Chinese Journal of Physiology 60(3): 151-157, 2017

151
DOI: 10.4077/CJP.2017.BAF461

Comparative Induction of Controlled

Hypotension by Electroacupuncture at
DU20 Acupoint and Remifentanil in Lumbar
Laminectomy
Mehdi Ghaemi 1, Majid Ansari 1, and Kourosh Amini 2

1
Department of Anesthesiology
and
2
Zanjan Social Determinations of Health Research Center, Zanjan University of Medical Sciences,
Zanjan, Iran

Abstract
Hypotensive anesthesia is utilized to reduce bleeding during orthopedic surgery. One of the
various drugs that have been used to reduce blood pressure is remifentanil. This study was an attempt
to compare the effect of remifentanil with that of electroacupuncture (EA) at DU20 on reducing blood
pressure. In this randomized controlled clinical trial, 54 patients undergoing lumbar laminectomy were
allocated to two groups. Hypotensive anesthesia was performed through infusion of remifentanil 100
µg/kg/min for the control group, and EA at DU20 acupoint with a frequency of 2-10 Hz and intensity of
1-5 mA for the intervention group. Blood pressure, pulse rate, volume of blood lost and the quality of
surgical field were evaluated every 10 min. There were no statistically significant differences between
the two groups in terms of the changes in mean arterial pressure (MAP), pulse rate, and the quality
of surgical field (P > 0.05). Therefore, EA can be as effective as remifentanil to reduce blood pressure
in the patients undergoing lumbar laminectomy.

Key Words: acupuncture, controlled hypotension, electroacupuncture, hypotensive anesthesia,

remifentanil, spine

Introduction inhaled anesthetics (Isoflurane, Sevoflurane), and

Orthopedic surgeries are often associated with
excessive bleeding (11). Hypotensive anesthesia is
utilized to reduce bleeding during surgery, to achieve
a bloodless surgical field and to reduce the duration
of surgery (9, 16, 20). Hypotensive anesthesia (con-
trolled hypotension) is defined as a reduction in
the mean arterial pressure (MAP) to 50 - 65 mmHg
after using drugs (17, 23). Various drugs such as
vasodilators (Nitroglycerin, Nitroprusside), beta-
adrenergic antagonists (Esmolol, Propranolol), α2-
receptor agonists (Clonidine, Dexmetodomidine),
opioids (Remifentanil) are utilized for this purpose
(1, 3, 11, 13).
Antihypertensive drugs may have many side effects
such as reflex tachycardia and tachyphylaxis. Peripheral
vasodilators result in tachycardia and increased
myocardial contractibility via baroreceptor-mediated
sympathetic response. Under such circumstance, renin-
angiotensin system and sympathetic nervous system
are also activated and these changes would lead to an
increase in cardiac output and may compensate the
initial reduction of blood pressure (1). Remifentanil
is an ultra-short acting opioid that has been frequently

Corresponding author: Dr. Mehdi Ghaemi, No. 10-5, Kosar 14 St., Niksazan, Zanjan, Iran, Zip Code: 45159-87495, Tel: +989121412478,
Fax: +2433131203, E-mails: ghaemi_mp@yahoo.com/mahiar@zums.ac.ir
Received: August 24, 2016; Revised: October 28, 2016; Accepted: November 3, 2016.
2017 by The Chinese Physiological Society and Airiti Press Inc. ISSN : 0304-4920. http://www.cps.org.tw
152 Ghaemi, Ansari and Amini

Chart 1: CONSORT Flow Diagram

Assessed for eligibility
Enrollment (n = 65)

Excluded (n = 11)
♦ Not meeting inclusion
criteria (n = 5)
♦ Declined to participate
(n = 6)
♦ Other reasons (n = 0)

Randomized (n = 54)

Allocation
Allocated to intervention Allocated to intervention
(Acupuncture) (n = 27) (Remifentanil) (n = 27)
♦ Received allocated intervention ♦ Received allocated intervention
(n = 27) (n = 27)
♦ Did not receive allocated ♦ Did not receive allocated
intervention (give reasons) intervention (give reasons)

Follow-Up

Lost to follow-up (give reasons) Lost to follow-up (give reasons)

(n = 0) (n = 0)
Discontinued intervention Discontinued intervention
(give reasons) (n = 0) (give reasons) (n = 0)

Analysis

Analysed (n = 27) Analysed (n = 27)

♦ Excluded from analysis (give ♦ Excluded from analysis (give
reasons) (n = 0) reasons) (n = 0)

used to induce controlled hypotension in the world
recently. Nevertheless, taking this drug in high doses
makes postoperative pain difficult to control and also
causes hyperalgesia (13).
In 1980, acupuncture was recommended as an
effective alternative therapy for 43 different disorders
by the World Health Organization. Autonomic nervous
system dysfunction was specified as one of the four
specific areas by this organization (7). Activation of
autonomic nervous system plays an important role in
controlling blood pressure. Acupuncture harmonizes
the body’s energy balance (2). Some studies have
demonstrated that electrical stimulation at DU20
(GV20 or Bai Hui) acupoint can prevent hypertension
in the body (2, 21). However, few studies have been
carried out to compare the effect of electroacupunc-
ture (EA) with other drugs used for hypotensive
anesthesia. The effect of EA at DU20 point was,
therefore, compared with that of remifentanil on
reducing blood pressure in the patients undergoing
lumbar laminectomy.
Materials and Methods
Subjects
This randomized controlled clinical trial
study was approved by the Ethics Committee of
Zanjan University of Medical Sciences; and re-
corded in Iranian Registry of Clinical Trials,
(IRCT201509213379N3).
Sampling Methods
Sample size was determined based on a pilot study
on 20 patients. Conventional sampling method was
utilized to select the research units. All the patients
candidate for lumbar laminectomy and met the in-
 Controlled Hypotension by Electroacupuncture at DU20 153
clusion criteria were enrolled in the study. Sampling
was continued until 27 patients were recruited in two
groups (Chart 1). Allocation of samples to two groups
was performed randomly using colored balls (white for
group A and black for group B).
Patients with American Society of Anesthesiol-
ogists (ASA) physical status 1 and 2, aged between
20-60, candidate for elective lumbar laminectomy were
enrolled in the study with informed written consent.
Patients taking anticoagulant or medications that impair
coagulation such as nonsteroidal anti-inflammatory
drugs (NSAIDs) and aspirin and patients with kidney,
liver or blood disease and those taking beta-blockers
and calcium-channel blockers were excluded.
Anesthetization
Patients received 7 ml/kg lactated Ringer's solution
and midazolam 0.03 µg/kg before anesthesia induction.
Induction of anesthesia was performed with fentanyl
2 µg/kg, propofol 2 mg/kg and atracurium 0.5 mg/kg.
All standard monitors of anesthesia were applied for
the patients. Maintenance of anesthesia was performed
for patients based on our usual experience, so that is-
oflurane was titrated to achieve bispectral index (BIS)
between 40-60. All the patients received morphine
0.05 mg/kg, bolus of atracurium 0.15 mg/kg every
20 min and were ventilated with mixture of oxygen
50% and N 2O 50%. Infusion of remifentanil 100
µg/kg/min for group (R), and EA at DU20 point for
group (A) were performed. If MAPs of the patients
were still higher than 65 mmHg after ten min, infu-
sion of nitroglycerin 5 µg/min would be started for
both groups. Bolus of fentanyl 1 µg/kg would be
given if tachycardia occurred.
EA
To perform EA, a sterile disposable needle with
a diameter of 3.0 mm and a length of 25 mm was
inserted subcutaneously and posteriorly to a depth
of 5-10 mm at DU20 point. The needle was then
connected to a generator with a frequency of 2-10 Hz
and intensity of 1-5 mA and whose intensity was adjusted
based on patient response. DU20 is located at the point
where the head’s midline meets the line connecting the
apexes of the ears and 5 cm above the anterior hairline.
The patients were put in prone position during surgery
and blood pressure, pulse rate, end-tidal concentration
of isoflurane, volume of blood lost, and the quality of
surgical field were all evaluated every 10 min. The
volume of blood lost was assessed based on the es-
timated blood in suction bottle, sponges, drapes and
gowns. The quality of surgical field was estimated by
surgeon using the scale adopted from that of Dolman
et al. (10):
"1- Minimal bleeding: not a surgical nuisance
2- Mild bleeding: but does not affect dissection
3- Moderate bleeding: slightly compromises
dissection
4- Severe bleeding: significantly compromises
dissection
5- Massive bleeding: prevent dissection"
Statistics
SPSS software version 16 was utilized for data
analysis. The Kolmogorov-Smirnov test was utilized
to examine the normality of curve of blood pressure
and heart rate of both groups. According to the results
of this test, blood pressure and heart rate curve were
normal in both groups; therefore parametric test and
analysis of variance (ANOVA) with Repeated
Measures were utilized to compare the trend of the
changes of heart rate and blood pressure within each
group and between the two groups. The Fisher exact
test, Chi-square, Independent t-tests were utilized
to compare the two groups based on demographic
factors and perioperative variables. In this study,
the level of statistical significance was set at P < 0.05.
Results
Fifty four patients were enrolled in the study in
two groups of 27 patients. Table 1 shows a comparison
of demographic and perioperative variables of the
patients in both groups.
The changes in MAPs and the changes in heart
rates of the patients during surgery of both groups of
A and R are displayed in Figures 1 and 2 respectively.
Repeated measures ANOVA demonstrated that
there was no statistically significant difference between
the two groups in terms of MAP and heart rate (P >
0.05). Nevertheless, blood pressure and heart rate
of patients over 11 measurements within the groups
were significantly different (P < 0.05) (Table 2).
Five patients in the remifentanil group and eight
patients in acupuncture group were in need of nitro-
glycerin injection with a dose of 5 mg/min. End-tidal
concentration of isoflurane for surgical anesthesia (BIS
40-60) was similar in both groups. No complications
were observed in the patients.
Discussion
This study showed that EA at DU20 point
can be as effective as remifentanil to reduce blood
pressure and create hypotensive anesthesia. The
number of the patients who were in need of further
nitroglycerin was similar in both groups. No
arrhythmias or severe fluctuation in blood pressures
and heart rates were observed. The surgical condi-
154 Ghaemi, Ansari and Amini

Table 1. Comparison of patient characteristics in remifentional (R) and acupuncture (A) groups
Group R* Group A∞
P-value
n = 27 n = 27
Age (yr) t = -0.088 39.2 ± 11.76 39.3 ± 7.9 P = 0.932
Male/female ratio X2 = 0.081 17/10 18/9 P = 0.776
Weight (kg) t = -1.756 68.3 ± 3.8 68.7 ± 4.5 P = 0.087
ASA** class ratio (Ι/ΙΙ) X2 = 0.920 19/8 20/7 P = 0.761
MAP t = 0.447 98.7 ± 11.4 101.1 ± 12.6 P = 0.657
Heart rate t = 0.781 84.2 ± 18.3 81.8 ± 15.2 P = 0.438
Duration of
67.4 ± 13.1 69 ± 15.6 t = 0.667 P = 0.508
surgery (min)
Surgery location X2 = 0.092 P = 0.761
L4 – L5 7 8
L 5 – S1 20 19
Surgical condition FETᶲ = 1.338 P = 0.582
1 7 5
2 15 17
3 5 6
4 0 0
5 0 0
Intraoperative
175.6 ± 43.2 182.1 ± 46.6 t = 0.789 P = 0.434
Blood loss (ml)
Transfusion
0 0
Frequency
R*: Remifentanil; A∞: Acupuncture; ASA**: American Society of Anesthesiology; FETᶲ: Fisher Exact Test

110.00 Acupuncture Acupuncture

85.00 Remifentanil
Remifentanil
Arterial Pressure (mmhg)

100.00
82.50
Pulse Rate

90.00 80.00

80.00 77.50

75.00
70.00
72.50
60.00
Baseline
Induction
Positioning
10 min
20 min
30 min
40 min
50 min
60 min
70 min
80 min
Baseline
Induction
Positioning
10 min
20 min
30 min
40 min
50 min
60 min
70 min
80 min

Time
Time
Fig. 2. Changes in trend of average heart rate in two groups.
Fig. 1. Changes in MAP of the patients during surgery in both
groups.
is not completely known yet. It has been reported
(18) that the EA increases the concentration of pe-
tion scores of most of the patients were between riarteriolar nitric oxide in hamsters. According to
1-3, which represented fairly bloodless surgical this study, hypertension would reduce endothelial
fields and surgeon satisfaction. nitric oxide synthase and neuronal nitric oxide syn-
The mechanism of EA reducing blood pressure thase. Another study (14) reported that therapeutic
 Controlled Hypotension by Electroacupuncture at DU20 155

Table 2. Changes in blood pressure and heart rate in 11 measurements of acupuncture (A) and remifentanil (R)
groups

Arterial blood pressure Heart rate

Group Time Standard Standard
Mean P-value Mean P-value
deviation deviation
Baseline 98.44 1.22 84.51 13.23
Induction 88.29 8.14 84.33 9.16
Positioning 85.70 8.14 79.62 10.18
10 min later 72.34 4.65 80.18 5.09
20 min later 69.25 4.07 76.85 4.07
F = 5.12 F = 4.576
A 30 min later 68.14 4.35 77.18 5.09
P = 0.000 P = 0.000
40 min later 67.55 4.07 74.85 4.07
50 min later 67.72 3.56 76.18 5.1
60 min later 65.35 4.03 74.88 3.05
70 min later 65.14 4.09 75.14 4.07
80 min later 64.38 3.11 75.85 4.11
Baseline 100.63 10.11 81.33 18.33
Induction 90.29 8.14 81.44 12.22
Positioning 86.74 7.12 80.66 9.16
10 min later 70.46 4.58 85.18 5.09
20 min later 67.28 3.05 75.77 6.11
F = 1.16 F = 3.622
R 30 min later 65.68 5.09 74.11 3.05
P = 0.000 P = 0.000
40 min later 65.55 4.07 75.85 4.07
50 min later 64.74 4.07 73.18 5.09
60 min later 63.38 3.13 72.85 4.07
70 min later 63.11 3.16 73.11 3.05
80 min later 62.88 3.06 72.85 4.08
P = 1.972, F = 0.166 P = 0.489 , F= 0.487

mechanism of acupuncture on hypertension induced nitroglycerin is facilitated by transcutaneous electrical

by stress is related to the changes in neuronal and
inducible nitric oxide synthase in the rostral ventro-
lateral medulla in rats.
Physiological effects of acupuncture on reducing
blood pressure which can be mentioned here include
(2, 8, 19, 25): [1] upregulation of endogenous opioids
that regulate other neurotransmitters such as noradrena-
line, dopamine and 5-hydroxytryptamine, therefore,
sympathetic activity and blood pressure are modulated,
[2] reduction of plasma renin activity by acupuncture
which can be related to γ-aminobutyric acid (GABA)
receptors activity in rostral ventrolateral medulla
and [3] reduction of peripheral resistance of small
arteries.
The conclusion of a study (15) indicated that blood
pressure begins to reduce 3 min after acupuncture, and
the onset of the therapeutic effect of acupuncture is
earlier than that of sublingual nifedipine. The result
of our study is in agreement with those of the two studies
demonstrated that transdermal electrical stimulation
of acupoint potentiates the isoflurane-induced hy-
potension (24), and blood pressure lowering effect of
stimulation at ST36 (Zusanli) point (22).
DU20 point, also called Governing Vessel or Hun-
dred Govergences, is one of the most common points of
acupuncture utilized for several purposes including
lowering of blood pressure. DU20 was one of the
acupoints stimulated in the study (2) to reduce blood
pressure in hypertensive patients. Another study (21)
demonstrated that warming acup-moxibustion at DU20
point and acupuncture at Siguan points can respectively
increase and decrease plasma content of nitric ox-
ide (NO) and enthelin (ET) to a certain degree and
reduce ET/NO ratio. This finding emphasizes that
the mechanism of acupuncture-moxibustion for re-
ducing blood pressure in the patients with essential
hypertension depends on the two-way regulation
function of the vascular endothelial cells.
To shed more light on the mechanism of acupunc-
ture, we need to elaborate more on it. The essence
of meridian system is important in the study of acu-
puncture mechanism. "The meridian system has been
designated as the complex network of neurovascular
bundles and their smaller branches of fractal continuum.
156 Ghaemi, Ansari and Amini
The key properties of this network can be charac-
terized by its distributed electromagnetic dynamic
variables of conductance, resistance, inductance and
capacitance" (4). According to traditional Chinese
medicine, all organs of the human body including the
viscera in the internal part and the limbs and sensory
organs in the external part are connected together
through this network and they cannot be treated alone
clinically. In acupuncture, if the properties of neuro-
vascular bundles are adjusted in the right place at the
right time, the normal physiologic state of the body will
be restored. The injury current caused by a needling
at an acupoint triggers electromagnetic inductive effects
and changes the impedances of correlated neurovascular
bundles (5). The way how acupuncture works can be
explained by the match/mismatch of the impedances
of the meridian system. For instance, "the mechanism
of acupuncture in treating hypotension and hyper-
tension are that needling in the right meridian at the
right time can change the impedance of neurovascular
bundles so that blood flow can be regulated" (6).
One of the limitations of this study was that we
could not figure out if EA has any effects on pain control
because there is no specific sign under general anesthesia
to help us evaluate patients' pain signs and also because
drugs especially analgesics obscure the signs. Given
these possibilities, we postulate that EA at DU20 might
have analgesic effect and thus it can also control blood
pressure indirectly.
In conclusion, EA is effective for hypotensive
anesthesia and the use of it can reduce or eliminate
the side effects of antihypertensive drugs, therefore,
EA is recommended as an appropriate replacement
for pressure-lowering drugs to induce controlled
hypotension.
Conflict of Interest
The authors declared no conflicts of interest.
Acknowledgments
The authors would like to express their gratitude
to Dr. Babak Mahbubi for his cooperation as well as the
vice- chancellery for research of Zanjan university of
Medical Sciences for funding this study with the grant
number of A-11-700-1.
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