{"paper_id":"024892ea-7795-478c-871a-42b35f88b4bc","body_text":"Transcutaneous ST6 Stimulation Versus Shoulder Tapping on Laryngeal Mask Airway Removal in Pediatric Patients: A Randomized Controlled Trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Transcutaneous ST6 Stimulation Versus Shoulder Tapping on Laryngeal Mask Airway Removal in Pediatric Patients: A Randomized Controlled Trial Jun Hu, Yanmin Sun, Fenfen Kou, Ping Zhao, Jianhui Ma, Yanhua Luo, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7641523/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Extubation timing is crucial in pediatric anesthesia recovery to avoid complications such as hypoxia and laryngospasm. Non-pharmacological techniques that stimulate arousal and respiration could aid in timely and safe removal of airway devices. This study evaluated whether applying pressure at the jaw angle (masseter region corresponding to the ST6 acupoint) would hasten emergence from anesthesia and improve the safety and efficiency of laryngeal mask airway (LMA) removal in children. Methods In this randomized controlled trial, 175 ASA I children (ages 1–12) undergoing elective laparoscopic hernia repair with a laryngeal mask airway (LMA) were allocated 1:1 to jaw-angle (ST6) stimulation or gentle shoulder tapping (control) during emergence. Anesthesia was standardized: induction with sufentanil 0.3 µg/kg, propofol 3 mg/kg, and cisatracurium 0.15 mg/kg; maintenance with propofol–remifentanil titrated to BIS 40–60. At surgery end, all anesthetics were stopped; after spontaneous breathing returned, the intervention group received repeated bilateral 5-second firm presses at the jaw angles (~ 1.5 kg force) and controls received shoulder taps of similar force. Extubation (LMA removal) occurred at eye opening or purposeful movement. The primary outcome was extubation time (T1–T0: first stimulation to LMA removal). Secondary outcomes were change in BIS from start of stimulation to extubation and the incidence of adverse events (coughing, agitation, hypoxemia, laryngospasm, aspiration). Results Baseline characteristics were similar between the ST6 stimulation group (n = 86) and control group (n = 89). Extubation was significantly faster with ST6 stimulation, with a median time of 7.2 minutes (IQR 5.7–9.3) versus 13.3 minutes (11.9–15.7) in controls ( P < 0.001). The intervention group also had a greater increase in BIS during emergence (median ΔBIS + 9.0 vs + 4.0, P < 0.001), indicating higher arousal at extubation. Kaplan–Meier analysis confirmed a shorter time to extubation with intervention (log-rank P < 0.001). In a multivariate Weibull regression adjusting for age, BMI, and anesthesia duration, ST6 stimulation reduced extubation time by approximately 37% (time ratio 0.63, 95% CI 0.56–0.69, P < 0.001) compared to control. Fewer participants in the ST6 stimulation group experienced coughing (10% vs 22%, P = 0.033) or emergence agitation (8% vs 19%, P = 0.035). The incidence of hypoxemia was low and similar between groups (7% vs 6%, P = 0.71). No laryngospasm or aspiration occurred in either group. Conclusions Targeted bilateral jaw angle pressure (ST6 acupoint stimulation) significantly shortened LMA removal time in children without increasing adverse events. This simple technique may serve as a useful non-pharmacological adjunct to enhance pediatric anesthesia recovery, potentially complementing conventional Enhanced Recovery After Surgery (ERAS) strategies. Trial registration: International Traditional Medicine Clinical Trial Registry, http://itmctr.ccebtcm.org.cn,ITMCTR2024000464 (registered on 13 September 2024). Trigeminal nerve Laryngeal mask airway Airway extubation Anesthesia recovery Child Physical stimulation Emergence delirium General anesthesia Pediatric anesthesia Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Children are particularly prone to respiratory depression and hypoxemia after removal of airway devices due to unique physiological and developmental factors[ 1 ]. Determining the optimal timing for LMA removal in pediatric patients remains a challenge for anesthesiologists[ 2 ]. Extubation (removal of an LMA or endotracheal tube) can be performed when the patient is awake or under deep anesthesia[ 3 ]. Awake extubation requires the child to be fully conscious with intact airway protective reflexes and spontaneous breathing. This approach is common but can provoke marked stress responses, including significant coughing and agitation in children. Deep extubation (removing the airway device while the patient is still deeply anesthetized) avoids immediate airway reflex stimulation; however, if done prematurely it risks hypoventilation and carbon dioxide retention, necessitating rescue ventilation support. There is currently no perfect method to decide between awake and deep extubation in children, and more objective indicators are needed to guide extubation timing in pediatric anesthesia. In practice, anesthesiologists often use gentle physical stimulation (calling the child’s name or tapping the shoulder) to encourage emergence. We hypothesized that a more targeted stimulus might more effectively provoke the return of consciousness and respiratory effort. The jaw angle region over the masseter muscle was selected as the stimulation site because pressure there produces a pronounced sensation. This location(one finger-breadth anterior and superior to the lower angle of the mandible, at the prominence of the masseter muscle when the teeth are clenched) corresponds to the acupuncture point “Jiache” (ST6) and is innervated by the mandibular branch of the trigeminal nerve[ 4 , 5 ]. Notably, applying painful pressure to specific points has precedent in anesthesia—for example, pressing the “laryngospasm notch” behind the earlobe can help break laryngospasm via a trigeminal-vagal reflex[ 6 ]. We theorized that a similar concept could expedite awakening in anesthetized children. To date, ST6 acupoint stimulation has not been well studied as a cue or aid for extubation readiness, especially in pediatric patients. We therefore conducted a randomized controlled trial to evaluate whether bilateral pressure at ST6 could safely shorten extubation time in children recovering from anesthesia. We also assessed whether this intervention would impact the incidence of common emergence complications such as hypoxemia, coughing, and agitation, compared to standard gentle stimulation. Methods Study design This study was a single-center, parallel-group randomized controlled trial. All procedures performed in this study conformed to the ethical guidelines of the Declaration of Helsinki, and ethical approval for this study (No. KYLL20240729-2) was provided by the Ethics Committee of Weifang People’s Hospital, Shandong, China on July 29, 2024. The trial was registered in the International Traditional Medicine Clinical Trial Registry (ITMCTR2024000464) on 13 September 2024. Written informed consent was obtained from the parents or legal guardians of all participants. The trial adhered to the CONSORT guidelines for randomized trials. Participants Pediatric patients scheduled for elective laparoscopic hernia repair at Weifang People’s Hospital from October 2024 to March 2025 were screened against the following criteria: Inclusion : Age 1–12 years; American Society of Anesthesiologists (ASA) physical status I (healthy, no systemic disease). Exclusion : Recent upper respiratory infection within 2 weeks; significant cardiac or pulmonary dysfunction; contraindications to facial pressure stimulation (e.g. local cheek infection or neurologic disorder affecting the face); loose teeth in the jaw area (to avoid risk of tooth dislodgement). A total of 186 children met the initial criteria and were enrolled. Participants were randomly assigned 1:1 to the intervention or control group using a random-number table. After enrollment, 11 patients were excluded prior to analysis: four in the intervention group had loose teeth and did not receive stimulation, three in the intervention group and four in the control group did not meet extubation criteria within 20 minutes after surgery and were withdrawn. Ultimately, 175 children completed the trial and were included in the analysis (86 in the ST6 stimulation group and 89 in the control group). All anesthetic procedures and interventions were performed by the same experienced anesthesiologist to ensure consistency, although this provider was necessarily aware of group assignments. Anesthesia and monitoring All patients underwent standardized general anesthesia with an LMA. Anesthesia was induced with sufentanil 0.3 µg/kg, propofol 3 mg/kg, and cisatracurium 0.15 mg/kg. After LMA placement, anesthesia was maintained with a continuous infusion of propofol combined with remifentanil (approximately 0.2 µg/kg/min) using target-controlled infusion. Depth of anesthesia was monitored via the bispectral index (BIS), adjusting infusion rates to maintain BIS 40–60. Patients were ventilated with pressure-controlled mode, and standard monitors (electrocardiogram, pulse oximetry, capnography, and noninvasive blood pressure) were applied throughout. Interventions At the completion of surgery, all anesthetic agents were discontinued and the child was allowed to resume spontaneous breathing. The assigned tactile stimulation was then initiated during emergence: ST6 acupoint stimulation (intervention) : The anesthesiologist applied intermittent firm pressure with the middle finger to each of the child’s ST6 acupoints (bilateral jaw angles). Each press lasted ~ 5 seconds with up to 1.5 kg of force, guided by prior pediatric acupressure studies[ 7 , 8 ]. For younger or smaller patients, pressure was adjusted to a tolerable level. Presses were repeated every few seconds until the child showed signs of awakening. Shoulder tapping (control) : The anesthesiologist delivered gentle taps to the child’s shoulders with force similar to that used in the intervention – a common method to rouse patients during recovery. If the child opened eyes, grimaced, or made a purposeful movement (e.g. raising an arm or turning the head) indicating return of consciousness and airway tone, the LMA was promptly removed. The time of first stimulation was recorded as T0, and the time of successful LMA removal was T1. The difference (T1–T0) was defined as the extubation time. If a patient did not meet criteria for extubation within 20 minutes after starting stimulation, the protocol dictated that the airway would be managed as clinically appropriate and the patient would be withdrawn from the study analysis. Outcomes and data collection Primary outcome Extubation time (minutes), defined for each patient as the interval from T0 (first stimulation) to T1 (LMA removal). Secondary outcomes : - Change in BIS : The BIS value was recorded at T0 (immediately before beginning stimulation) and at T1 (just before extubation). The difference (ΔBIS = T1 value − T0 value) was calculated to quantify the increase in level of consciousness during emergence. - Emergence adverse events : From the start of stimulation until shortly after extubation, an observer (blinded to group) recorded any occurrence of the following events: - Hypoxemia : peripheral oxygen saturation (SpO₂) < 90% at any point during the extubation process. - Coughing : sustained cough occurring within 5 minutes after LMA removal. - Agitation : significant emergence agitation or delirium, defined as a Pediatric Anesthesia Emergence Delirium (PAED) scale score ≥ 10. - Laryngospasm : evidence of partial or complete airway obstruction (e.g. stridor) requiring intervention. - Aspiration : any sign of gastric contents in the airway (e.g. visible regurgitation with clinical evidence of aspiration). Any adverse events were treated immediately per standard protocols and documented. Statistical analysis The sample size was calculated for the time-to-event outcome of laryngeal mask airway removal. Based on our pilot study, a hazard ratio (HR) of 0.64 was used for the calculation. With 80% power at a two-sided alpha of 0.05, 160 events were required, as determined using the Cox proportional hazards model in PASS software. Allowing for a 15% attrition rate, a total of 186 participants were planned. Statistical analysis was performed using R version 4.4.3 (R Foundation for Statistical Computing). Continuous variables were tested for normality. Normally distributed data are reported as mean ± standard deviation (SD) and compared between groups with independent-samples t tests. Non-normally distributed data are reported as median with interquartile range (IQR) and compared with the Mann–Whitney U test. Categorical variables (e.g. incidence of adverse events, sex distribution) are summarized as count (percentage) and compared using Pearson’s chi-square or Fisher’s exact test, as appropriate. Time-to-event methods were also applied to the primary outcome (extubation time). A Kaplan–Meier curve was constructed for time from T0 to extubation in each group and compared using the log-rank test. Additionally, a parametric survival regression (Weibull distribution) was used to estimate the effect of the intervention on extubation time while adjusting for potential confounders. Three models were specified: Model 1 included only group (ST6 stimulation vs. control); Model 2 included group plus patient age, sex, and BMI; Model 3 included group plus age, sex, BMI, and duration of anesthesia. From these models, we report the estimated time ratio (TR) for the intervention (ST6 stimulation) relative to control, with TR < 1 indicating a reduction in extubation time. Two-sided P < 0.05 was considered statistically significant for all analyses. Results Participant characteristics A total of 175 children were included in the final analysis (Fig. 1 ). Of these, 86 were allocated to the ST6 stimulation group and 89 to the shoulder tapping control group. The two groups were comparable in baseline demographics (Table 1 ). There were no significant differences between intervention and control in age (median 5.5 vs 5.0 years), sex distribution (79% vs 83% male), body mass index (BMI), or anesthesia duration (all P > 0.1). Table 1 Patient Demographics and Baseline Characteristics Experimental Group (n = 86) Control Group (n = 89) P -value Sex (male%) 68 (79.1%) 74 (83.1%) 0.620 Age (year) 5.5 (3.0, 8.0) 5.0 (3.0, 8.0) 0.411 BMI (kg/m 2 ) 15.4 (14.6, 16.4) 15.9 (14.3, 17.4) 0.231 Anesthesia Time (min) 35.4 (24.3, 45.0) 37.2 (28.8, 48.0) 0.162 Extubation Time (min) 7.2 (5.7, 9.3) 13.3 (11.9, 15.7) < 0.001 BIS Change (number) 9.0 (5.2, 12.0) 4.0 (3.0, 6.0) < 0.001 Values are presented as median (interquartile range) or number (%). Experimental Group: ST6 stimulation intervention; Control Group: Shoulder tapping. Abbreviations: BMI, body mass index; BIS, bispectral index. Extubation time and BIS change The ST6 stimulation resulted in markedly faster LMA removal compared to control. The median time from first stimulus to extubation was 7.2 minutes (IQR 5.7–9.3) in the ST6 stimulation group versus 13.3 minutes (IQR 11.9–15.7) in the control group (Mann–Whitney U test, P < 0.001) (Table 1 ). Correspondingly, children in the intervention group achieved a greater rise in BIS during emergence. The median increase in BIS (ΔBIS) from start of stimulation to extubation was + 9.0 in the ST6 stimulation group, significantly higher than the + 4.0 median change in controls ( P < 0.001) (Table 1 , Fig. 2 ). This indicates that targeted trigeminal nerve pressure produced a faster arousal from the anesthetized state. Time-to-event analysis Figure 3 illustrates the cumulative proportion of children extubated over time in each group. The Kaplan–Meier curves diverged early, with the ST6 stimulation group consistently extubating more quickly; the difference between groups was highly significant (log-rank P < 0.001). Even after controlling for other factors, the benefit of the intervention persisted. In the multivariate Weibull regression, the ST6 stimulation group had a significantly shorter extubation time across all models. In the fully adjusted model (controlling for age, sex, BMI, and anesthesia duration), the intervention was associated with a time ratio of 0.626 (95% CI 0.563–0.694, P < 0.001) (Table 2 ). This corresponds to approximately a 37% reduction in extubation time relative to the control condition. Table 2 Univariate and multivariate analysis using the Weibull regression model Time Ratio (95% CI ) P -value Model 1 0.643 (0.579, 0.715) < 0.001 Model 2 0.646 (0.580, 0.720) < 0.001 Model 3 0.626 (0.563, 0.694) < 0.001 Time Ratio (TR) < 1 indicates shorter extubation time. Model 1: Adjusted for intervention only; Model 2: Adjusted for intervention, age, sex, and BMI; Model 3: Adjusted for Model 2 covariates plus anesthesia duration. Adverse events The incidence of adverse emergence events is summarized in Table 3 . Notably, the ST6 stimulation group experienced fewer respiratory and emergence-related complications compared to controls. Only 9 of 86 children (10.5%) in the intervention group had an episode of coughing, versus 20 of 89 (22.5%) in the control group ( P = 0.033). Similarly, significant agitation (PAED score ≥ 10) was observed in 7 patients (8.1%) in the intervention group compared to 17 (19.1%) in controls ( P = 0.035). Rates of hypoxemia were low in both groups (6.9% vs 5.6%, P = 0.711). Importantly, there were no instances of laryngospasm or aspiration in either group during the study (Table 3 , Fig. 4 ). Table 3 The incidence of adverse outcomes includes hypoxemia, laryngospasm, coughing, agitation, and aspiration Experimental Group (n = 86) Control Group (n = 89) P -value Coughing (%) 10.5 22.5 0.033 Agitation (%) 8.1 19.1 0.035 Hypoxemia (%) 6.9 5.6 0.711 Aspiration (%) 0 0 - Laryngospasm (%) 0 0 - Values are presented as number of events (%). Experimental Group: ST6 stimulation; Control Group: Shoulder tapping. Discussion In this randomized trial, targeted stimulation of the ST6 acupoints significantly hastened emergence from anesthesia in pediatric patients, as evidenced by a roughly 6-minute reduction in median extubation time. Importantly, this intervention did not compromise safety; on the contrary, children receiving ST6 stimulation had lower frequencies of coughing and emergence agitation compared to those who received standard gentle tapping. These findings suggest that focused stimulation at the jaw angle can improve both the efficiency and quality of recovery in children after anesthesia. Given that emergence delirium and coughing are common challenges in pediatric anesthetic recovery, an intervention that reduces these events while speeding awakening is particularly valuable[ 9 , 10 ]. The concept of using point pressure to influence anesthesia emergence is supported by both traditional practice and neurophysiological evidence[ 4 ]. Pressing on the ST6 region produces a strong, diffuse acupressure sensation, likely via synergistic peripheral receptor activation and central neural integration. The ST6 point lies in the belly of the masseter, a region densely innervated by the trigeminal nerve. Applying approximately 1.5 kg of pressure can simultaneously activate mechanoreceptors and nociceptors in the deep muscle tissue, generating high-intensity, multimodal afferent signals[ 11 , 12 ]. These signals ascend via the trigeminal nerve to the brainstem sensory nuclei, where they converge with other craniofacial inputs and undergo extensive synaptic integration[ 13 ]. Such central processing leads to a widespread neural activation that produces a referred aching sensation beyond the stimulus site. This intense afferent barrage may underlie the arousal effect observed with ST6 stimulation. Consistent with this mechanism, we observed a greater BIS increase in the stimulation group, reflecting enhanced cortical arousal from trigeminal activation. Prior studies on acupuncture have shown that sensory stimulation at specific points can modulate neurotransmitters and neural pathways involved in consciousness and autonomic function[ 14 ]. For instance, acupressure and acupuncture techniques have been reported to aid recovery of consciousness in patients with traumatic brain injury and to improve postoperative recovery quality[ 15 – 17 ]. Pressing the Neiguan (PC6) point on the wrist is a well-known example—this maneuver effectively reduces postoperative nausea and vomiting and is an accepted adjunct in anesthesia care[ 18 – 21 ]. Similarly, our study provides evidence that stimulating a point on the face can beneficially influence emergence from anesthesia. Using a physical stimulus as a determinant for extubation readiness is further justified by practical considerations. Common criteria for awake extubation in children include signs like facial grimace, eye opening, purposeful movement, adequate tidal volume, and responsiveness to stimulation[ 22 ]. In some situations these signs may be difficult to observe—for example, after certain surgeries (such as pediatric ophthalmic procedures where the eyes are covered by dressings) it can be challenging to judge the appropriate timing for extubation[ 23 ]. In such cases, an external stimulus that elicits a clear movement response can serve as an objective indicator of consciousness. The ST6 pressure technique described here typically induces a reflex head withdrawal or limb motion in response to the jaw pain stimulus, signaling that the child has regained sufficient protective reflexes to safely remove the airway device. Moreover, this technique is simple, quick, and requires no special equipment, underscoring its clinical practicality. It essentially leverages the patient’s own nervous system to indicate readiness for extubation. An analogy can be drawn to the established “laryngospasm notch” maneuver: a vigorous push at a spot just behind the jaw (near the earlobe) is known to relieve laryngospasm during extubation[ 6 ]. Both techniques rely on intense peripheral stimulation to elicit a beneficial reflex—one to break glottic closure (via cranial nerve pathways that relax the vocal cords), and in our case to provoke awakening. Several limitations of our study should be acknowledged. First, this was a single-center study in a relatively controlled surgical context (short procedures in ASA I children). The results may not generalize to higher-risk patients, other surgical types, or settings with different anesthetic protocols. Second, while we standardized the applied pressure (~ 1.5 kg) based on prior literature, the optimal intensity and frequency of stimulation for different ages or deeper anesthesia levels was not determined. It is possible that older children or those in a heavier anesthetic state might benefit from a different stimulation intensity or timing; future studies could explore the dose-response relationship for this stimulation. Lastly, we focused on immediate recovery endpoints and did not assess longer-term outcomes such as post-anesthesia behavioral changes or cognitive recovery. It would be worthwhile to examine in future research whether this intervention has any impact—positive or negative—on longer-term recovery parameters. Despite these limitations, our trial provides novel evidence supporting a low-cost, non-pharmacological strategy to enhance pediatric anesthesia recovery. By translating a concept rooted in traditional practice into modern clinical care, we have shown that stimulating a trigeminal nerve reflex can effectively address a long-standing challenge in anesthesiology. This approach fits well within the framework of multimodal ERAS (Enhanced Recovery After Surgery) pathways, which aim to accelerate recovery while maintaining safety. The ST6 pressure technique requires minimal training and no equipment, and it caused no complications in our study, making it an attractive option to incorporate into pediatric anesthetic practice. As healthcare systems continue to prioritize interventions that improve outcomes without adding cost or risk, such simple techniques warrant attention[ 24 ]. Future studies using advanced monitoring (e.g. electroencephalography or functional neuroimaging) could further elucidate the neurobiological mechanisms by which trigeminal nerve stimulation affects arousal and recovery. Conclusions Applying targeted pressure to the ST6 acupoints is a safe and effective adjunct for accelerating the return of consciousness and facilitating airway device removal in pediatric anesthesia. This technique leverages well-defined neurophysiological pathways to hasten awakening without pharmacological intervention. Implementing such a simple maneuver can improve extubation timing and may enhance overall recovery quality in children, demonstrating how non-drug interventions can complement standard anesthetic practice. Abbreviations • ASA American Society of Anesthesiologists • BIS Bispectral index • BMI Body mass index • ERAS Enhanced Recovery After Surgery • LMA Laryngeal mask airway • PAED Pediatric Anesthesia Emergence Delirium • SpO₂ Peripheral oxygen saturation Declarations Ethics approval and consent to participate: All procedures performed in this study conformed to the ethical guidelines of the Declaration of Helsinki, and ethical approval for this study (No. KYLL20240729-2) was provided by the Ethics Committee of Weifang People’s Hospital, Shandong, China on July 29, 2024. Written informed consent was obtained from the parents or legal guardians of all participants. Consent for publication: Not applicable. Availability of data and materials: The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: This research received no external funding. Authors’ contributions: Zhang and Sun collected the clinical data and drafted the initial manuscript. Kou and Luo performed the statistical analysis. Ma,Zhao and Lang provided expertise in anesthesiology, supervised patient management, and assisted with data collection. Hu conceived and designed the study, oversaw study execution, and critically revised the manuscript. All authors read and approved the final version of the manuscript. Acknowledgements: The authors thank the entire surgical and anesthesia team at Weifang People’s Hospital for their support in conducting this trial. We are also grateful to the post-anesthesia care unit nurses and staff for their assistance with patient monitoring and data recording. Finally, we thank our colleagues for their valuable suggestions and help in manuscript editing. References Abbasi S, Siddiqui KM, Qamar-Ul-Hoda M. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-7641523\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":538558007,\"identity\":\"8f51c1e0-9529-44eb-9a7c-c2c102f8825f\",\"order_by\":0,\"name\":\"Jun Hu\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Weifang People's Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Jun\",\"middleName\":\"\",\"lastName\":\"Hu\",\"suffix\":\"\"},{\"id\":538558008,\"identity\":\"608e8c92-fa45-45a7-a1e4-40ada1ea8e83\",\"order_by\":1,\"name\":\"Yanmin 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05:36:09\",\"extension\":\"html\",\"order_by\":13,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":90956,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"earlyproof.html\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7641523/v1/61d65052295fc7111d733e88.html\"},{\"id\":94981311,\"identity\":\"af722a13-a5e6-4c76-9f87-7d70fc44a46f\",\"added_by\":\"auto\",\"created_at\":\"2025-11-03 05:36:08\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":23904,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eFlowchart of participant inclusion and exclusion\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"image1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7641523/v1/328dc97843fd43ad83389909.png\"},{\"id\":94988601,\"identity\":\"c6f82fd2-0383-4f35-8680-8d5d54e50212\",\"added_by\":\"auto\",\"created_at\":\"2025-11-03 07:10:04\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":83802,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eThe change in BIS value at the time of tracheal extubation.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eP\\u003c/em\\u003e-value derived from Mann-Whitney U test.\\u003c/p\\u003e\\n\\u003cp\\u003eAbbreviations: BIS, bispectral index.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"image2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7641523/v1/027d789d7bc2ed4bb34571aa.png\"},{\"id\":94988874,\"identity\":\"3feced0d-0632-4ac7-907e-70a3c34474d7\",\"added_by\":\"auto\",\"created_at\":\"2025-11-03 07:11:14\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":39145,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eComparison of the overall difference in extubation time between the two groups using Kaplan-Meier curves and log-rank tests\\u003c/p\\u003e\\n\\u003cp\\u003eKaplan–Meier curves for time from first stimulation (T0) to extubation (LMA removal) in the two groups. The ST6 stimulation group exhibited significantly faster extubation times (log-rank \\u003cem\\u003eP\\u003c/em\\u003e \\u0026lt; 0.001).\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"image3.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7641523/v1/eb56830c4b25b432b37d57a3.png\"},{\"id\":94981324,\"identity\":\"20c12a67-d018-4bda-b62e-efcea0ee0c3c\",\"added_by\":\"auto\",\"created_at\":\"2025-11-03 05:36:09\",\"extension\":\"jpeg\",\"order_by\":4,\"title\":\"Figure 4\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":38082,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eComparison of adverse outcome incidence rates between two groups.\\u003c/p\\u003e\\n\\u003cp\\u003eCoughing:*\\u003cem\\u003eP\\u003c/em\\u003e=0.033, Agitation:**\\u003cem\\u003eP\\u003c/em\\u003e = 0.035, Hypoxemia:***\\u003cem\\u003eP\\u003c/em\\u003e = 0.71. \\u003cem\\u003eP\\u003c/em\\u003e-values derived from Pearson's chi-square test (coughing, agitation) and Fisher's exact test (hypoxemia).No laryngospasm or aspiration occurred in either group.\\u003c/p\\u003e\\n\\u003cp\\u003eExperimental Group: ST6 stimulation; Control Group: Shoulder tapping.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"image4.jpeg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7641523/v1/b183d7d0ef18f75fa2789bbe.jpeg\"},{\"id\":95800139,\"identity\":\"ad9a5e2d-15db-456c-a964-4643cb331ebf\",\"added_by\":\"auto\",\"created_at\":\"2025-11-13 08:21:42\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":938723,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7641523/v1/67daff3e-84c5-4a7b-9317-53a9972d33ce.pdf\"},{\"id\":94981312,\"identity\":\"cf0f3ffb-2a68-46aa-a68e-583e8839a58b\",\"added_by\":\"auto\",\"created_at\":\"2025-11-03 05:36:08\",\"extension\":\"jpg\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":155788,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"JiacheAcupointST6.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7641523/v1/3d277dbb1fe4671a59ab7457.jpg\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Transcutaneous ST6 Stimulation Versus Shoulder Tapping on Laryngeal Mask Airway Removal in Pediatric Patients: A Randomized Controlled Trial\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eChildren are particularly prone to respiratory depression and hypoxemia after removal of airway devices due to unique physiological and developmental factors[\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]. Determining the optimal timing for LMA removal in pediatric patients remains a challenge for anesthesiologists[\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]. Extubation (removal of an LMA or endotracheal tube) can be performed when the patient is awake or under deep anesthesia[\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eAwake extubation requires the child to be fully conscious with intact airway protective reflexes and spontaneous breathing. This approach is common but can provoke marked stress responses, including significant coughing and agitation in children. Deep extubation (removing the airway device while the patient is still deeply anesthetized) avoids immediate airway reflex stimulation; however, if done prematurely it risks hypoventilation and carbon dioxide retention, necessitating rescue ventilation support. There is currently no perfect method to decide between awake and deep extubation in children, and more objective indicators are needed to guide extubation timing in pediatric anesthesia.\\u003c/p\\u003e\\u003cp\\u003eIn practice, anesthesiologists often use gentle physical stimulation (calling the child\\u0026rsquo;s name or tapping the shoulder) to encourage emergence. We hypothesized that a more targeted stimulus might more effectively provoke the return of consciousness and respiratory effort. The jaw angle region over the masseter muscle was selected as the stimulation site because pressure there produces a pronounced sensation. This location(one finger-breadth anterior and superior to the lower angle of the mandible, at the prominence of the masseter muscle when the teeth are clenched) corresponds to the acupuncture point \\u0026ldquo;Jiache\\u0026rdquo; (ST6) and is innervated by the mandibular branch of the trigeminal nerve[\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]. Notably, applying painful pressure to specific points has precedent in anesthesia\\u0026mdash;for example, pressing the \\u0026ldquo;laryngospasm notch\\u0026rdquo; behind the earlobe can help break laryngospasm via a trigeminal-vagal reflex[\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]. We theorized that a similar concept could expedite awakening in anesthetized children.\\u003c/p\\u003e\\u003cp\\u003eTo date, ST6 acupoint stimulation has not been well studied as a cue or aid for extubation readiness, especially in pediatric patients. We therefore conducted a randomized controlled trial to evaluate whether bilateral pressure at ST6 could safely shorten extubation time in children recovering from anesthesia. We also assessed whether this intervention would impact the incidence of common emergence complications such as hypoxemia, coughing, and agitation, compared to standard gentle stimulation.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eStudy design\\u003c/h2\\u003e\\u003cp\\u003eThis study was a single-center, parallel-group randomized controlled trial. All procedures performed in this study conformed to the ethical guidelines of the Declaration of Helsinki, and ethical approval for this study (No. KYLL20240729-2) was provided by the Ethics Committee of Weifang People\\u0026rsquo;s Hospital, Shandong, China on July 29, 2024. The trial was registered in the International Traditional Medicine Clinical Trial Registry (ITMCTR2024000464) on 13 September 2024. Written informed consent was obtained from the parents or legal guardians of all participants. The trial adhered to the CONSORT guidelines for randomized trials.\\u003c/p\\u003e\\u003c/div\\u003e\\n\\u003ch3\\u003eParticipants\\u003c/h3\\u003e\\n\\u003cp\\u003ePediatric patients scheduled for elective laparoscopic hernia repair at Weifang People\\u0026rsquo;s Hospital from October 2024 to March 2025 were screened against the following criteria:\\u003c/p\\u003e\\u003cp\\u003e\\u003cul\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eInclusion\\u003c/b\\u003e: Age 1\\u0026ndash;12 years; American Society of Anesthesiologists (ASA) physical status I (healthy, no systemic disease).\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eExclusion\\u003c/b\\u003e: Recent upper respiratory infection within 2 weeks; significant cardiac or pulmonary dysfunction; contraindications to facial pressure stimulation (e.g. local cheek infection or neurologic disorder affecting the face); loose teeth in the jaw area (to avoid risk of tooth dislodgement).\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/ul\\u003e\\u003c/p\\u003e\\u003cp\\u003eA total of 186 children met the initial criteria and were enrolled. Participants were randomly assigned 1:1 to the intervention or control group using a random-number table. After enrollment, 11 patients were excluded prior to analysis: four in the intervention group had loose teeth and did not receive stimulation, three in the intervention group and four in the control group did not meet extubation criteria within 20 minutes after surgery and were withdrawn. Ultimately, 175 children completed the trial and were included in the analysis (86 in the ST6 stimulation group and 89 in the control group). All anesthetic procedures and interventions were performed by the same experienced anesthesiologist to ensure consistency, although this provider was necessarily aware of group assignments.\\u003c/p\\u003e\\n\\u003ch3\\u003eAnesthesia and monitoring\\u003c/h3\\u003e\\n\\u003cp\\u003eAll patients underwent standardized general anesthesia with an LMA. Anesthesia was induced with sufentanil 0.3 \\u0026micro;g/kg, propofol 3 mg/kg, and cisatracurium 0.15 mg/kg. After LMA placement, anesthesia was maintained with a continuous infusion of propofol combined with remifentanil (approximately 0.2 \\u0026micro;g/kg/min) using target-controlled infusion. Depth of anesthesia was monitored via the bispectral index (BIS), adjusting infusion rates to maintain BIS 40\\u0026ndash;60. Patients were ventilated with pressure-controlled mode, and standard monitors (electrocardiogram, pulse oximetry, capnography, and noninvasive blood pressure) were applied throughout.\\u003c/p\\u003e\\n\\u003ch3\\u003eInterventions\\u003c/h3\\u003e\\n\\u003cp\\u003eAt the completion of surgery, all anesthetic agents were discontinued and the child was allowed to resume spontaneous breathing. The assigned tactile stimulation was then initiated during emergence:\\u003c/p\\u003e\\u003cp\\u003e\\u003cul\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eST6 acupoint stimulation (intervention)\\u003c/b\\u003e: The anesthesiologist applied intermittent firm pressure with the middle finger to each of the child\\u0026rsquo;s ST6 acupoints (bilateral jaw angles). Each press lasted\\u0026thinsp;~\\u0026thinsp;5 seconds with up to 1.5 kg of force, guided by prior pediatric acupressure studies[\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]. For younger or smaller patients, pressure was adjusted to a tolerable level. Presses were repeated every few seconds until the child showed signs of awakening.\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eShoulder tapping (control)\\u003c/b\\u003e: The anesthesiologist delivered gentle taps to the child\\u0026rsquo;s shoulders with force similar to that used in the intervention \\u0026ndash; a common method to rouse patients during recovery.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/ul\\u003e\\u003c/p\\u003e\\u003cp\\u003eIf the child opened eyes, grimaced, or made a purposeful movement (e.g. raising an arm or turning the head) indicating return of consciousness and airway tone, the LMA was promptly removed. The time of first stimulation was recorded as T0, and the time of successful LMA removal was T1. The difference (T1\\u0026ndash;T0) was defined as the extubation time. If a patient did not meet criteria for extubation within 20 minutes after starting stimulation, the protocol dictated that the airway would be managed as clinically appropriate and the patient would be withdrawn from the study analysis.\\u003c/p\\u003e\\n\\u003ch3\\u003eOutcomes and data collection\\u003c/h3\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003ePrimary outcome\\u003c/strong\\u003e\\u003cp\\u003eExtubation time (minutes), defined for each patient as the interval from T0 (first stimulation) to T1 (LMA removal).\\u003c/p\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eSecondary outcomes\\u003c/b\\u003e: - \\u003cb\\u003eChange in BIS\\u003c/b\\u003e: The BIS value was recorded at T0 (immediately before beginning stimulation) and at T1 (just before extubation). The difference (ΔBIS\\u0026thinsp;=\\u0026thinsp;T1 value\\u0026thinsp;\\u0026minus;\\u0026thinsp;T0 value) was calculated to quantify the increase in level of consciousness during emergence. - \\u003cb\\u003eEmergence adverse events\\u003c/b\\u003e: From the start of stimulation until shortly after extubation, an observer (blinded to group) recorded any occurrence of the following events: - \\u003cem\\u003eHypoxemia\\u003c/em\\u003e: peripheral oxygen saturation (SpO₂)\\u0026thinsp;\\u0026lt;\\u0026thinsp;90% at any point during the extubation process. - \\u003cem\\u003eCoughing\\u003c/em\\u003e: sustained cough occurring within 5 minutes after LMA removal. - \\u003cem\\u003eAgitation\\u003c/em\\u003e: significant emergence agitation or delirium, defined as a Pediatric Anesthesia Emergence Delirium (PAED) scale score\\u0026thinsp;\\u0026ge;\\u0026thinsp;10. - \\u003cem\\u003eLaryngospasm\\u003c/em\\u003e: evidence of partial or complete airway obstruction (e.g. stridor) requiring intervention. - \\u003cem\\u003eAspiration\\u003c/em\\u003e: any sign of gastric contents in the airway (e.g. visible regurgitation with clinical evidence of aspiration).\\u003c/p\\u003e\\u003cp\\u003eAny adverse events were treated immediately per standard protocols and documented.\\u003c/p\\u003e\\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eStatistical analysis\\u003c/h2\\u003e\\u003cp\\u003eThe sample size was calculated for the time-to-event outcome of laryngeal mask airway removal. Based on our pilot study, a hazard ratio (HR) of 0.64 was used for the calculation. With 80% power at a two-sided alpha of 0.05, 160 events were required, as determined using the Cox proportional hazards model in PASS software. Allowing for a 15% attrition rate, a total of 186 participants were planned.\\u003c/p\\u003e\\u003cp\\u003eStatistical analysis was performed using R version 4.4.3 (R Foundation for Statistical Computing). Continuous variables were tested for normality. Normally distributed data are reported as mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;standard deviation (SD) and compared between groups with independent-samples \\u003cem\\u003et\\u003c/em\\u003e tests. Non-normally distributed data are reported as median with interquartile range (IQR) and compared with the Mann\\u0026ndash;Whitney \\u003cem\\u003eU\\u003c/em\\u003e test. Categorical variables (e.g. incidence of adverse events, sex distribution) are summarized as count (percentage) and compared using Pearson\\u0026rsquo;s chi-square or Fisher\\u0026rsquo;s exact test, as appropriate.\\u003c/p\\u003e\\u003cp\\u003eTime-to-event methods were also applied to the primary outcome (extubation time). A Kaplan\\u0026ndash;Meier curve was constructed for time from T0 to extubation in each group and compared using the log-rank test. Additionally, a parametric survival regression (Weibull distribution) was used to estimate the effect of the intervention on extubation time while adjusting for potential confounders. Three models were specified: Model 1 included only group (ST6 stimulation vs. control); Model 2 included group plus patient age, sex, and BMI; Model 3 included group plus age, sex, BMI, and duration of anesthesia. From these models, we report the estimated time ratio (TR) for the intervention (ST6 stimulation) relative to control, with TR\\u0026thinsp;\\u0026lt;\\u0026thinsp;1 indicating a reduction in extubation time. Two-sided \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05 was considered statistically significant for all analyses.\\u003c/p\\u003e\\u003c/div\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eParticipant characteristics\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eA total of 175 children were included in the final analysis (Fig. \\u003cspan class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). Of these, 86 were allocated to the ST6 stimulation group and 89 to the shoulder tapping control group. The two groups were comparable in baseline demographics (Table \\u003cspan class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). There were no significant differences between intervention and control in age (median 5.5 vs 5.0 years), sex distribution (79% vs 83% male), body mass index (BMI), or anesthesia duration (all \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.1).\\u003c/p\\u003e\\n\\u003ctable id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e\\n \\u003ccaption language=\\\"En\\\"\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003ePatient Demographics and Baseline Characteristics\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eExperimental Group\\u003c/p\\u003e\\n \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;86)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eControl Group\\u003c/p\\u003e\\n \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;89)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eP\\u003c/em\\u003e-value\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eSex (male%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e68 (79.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e74 (83.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e0.620\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAge (year)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e5.5 (3.0, 8.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e5.0 (3.0, 8.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e0.411\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eBMI (kg/m\\u003csup\\u003e2\\u003c/sup\\u003e)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e15.4 (14.6, 16.4)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e15.9 (14.3, 17.4)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e0.231\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAnesthesia Time (min)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e35.4 (24.3, 45.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e37.2 (28.8, 48.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e0.162\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eExtubation Time (min)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e7.2 (5.7, 9.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e13.3 (11.9, 15.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eBIS Change (number)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e9.0 (5.2, 12.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e4.0 (3.0, 6.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003ctfoot\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"4\\\"\\u003eValues are presented as median (interquartile range) or number (%).\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"4\\\"\\u003eExperimental Group: ST6 stimulation intervention; Control Group: Shoulder tapping. Abbreviations: BMI, body mass index; BIS, bispectral index.\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tfoot\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cbr\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eExtubation time and BIS change\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe ST6 stimulation resulted in markedly faster LMA removal compared to control. The median time from first stimulus to extubation was 7.2 minutes (IQR 5.7\\u0026ndash;9.3) in the ST6 stimulation group versus 13.3 minutes (IQR 11.9\\u0026ndash;15.7) in the control group (Mann\\u0026ndash;Whitney \\u003cem\\u003eU\\u003c/em\\u003e test, \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) (Table \\u003cspan class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). Correspondingly, children in the intervention group achieved a greater rise in BIS during emergence. The median increase in BIS (\\u0026Delta;BIS) from start of stimulation to extubation was +\\u0026thinsp;9.0 in the ST6 stimulation group, significantly higher than the +\\u0026thinsp;4.0 median change in controls (\\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) (Table \\u003cspan class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e, Fig. \\u003cspan class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). This indicates that targeted trigeminal nerve pressure produced a faster arousal from the anesthetized state.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTime-to-event analysis\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eFigure \\u003cspan class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e illustrates the cumulative proportion of children extubated over time in each group. The Kaplan\\u0026ndash;Meier curves diverged early, with the ST6 stimulation group consistently extubating more quickly; the difference between groups was highly significant (log-rank \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). Even after controlling for other factors, the benefit of the intervention persisted. In the multivariate Weibull regression, the ST6 stimulation group had a significantly shorter extubation time across all models. In the fully adjusted model (controlling for age, sex, BMI, and anesthesia duration), the intervention was associated with a time ratio of 0.626 (95% CI 0.563\\u0026ndash;0.694, \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) (Table \\u003cspan class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). This corresponds to approximately a 37% reduction in extubation time relative to the control condition.\\u003c/p\\u003e\\n\\u003ctable id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e\\n \\u003ccaption language=\\\"En\\\"\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003eUnivariate and multivariate analysis using the Weibull regression model\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eTime Ratio (95% CI )\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eP\\u003c/em\\u003e-value\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eModel 1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e0.643 (0.579, 0.715)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eModel 2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e0.646 (0.580, 0.720)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eModel 3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e0.626 (0.563, 0.694)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003ctfoot\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"3\\\"\\u003eTime Ratio (TR)\\u0026thinsp;\\u0026lt;\\u0026thinsp;1 indicates shorter extubation time. Model 1: Adjusted for intervention only; Model 2: Adjusted for intervention, age, sex, and BMI; Model 3: Adjusted for Model 2 covariates plus anesthesia duration.\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tfoot\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cbr\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAdverse events\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe incidence of adverse emergence events is summarized in Table \\u003cspan class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e. Notably, the ST6 stimulation group experienced fewer respiratory and emergence-related complications compared to controls. Only 9 of 86 children (10.5%) in the intervention group had an episode of coughing, versus 20 of 89 (22.5%) in the control group (\\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;0.033). Similarly, significant agitation (PAED score\\u0026thinsp;\\u0026ge;\\u0026thinsp;10) was observed in 7 patients (8.1%) in the intervention group compared to 17 (19.1%) in controls (\\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;0.035). Rates of hypoxemia were low in both groups (6.9% vs 5.6%, \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;0.711). Importantly, there were no instances of laryngospasm or aspiration in either group during the study (Table \\u003cspan class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e, Fig. \\u003cspan class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e).\\u003c/p\\u003e\\n\\u003ctable id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e\\n \\u003ccaption language=\\\"En\\\"\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003eThe incidence of adverse outcomes includes hypoxemia, laryngospasm, coughing, agitation, and aspiration\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eExperimental Group\\u003c/p\\u003e\\n \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;86)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eControl Group\\u003c/p\\u003e\\n \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;89)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eP\\u003c/em\\u003e-value\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eCoughing (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e10.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e22.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.033\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAgitation (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e8.1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e19.1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.035\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eHypoxemia (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e6.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e5.6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.711\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAspiration (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eLaryngospasm (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003ctfoot\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"4\\\"\\u003eValues are presented as number of events (%). Experimental Group: ST6 stimulation; Control Group: Shoulder tapping.\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tfoot\\u003e\\n\\u003c/table\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eIn this randomized trial, targeted stimulation of the ST6 acupoints significantly hastened emergence from anesthesia in pediatric patients, as evidenced by a roughly 6-minute reduction in median extubation time. Importantly, this intervention did not compromise safety; on the contrary, children receiving ST6 stimulation had lower frequencies of coughing and emergence agitation compared to those who received standard gentle tapping. These findings suggest that focused stimulation at the jaw angle can improve both the efficiency and quality of recovery in children after anesthesia. Given that emergence delirium and coughing are common challenges in pediatric anesthetic recovery, an intervention that reduces these events while speeding awakening is particularly valuable[\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eThe concept of using point pressure to influence anesthesia emergence is supported by both traditional practice and neurophysiological evidence[\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e]. Pressing on the ST6 region produces a strong, diffuse acupressure sensation, likely via synergistic peripheral receptor activation and central neural integration. The ST6 point lies in the belly of the masseter, a region densely innervated by the trigeminal nerve. Applying approximately 1.5 kg of pressure can simultaneously activate mechanoreceptors and nociceptors in the deep muscle tissue, generating high-intensity, multimodal afferent signals[\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e]. These signals ascend via the trigeminal nerve to the brainstem sensory nuclei, where they converge with other craniofacial inputs and undergo extensive synaptic integration[\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]. Such central processing leads to a widespread neural activation that produces a referred aching sensation beyond the stimulus site. This intense afferent barrage may underlie the arousal effect observed with ST6 stimulation. Consistent with this mechanism, we observed a greater BIS increase in the stimulation group, reflecting enhanced cortical arousal from trigeminal activation. Prior studies on acupuncture have shown that sensory stimulation at specific points can modulate neurotransmitters and neural pathways involved in consciousness and autonomic function[\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e]. For instance, acupressure and acupuncture techniques have been reported to aid recovery of consciousness in patients with traumatic brain injury and to improve postoperative recovery quality[\\u003cspan additionalcitationids=\\\"CR16\\\" citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e]. Pressing the Neiguan (PC6) point on the wrist is a well-known example\\u0026mdash;this maneuver effectively reduces postoperative nausea and vomiting and is an accepted adjunct in anesthesia care[\\u003cspan additionalcitationids=\\\"CR19 CR20\\\" citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e]. Similarly, our study provides evidence that stimulating a point on the face can beneficially influence emergence from anesthesia.\\u003c/p\\u003e\\u003cp\\u003eUsing a physical stimulus as a determinant for extubation readiness is further justified by practical considerations. Common criteria for awake extubation in children include signs like facial grimace, eye opening, purposeful movement, adequate tidal volume, and responsiveness to stimulation[\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e]. In some situations these signs may be difficult to observe\\u0026mdash;for example, after certain surgeries (such as pediatric ophthalmic procedures where the eyes are covered by dressings) it can be challenging to judge the appropriate timing for extubation[\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e]. In such cases, an external stimulus that elicits a clear movement response can serve as an objective indicator of consciousness. The ST6 pressure technique described here typically induces a reflex head withdrawal or limb motion in response to the jaw pain stimulus, signaling that the child has regained sufficient protective reflexes to safely remove the airway device. Moreover, this technique is simple, quick, and requires no special equipment, underscoring its clinical practicality. It essentially leverages the patient\\u0026rsquo;s own nervous system to indicate readiness for extubation. An analogy can be drawn to the established \\u0026ldquo;laryngospasm notch\\u0026rdquo; maneuver: a vigorous push at a spot just behind the jaw (near the earlobe) is known to relieve laryngospasm during extubation[\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]. Both techniques rely on intense peripheral stimulation to elicit a beneficial reflex\\u0026mdash;one to break glottic closure (via cranial nerve pathways that relax the vocal cords), and in our case to provoke awakening.\\u003c/p\\u003e\\u003cp\\u003eSeveral limitations of our study should be acknowledged. First, this was a single-center study in a relatively controlled surgical context (short procedures in ASA I children). The results may not generalize to higher-risk patients, other surgical types, or settings with different anesthetic protocols. Second, while we standardized the applied pressure (~\\u0026thinsp;1.5 kg) based on prior literature, the optimal intensity and frequency of stimulation for different ages or deeper anesthesia levels was not determined. It is possible that older children or those in a heavier anesthetic state might benefit from a different stimulation intensity or timing; future studies could explore the dose-response relationship for this stimulation. Lastly, we focused on immediate recovery endpoints and did not assess longer-term outcomes such as post-anesthesia behavioral changes or cognitive recovery. It would be worthwhile to examine in future research whether this intervention has any impact\\u0026mdash;positive or negative\\u0026mdash;on longer-term recovery parameters.\\u003c/p\\u003e\\u003cp\\u003eDespite these limitations, our trial provides novel evidence supporting a low-cost, non-pharmacological strategy to enhance pediatric anesthesia recovery. By translating a concept rooted in traditional practice into modern clinical care, we have shown that stimulating a trigeminal nerve reflex can effectively address a long-standing challenge in anesthesiology. This approach fits well within the framework of multimodal ERAS (Enhanced Recovery After Surgery) pathways, which aim to accelerate recovery while maintaining safety. The ST6 pressure technique requires minimal training and no equipment, and it caused no complications in our study, making it an attractive option to incorporate into pediatric anesthetic practice. As healthcare systems continue to prioritize interventions that improve outcomes without adding cost or risk, such simple techniques warrant attention[\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e]. Future studies using advanced monitoring (e.g. electroencephalography or functional neuroimaging) could further elucidate the neurobiological mechanisms by which trigeminal nerve stimulation affects arousal and recovery.\\u003c/p\\u003e\"},{\"header\":\"Conclusions\",\"content\":\"\\u003cp\\u003eApplying targeted pressure to the ST6 acupoints is a safe and effective adjunct for accelerating the return of consciousness and facilitating airway device removal in pediatric anesthesia. This technique leverages well-defined neurophysiological pathways to hasten awakening without pharmacological intervention. Implementing such a simple maneuver can improve extubation timing and may enhance overall recovery quality in children, demonstrating how non-drug interventions can complement standard anesthetic practice.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cdiv class=\\\"DefinitionList\\\"\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u0026bull; \\u003cb\\u003eASA\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eAmerican Society of Anesthesiologists\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u0026bull; \\u003cb\\u003eBIS\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eBispectral index\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u0026bull; \\u003cb\\u003eBMI\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eBody mass index\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u0026bull; \\u003cb\\u003eERAS\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eEnhanced Recovery After Surgery\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u0026bull; \\u003cb\\u003eLMA\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eLaryngeal mask airway\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u0026bull; \\u003cb\\u003ePAED\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003ePediatric Anesthesia Emergence Delirium\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u0026bull; \\u003cb\\u003eSpO₂\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003ePeripheral oxygen saturation\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate:\\u003c/strong\\u003e All procedures performed in this study conformed to the ethical guidelines of the Declaration of Helsinki, and ethical approval for this study (No. KYLL20240729-2) was provided by the Ethics Committee of Weifang People\\u0026rsquo;s Hospital, Shandong, China on July 29, 2024. Written informed consent was obtained from the parents or legal guardians of all participants.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication:\\u003c/strong\\u003e Not applicable.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and materials:\\u003c/strong\\u003e The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting interests:\\u003c/strong\\u003e The authors declare that they have no competing interests.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding:\\u003c/strong\\u003e This research received no external funding.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors\\u0026rsquo; contributions:\\u003c/strong\\u003e Zhang and Sun collected the clinical data and drafted the initial manuscript. Kou and Luo performed the statistical analysis. Ma,Zhao and Lang provided expertise in anesthesiology, supervised patient management, and assisted with data collection. Hu conceived and designed the study, oversaw study execution, and critically revised the manuscript. All authors read and approved the final version of the manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgements:\\u003c/strong\\u003e The authors thank the entire surgical and anesthesia team at Weifang People\\u0026rsquo;s Hospital for their support in conducting this trial. We are also grateful to the post-anesthesia care unit nurses and staff for their assistance with patient monitoring and data recording. Finally, we thank our colleagues for their valuable suggestions and help in manuscript editing.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eAbbasi S, Siddiqui KM, Qamar-Ul-Hoda M. Adverse Respiratory Events After Removal of Laryngeal Mask Airway in Deep Anesthesia Versus Awake State in Children: A Randomized Trial. Cureus. 2022;14:e24296.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eVitale L, Rodriguez B, Baetzel A, Christensen R, Haydar B. Complications associated with removal of airway devices under deep anesthesia in children: an analysis of the Wake Up Safe database. BMC Anesthesiol. 2022;22:223.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eBenham-Hermetz J, Mitchell V. Safe tracheal extubation after general anaesthesia. BJA Educ. 2021;21:446\\u0026ndash;54.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eLi F, He T, Xu Q, et al. What is the Acupoint? A preliminary review of Acupoints. Pain Med. 2015;16:1905\\u0026ndash;15.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eWang J, Cui J, Xu D, et al. Sensory and autonomic innervation of the local tissues at traditional acupuncture point locations GB14, ST2 and ST6. Acupunct Med. 2022;40:546\\u0026ndash;55.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eLarson CP. Laryngospasm\\u0026ndash;the best treatment. Anesthesiology. 1998;89:1293\\u0026ndash;4.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eNoll E, Shodhan S, Madariaga MC, et al. Randomized trial of acupressure to improve patient satisfaction and quality of recovery in hospitalized patients: study protocol for a randomized controlled trial. Trials. 2017;18:110.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eLin G-H, Chang W-C, Chen K-J, Tsai C-C, Hu S-Y, Chen L-L. Effectiveness of Acupressure on the Taichong Acupoint in Lowering Blood Pressure in Patients with Hypertension: A Randomized Clinical Trial. 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P6 acupressure may relieve nausea and vomiting after gynecological surgery: an effectiveness study in 410 women. Can J Anaesth. 2002;49:1034\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eBoehler M, Mitterschiffthaler G, Schlager A. Korean hand acupressure reduces postoperative nausea and vomiting after gynecological laparoscopic surgery. Anesth Analg. 2002;94:872\\u0026ndash;5. table of contents.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eYang J, Jiang Y, Chen Y, et al. Acupressure the PC6 point for alleviating postoperative nausea and vomiting: A systematic review protocol. Med (Baltim). 2019;98:e16857.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eTempleton TW, Goenaga-D\\u0026iacute;az EJ, Downard MG, et al. Assessment of Common Criteria for Awake Extubation in Infants and Young Children. Anesthesiology. 2019;131:801\\u0026ndash;8.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eShalish W, Keszler M, Davis PG, Sant\\u0026rsquo;Anna GM. Decision to extubate extremely preterm infants: art, science or gamble? Arch Dis Child Fetal Neonatal Ed. 2022;107:105\\u0026ndash;12.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eLoganathan AK, Joselyn AS, Babu M, Jehangir S. Implementation and outcomes of enhanced recovery protocols in pediatric surgery: a systematic review and meta-analysis. Pediatr Surg Int. 2022;38:157\\u0026ndash;68.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Trigeminal nerve, Laryngeal mask airway, Airway extubation, Anesthesia recovery, Child, Physical stimulation, Emergence delirium, General anesthesia, Pediatric anesthesia\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-7641523/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-7641523/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e\\u003cp\\u003eExtubation timing is crucial in pediatric anesthesia recovery to avoid complications such as hypoxia and laryngospasm. Non-pharmacological techniques that stimulate arousal and respiration could aid in timely and safe removal of airway devices. This study evaluated whether applying pressure at the jaw angle (masseter region corresponding to the ST6 acupoint) would hasten emergence from anesthesia and improve the safety and efficiency of laryngeal mask airway (LMA) removal in children.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e\\u003cp\\u003eIn this randomized controlled trial, 175 ASA I children (ages 1\\u0026ndash;12) undergoing elective laparoscopic hernia repair with a laryngeal mask airway (LMA) were allocated 1:1 to jaw-angle (ST6) stimulation or gentle shoulder tapping (control) during emergence. Anesthesia was standardized: induction with sufentanil 0.3 \\u0026micro;g/kg, propofol 3 mg/kg, and cisatracurium 0.15 mg/kg; maintenance with propofol\\u0026ndash;remifentanil titrated to BIS 40\\u0026ndash;60. At surgery end, all anesthetics were stopped; after spontaneous breathing returned, the intervention group received repeated bilateral 5-second firm presses at the jaw angles (~\\u0026thinsp;1.5 kg force) and controls received shoulder taps of similar force. Extubation (LMA removal) occurred at eye opening or purposeful movement. The primary outcome was extubation time (T1\\u0026ndash;T0: first stimulation to LMA removal). Secondary outcomes were change in BIS from start of stimulation to extubation and the incidence of adverse events (coughing, agitation, hypoxemia, laryngospasm, aspiration).\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e\\u003cp\\u003eBaseline characteristics were similar between the ST6 stimulation group (n\\u0026thinsp;=\\u0026thinsp;86) and control group (n\\u0026thinsp;=\\u0026thinsp;89). Extubation was significantly faster with ST6 stimulation, with a median time of 7.2 minutes (IQR 5.7\\u0026ndash;9.3) versus 13.3 minutes (11.9\\u0026ndash;15.7) in controls (\\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). The intervention group also had a greater increase in BIS during emergence (median ΔBIS\\u0026thinsp;+\\u0026thinsp;9.0 vs\\u0026thinsp;+\\u0026thinsp;4.0, \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), indicating higher arousal at extubation. Kaplan\\u0026ndash;Meier analysis confirmed a shorter time to extubation with intervention (log-rank \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). In a multivariate Weibull regression adjusting for age, BMI, and anesthesia duration, ST6 stimulation reduced extubation time by approximately 37% (time ratio 0.63, 95% CI 0.56\\u0026ndash;0.69, \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) compared to control. Fewer participants in the ST6 stimulation group experienced coughing (10% vs 22%, \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;0.033) or emergence agitation (8% vs 19%, P\\u0026thinsp;=\\u0026thinsp;0.035). The incidence of hypoxemia was low and similar between groups (7% vs 6%, \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;0.71). No laryngospasm or aspiration occurred in either group.\\u003c/p\\u003e\\u003ch2\\u003eConclusions\\u003c/h2\\u003e\\u003cp\\u003eTargeted bilateral jaw angle pressure (ST6 acupoint stimulation) significantly shortened LMA removal time in children without increasing adverse events. This simple technique may serve as a useful non-pharmacological adjunct to enhance pediatric anesthesia recovery, potentially complementing conventional Enhanced Recovery After Surgery (ERAS) strategies.\\u003c/p\\u003e\\u003ch2\\u003eTrial registration:\\u003c/h2\\u003e\\u003cp\\u003eInternational Traditional Medicine Clinical Trial Registry, \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttp://itmctr.ccebtcm.org.cn,ITMCTR2024000464\\u003c/span\\u003e\\u003cspan address=\\\"http://itmctr.ccebtcm.org.cn,ITMCTR2024000464\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (registered on 13 September 2024).\\u003c/p\\u003e\",\"manuscriptTitle\":\"Transcutaneous ST6 Stimulation Versus Shoulder Tapping on Laryngeal Mask Airway Removal in Pediatric Patients: A Randomized Controlled Trial\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-11-03 05:36:04\",\"doi\":\"10.21203/rs.3.rs-7641523/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"473dfb66-51ad-4fd6-bfe3-0280e635d6b6\",\"owner\":[],\"postedDate\":\"November 3rd, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-11-12T08:08:53+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-11-03 05:36:04\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-7641523\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-7641523\",\"identity\":\"rs-7641523\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}