standards of Reporting Trials
References
Acar HV, Yilmaz A, Demir G, Eruyar SG, Dikmen B. Capsicum plasters on acupoints decrease the incidence of emergence agitation in pediatric patients. Pediatr Anesth. 2012;22(11):1105–9.
Balshem H, Helfand M, Schunemann HJ, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011;64(4):401–6.
Begg C, Cho M, Eastwood S, et al. Improving the quality of reporting of randomized controlled trials The CONSORT Statement. JAMA. 1996;276(8):637–9.
Cibelli M, Fidalgo AR, Terrando N, et al. Role of interleukin-1beta in postoperative cognitive dysfunction. Ann Neurol. 2010;68(3):360–8.
da Silva MD, Bobinski F, Sato KL, Kolker SJ, Sluka KA, Santos AR. IL-10 cytokine released from M2 macrophages is crucial for analgesic and anti-inflammatory effects of acupuncture in a model of inflammatory muscle pain. Mol Neurobiol. 2015;51(1):19–31.
Du Y, Zhang L, Liu W, et al. Effect of acupuncture treatment on post-stroke cognitive impairment: a randomized controlled trial. Medicine (baltimore). 2020;99(51):e23803.
Evered L, Silbert B, Knopman DS, et al. Recommendations for the nomenclature of cognitive change associated with anaesthesia and surgery-2018. Br J Anaesth. 2018;121(5):1005–12.
Gao XQ, Zhang ZY, Ma WH. Effects of electroacupuncture assistant general anesthesia on postoperative cognitive dysfunction of aged patients. Zhongguo Zhong Xi Yi Jie He Za Zhi. 2012;32(5):591–3.
Gao F, Zhang Q, Li Y, et al. Transcutaneous electrical acupoint stimulation for prevention of postoperative delirium in geriatric patients with silent lacunar infarction: a preliminary study. Clin Interv Aging. 2018;13:2127–34.
Guenther U, Riedel L, Radtke FM. Patients prone for postoperative delirium: preoperative assessment, perioperative prophylaxis, postoperative treatment. Curr Opin Anaesthesiol. 2016;29(3):384–90.
Heinrich M, Nottbrock A, Borchers F, et al. Preoperative medication use and development of postoperative delirium and cognitive dysfunction. Clin Transl Sci. 2021. https://doi.org/10.1111/cts.13031.
Higgins JP, Green S. Cochrane Handbook for Systematic Reviews of Interventions. England: John Wiley & Sons, Ltd; 2008.
Hijikata T, Mihara T, Nakamura N, Miwa T, Ka K, Goto T. Electrical stimulation of the heart 7 acupuncture site for preventing emergence agitation in children: a randomised controlled trial. Eur J Anaesthesiol. 2016;33(7):535–42.
Ho YS, Zhao FY, Yeung WF, Wong GT, Zhang HQ, Chang RC. Application of acupuncture to attenuate immune responses and oxidative stress in postoperative cognitive dysfunction: what do we know so far? Oxid Med Cell Longev. 2020;2020:9641904.
Hu J, Feng X, Valdearcos M, et al. Interleukin-6 is both necessary and sufficient to produce perioperative neurocognitive disorder in mice. Br J Anaesth. 2018;120(3):537–45.
Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials. 1996;17(1):1–12.
Kim HW, Uh DK, Yoon SY, et al. Low-frequency electroacupuncture suppresses carrageenan-induced paw inflammation in mice via sympathetic post-ganglionic neurons, while high-frequency EA suppression is mediated by the sympathoadrenal medullary axis. Brain Res Bull. 2008;75(5):698–705.
Kuriyama A, Maeda H. Preoperative intravenous dexamethasone prevents tracheal intubation-related sore throat in adult surgical patients: a systematic review and meta-analysis. Can J Anaesth. 2019;66(5):562–75.
Li G, Zeng L, Cheng H, Han J, Zhang X, Xie H. Acupuncture administration improves cognitive functions and alleviates inflammation and nuclear damage by regulating phosphatidylinositol 3 kinase (PI3K)/phosphoinositol-dependent kinase 1 (PDK1)/novel protein kinase C (nPKC)/Rac 1 signaling pathway in senescence-accelerated prone 8 (SAM-P8) Mice. Med Sci Monit. 2019;25:4082–93.
Li M, Yang Y, Ma Y, Wang Q. Pharmacological agents that prevent postoperative cognitive dysfunction in patients with general anesthesia: a network meta-analysis. Am J Ther. 2020a;28(4):e420–33.
Li W, Wang Q, Du S, Pu Y, Xu G. Acupuncture for mild cognitive impairment in elderly people: Systematic review and meta-analyses. Medicine (baltimore). 2020b;99(39): e22365.
Lin SY, Gao J, Yin ZL, Zhou LJ, Chen X. Impacts of the different frequencies of electroacupunctrue on cognitive function in patients after abdominal operation under compound anesthesia of acupuncture and drugs. Zhongguo Zhen Jiu. 2013;33(12):1109–12.
Lin SY, Yin ZL, Gao J, Zhou LJ, Chen X. Effect of acupuncture-anesthetic composite anesthesia on the incidence of POCD and TNF-alpha, IL-1beta, IL-6 in elderly patients. Zhongguo Zhong Xi Yi Jie He Za Zhi. 2014;34(7):795–9.
Liu PR, Zhou Y, Zhang Y, Diao S. Electroacupuncture alleviates surgery-induced cognitive dysfunction by increasing α7-nAChR expression and inhibiting inflammatory pathway in aged rats. Neurosci Lett. 2017;659:1–6.
Liu T, Yin C, Li Y, et al. Effects of transcutaneous electrical acupoint stimulation on postoperative cognitive decline in elderly patients: a pilot study. Clin Interv Aging. 2021;16:757–65.
Lu Z, Dong H, Wang Q, Xiong L. Perioperative acupuncture modulation: more than anaesthesia. Br J Anaesth. 2015;115(2):183–93.
Lu Z, Wang Q, Sun X, et al. Transcutaneous electrical acupoint stimulation before surgery reduces chronic pain after mastectomy: a randomized clinical trial. J Clin Anesth. 2021;74:110453.
Martin CS, Yanez ND, Treggiari MM, Piper L, Cusick J, Lalwani K. Randomized controlled trial of acupuncture to prevent emergence delirium in children undergoing myringotomy tube placement. Minerva Anestesiol. 2020;86(2):141–9.
Mazidi M, Abbasi-Parizad P, Abdi H, et al. The effect of electro-acupuncture on pro-oxidant antioxidant balance values in overweight and obese subjects: a randomized controlled trial study. J Complement Integr Med. 2017; 15(2). https://doi.org/10.1515/jcim-2015-0081
Min D, Xu-Feng W. An updated meta-analysis of the efficacy and safety of acupuncture treatment for vascular cognitive impairment without dementia. Curr Neurovasc Res. 2016;13(3):230–8.
Nakamura N, Mihara T, Hijikata T, Goto T, Ka K. Unilateral electrical stimulation of the heart 7 acupuncture point to prevent emergence agitation in children: a prospective, double-blinded, randomized clinical trial. PLoS ONE. 2018;13(10):e0204533.
Olotu C. Postoperative neurocognitive disorders. Curr Opin Anaesthesiol. 2020;33(1):101–8.
Peng L, Xu L, Ouyang W. Role of peripheral inflammatory markers in postoperative cognitive dysfunction (POCD): a meta-analysis. PLoS ONE. 2013;8(11):e79624.
Spring LM, Gupta A, Reynolds KL, et al. Neoadjuvant endocrine therapy for estrogen receptor-positive breast cancer: a systematic review and meta-analysis. JAMA Oncol. 2016;2(11):1477–86.
Subramaniyan S, Terrando N. Neuroinflammation and Perioperative Neurocognitive Disorders. Anesth Analg. 2019;128(4):781–8.
Sweeting MJ, Sutton AJ, Lambert PC. What to add to nothing? Use and avoidance of continuity corrections in meta-analysis of sparse data. Stat Med. 2004;23(9):1351–75.
Terrando N, Monaco C, Ma D, Foxwell BM, Feldmann M, Maze M. Tumor necrosis factor-alpha triggers a cytokine cascade yielding postoperative cognitive decline. Proc Natl Acad Sci U S A. 2010;107(47):20518–22.
van Dellen E, van der Kooi AW, Numan T, et al. Decreased functional connectivity and disturbed directionality of information flow in the electroencephalography of intensive care unit patients with delirium after cardiac surgery. Anesthesiology. 2014;121(2):328–35.
van Zuylen ML, Gribnau A, Admiraal M, et al. The role of intraoperative hypotension on the development of postoperative cognitive dysfunction: a systematic review. J Clin Anesth. 2021;72: 110310.
Vasunilashorn SM, Ngo L, Inouye SK, et al. Cytokines and postoperative delirium in older patients undergoing major elective surgery. J Gerontol A Biol Sci Med Sci. 2015;70(10):1289–95.
Vincent C, Lewith G. Placebo controls for acupuncture studies. J R Soc Med. 1995;88(4):199–202.
Wang S, Yang H, Zhang J, et al. Efficacy and safety assessment of acupuncture and nimodipine to treat mild cognitive impairment after cerebral infarction: a randomized controlled trial. BMC Complement Altern Med. 2016;16(1):361.
Wiberg S, Holmgaard F, Zetterberg H, et al. Biomarkers of cerebral injury for prediction of postoperative cognitive dysfunction in patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth. 2021;S1053–0770(21):00427–34.
Yang A, Wu HM, Tang JL, Xu L, Yang M, Liu GJ. Acupuncture for stroke rehabilitation. Cochrane Database Syst Rev. 2016;2016(8):Cd004131.
Yang JW, Wang XR, Zhang M, et al. Acupuncture as a multifunctional neuroprotective therapy ameliorates cognitive impairment in a rat model of vascular dementia: a quantitative iTRAQ proteomics study. CNS Neurosci Ther. 2018;24(12):1264–74.
Yu CC, Wang Y, Shen F, et al. High-frequency (50 Hz) electroacupuncture ameliorates cognitive impairment in rats with amyloid beta 1–42-induced Alzheimer’s disease. Neural Regen Res. 2018;13(10):1833–41.
Yuan S, Zhang X, Bo Y, Li W, Zhang H, Jiang Q. The effects of electroacupuncture treatment on the postoperative cognitive function in aged rats with acute myocardial ischemia-reperfusion. Brain Res. 2014;1593:19–29.
Yuan J, Wu Y, Li JY, et al. Effect of Dexmedetomidine Combined Electrical Stimulation on Coanitive Function of Patients Receiving Extracerebral Intervention. Zhongguo Zhong Xi Yi Jie He Za Zhi. 2016;36(3):285–8.
Zhang Q, Li YN, Guo YY, et al. Effects of preconditioning of electro-acupuncture on postoperative cognitive dysfunction in elderly: a prospective, randomized, controlled trial. Medicine (baltimore). 2017;96(26): e7375.
Zhao FY, Zhang ZY, Zhao YX, et al. The effect of electroacupuncture preconditioning on cognitive impairments following knee replacement among elderly: A randomized controlled trial. World J Acupunct Moxibustion. 2018;28(4):231–6.
Acknowledgements
Not applicable
Funding
The National Science Foundation of China (Nos. 81871028 and 82293644), the TCM cultivating program (No. 2021ZY019) and the Aeromedical Flow PI Program (No. 2022HYPI02). The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.
Author information
Authors and Affiliations
Contributions
Zhihong Lu had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Liwen Shi, Junbao Zhang, Zhihong Lu, Zhuoma Cairen. Literature review and data extraction: Junbao Zhang and Minjuan Zhang. Bias analysis: Liwen Shi and Zhihong Lu. Statistical analysis: Manping Yang, Zhuoma Cairen. Writing of the draft: Junbao Zhang. Critical revision of the manuscript for important intellectual content: Zhihong Lu, Yun Wang. Obtained funding: Zhihong Lu. Administrative, technical, or material support: Zhihong Lu, Yun Wang. All authors read and approved the final manuscript.
Corresponding author
Ethics declarations
Ethics and approval and consent to participate
The corresponding author affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.
Consent for publication
We have reported whether we plan to disseminate the results to study participants and or patient organizations or stated that dissemination to these groups is not possible/applicable.
Competing interests
All authors have completed the Unified Competing Interest form and declare: no support from any organization for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3Â years, no other relationships or activities that could appear to have influenced the submitted work.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary Information
Additional file 1: Supplemental file 1 (eMethod).
Search Strategy. Table S1. Study Quality of Eligible Trials. Table S2. Grading of Recommendations Assessment, Development and Evaluation Summary of Quality of Evidence for primary and secondary Outcomes. Figure S1. Risk of bias summary: review authors' judgements about each risk of bias item for each included study. Figure S2. Forest plot for subgroup analysis of the incidence of PND by type of PND. Figure S3. Forest plot for subgroup analysis of the incidence of PND by acupuncture techniques. Figure S4. Forest plot for subgroup analysis of the incidence of PND by age. Figure S5. Sensitivity analyses with continuity corrections on zero events of PND incidence. Figure S6. Effect of acupuncture on PND in studies published in English and non-English. Figure S7. Effect of acupuncture on PND under different anesthetic techniques. Figure S8. Funnel Plots for Studies Evaluating.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
About this article
Cite this article
Zhang, J., Cairen, Z., Shi, L. et al. Acupuncture-related techniques for postoperative cognitive complications: a systemic review and meta-analysis. Perioper Med 12, 14 (2023). https://doi.org/10.1186/s13741-023-00303-5
Received:
Accepted:
Published:
DOI: https://doi.org/10.1186/s13741-023-00303-5
Keywords
- Acupuncture
- Postoperative cognitive dysfunction
- Meta-analysis