Acupuncture-assisted anesthesia in surgical procedures: A comprehensive review of operational methods, technical details, ear and body acupoints application

Table 1 Individualized strategies for various types of surgery

Surgical categories	Acupoint selection	Stimulation methods	Summary of mechanism and supporting basis	Perioperative management points	Evidence quality grading (Oxford/GRADE)	Grading rationale	Ref.
Craniocerebral surgery	Fengchi (GB20); Anmian (EX-HN22); Yuyao (EX-NH4); Cuanzhu (BL2); Shuaigu (GB8); Hanyan (GB4); Jinmen (BL63); Taichong (LR3); Shangxing (DU23); Quanliao (SI18)	For EA, sterile filiform needles are inserted obliquely or straightly into acupoints; after Deqi, an electroacupuncture instrument is connected for stimulation with 2/100Hz dense-disperse wave at a tolerable intensity, and the needles are fixed. For transcutaneous electrical acupoint stimulation, electrodes are attached to acupoints for stimulation at the same frequency with an intensity 2-3 times the sensory threshold	Acupoint stimulation activates the periaqueductal gray-RVM descending inhibitory system and promotes endogenous opioid release. Reduced nociceptive transmission from the surgical field feeds back to central pain-regulatory networks. In this way, it adjusts analgesic effects and forms a pain-control closed loop	No tracheal intubation is performed, or spontaneous breathing is maintained; postoperative nausea and vomiting is prevented (intradermal needle embedding at the Neiguan acupoint is significantly effective)	Level 2b/moderate	Included studies are single-center small-sample RCTs without double-blinding, with mild heterogeneity between studies, meeting Oxford level 2b criteria. GRADE initial high quality for RCTs, downgraded 1 level due to bias risk (no blinding) and small sample size to moderate quality	[66,67]
Cardiothoracic surgery	Yunmen (LU2); Zhongfu (LU1); Lieque (LU7); PC6; LI4		During the surgery, the dosage of anesthetics is reduced, the need for supplemental analgesics is lower, and the incidence of postoperative nausea and vomiting is also decreased, along with lower IL-6 levels and higher β-endorphin levels	It provides preoperative anxiety relief and preemptive analgesia; during surgery, it reduces anesthetic dosage, exerts anti-stress effects, stabilizes respiration and hemodynamics, and offers organ protection; postoperatively, it ensures analgesia, prevents nausea and vomiting, improves gastrointestinal function, prevents cognitive dysfunction, and enhances immunity	Level 2b/moderate	Included studies are single-center RCTs without practitioner blinding, with consistent conclusions, meeting Oxford level 2b criteria. GRADE initial high quality for RCTs, downgraded 1 level due to bias risk (no practitioner blinding) to moderate quality	[68-70]
Abdominal surgery	ST36; LI4; PC6; Sanyinjiao (SP6)		Stimulation of ST36, LI4, and PC6 activates descending pain inhibitory pathways and suppresses visceral nociceptive transmission. Altered visceral sensory input feeds back to central pain-processing regions, reinforcing analgesic regulation through a gut-brain pain-control loop	Monitor postoperative gastrointestinal function and manage dietary intake	Level 2a/Low	Meta-analysis of 17 RCTs with high heterogeneity between studies and methodological flaws in sham acupuncture controls, meeting Oxford level 2a criteria. GRADE initial high quality, downgraded 2 levels due to high heterogeneity, indirectness (flawed control scheme), and bias risk to low quality	[71]
Orthopedic surgery	Baihui (DU20); Dazhui (DU14); ST36		Acupuncture enhances endogenous opioid release and activates descending inhibitory pathways to reduce postoperative pain. Continuous feedback from peripheral inflammatory and nociceptive signals allows adaptive adjustment of central analgesic activity	Assess postoperative pain and administer additional analgesia, and guide exercise adaptation	Level 2b/moderate	Single-center RCT with inherent limitations in double-blinding implementation, meeting Oxford level 2b criteria. GRADE initial high quality for RCTs, downgraded 1 level due to bias risk (blinding limitations) to moderate quality	[26]
Thyroid surgery	Futu (LI18); LI4; PC6		Induces analgesia, regulates mean arterial pressure and heart rate, and decreases anesthetic consumption in thyroidectomy patients	Monitor hemodynamics during surgery and reduce the dosage of anesthetics	Level 2a/Low	Pooled analysis of 12 RCTs with publication bias and inconsistent EA protocols, meeting Oxford level 2a criteria. GRADE initial high quality, downgraded 2 levels due to publication bias and between-study heterogeneity to low quality	[72]

EA: Electroacupuncture; GRADE: Grading of Recommendations Assessment, Development and Evaluation; IL-6: Interleukin-6; RCT: Randomized controlled trial; RVM: Rostral ventromedial medulla.