Postoperative nausea is relieved by acupressure

Study protocol for a randomised, patient- and observer-blinded evaluation of P6 acustimulation for the prevention of nausea and vomiting in the postoperative period in patients receiving routine pharmacological prophylaxis (P6NV-Trial)

BACKGROUND

The efficacy of pericardium 6 (P6) acupoint stimulation to reduce the incidence of postoperative nausea and vomiting (PONV) has been proven in several randomised controlled clinical trials. However, little is known about the effectiveness in daily practice and its use in combination with traditional pharmacologic approaches.

METHODS

The primary objective of the P6NV study is to determine whether intraoperative acustimulation (acupuncture or acupressure) at the point P6 provides additional benefit when applied along with customary prophylactic intravenous antiemetics administered according to the local standard operating procedures (SOP). The primary endpoint is the incidence and severity of PONV within the first 24 h postoperatively reported with a validated postoperative nausea and vomiting intensity scale. The patient-reported outcome of perioperative quality of life (using the PPP33-questionnaire) and the detection of antiemetic-related side effects as well as the severity of PONV (via a standardised questionnaire) are secondary study objectives. P6NV is a national, multicentre, randomised, prospective, patient- and examiner-blinded interventional study and will be performed on 3500 adult patients with ASA classification I-III undergoing elective surgery under general anaesthesia and hospitalised for at least 24 h. Participating anaesthesiologists commit themselves to administer customised conventional antiemetic prophylaxis according to the local SOP by signing a statement before randomisation. The intervention group receives bilateral acupuncture or acupressure at P6. The control group receives no intervention. Before extubation, acustimulation is removed.

DISCUSSION

Since P6 acustimulation is performed by a wide range of anaesthesiologists receiving written and verbal information on acustimulation beforehand, this trial will provide information on the effectiveness of an ad hoc implementation of P6 stimulation techniques in anaesthesia departments using traditional pharmacologic PONV prophylaxis.

TRIAL REGISTRATION

DRKS DRKS00015272 . Registered on August 15, 2018.

The effects of psychological counseling and acupressure based on couple therapy procedure for alleviation of vomiting and nausea in pregnant women in Iran country

OBJECTIVES

Nausea and vomiting have psychological negative effects on some pregnant women during gestation. Different strategies have been used for the treatment of nausea and vomiting during pregnancy, such as acupressure and psychological interventions. This study was conducted to evaluate the effects of psychological counseling and acupressure based on couple therapy procedures on vomiting and nausea in pregnant women in Iran.

METHODS

Two hundred and eight women were divided into four groups (n=52): 1) they did not any intervention (control group), 2) they received the psychological intervention, 3) they received acupressure intervention, and 4) they received a combination of psychological + acupressure interventions. To investigate the effects of interventions on nausea and vomiting, the Rhodes index of nausea, vomiting and retching were used. The counseling period has lasted for 4 weeks. The pressure intervention on the site was conducted in clockwise form for 1 min and anticlockwise form for another 1 min.

RESULTS

Groups did not have a significant difference for abortion and income (p>0.05). The effects of counseling, and acupressure interventions on severity and period of vomiting and nausea were not significant (p>0.05), but the intervention based on counseling and acupressure decreased severity of vomiting and nausea (p<0.05).

CONCLUSIONS

The intervention based on counseling and acupressure could not reduce nausea and vomiting during the gestation, but the intervention based on a combination of both decreased nausea and vomiting. It can be suggested to apply an intervention based on a combination of counseling and acupressure in short-time period for decreasing nausea and vomiting in women during pregnancy.

Drugs for preventing postoperative nausea and vomiting in adults after general anaesthesia: a network meta-analysis

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common adverse effect of anaesthesia and surgery. Up to 80% of patients may be affected. These outcomes are a major cause of patient dissatisfaction and may lead to prolonged hospital stay and higher costs of care along with more severe complications. Many antiemetic drugs are available for prophylaxis. They have various mechanisms of action and side effects, but there is still uncertainty about which drugs are most effective with the fewest side effects.

OBJECTIVES

• To compare the efficacy and safety of different prophylactic pharmacologic interventions (antiemetic drugs) against no treatment, against placebo, or against each other (as monotherapy or combination prophylaxis) for prevention of postoperative nausea and vomiting in adults undergoing any type of surgery under general anaesthesia • To generate a clinically useful ranking of antiemetic drugs (monotherapy and combination prophylaxis) based on efficacy and safety • To identify the best dose or dose range of antiemetic drugs in terms of efficacy and safety SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), ClinicalTrials.gov, and reference lists of relevant systematic reviews. The first search was performed in November 2017 and was updated in April 2020. In the update of the search, 39 eligible studies were found that were not included in the analysis (listed as awaiting classification).

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing effectiveness or side effects of single antiemetic drugs in any dose or combination against each other or against an inactive control in adults undergoing any type of surgery under general anaesthesia. All antiemetic drugs belonged to one of the following substance classes: 5-HT₃ receptor antagonists, D₂ receptor antagonists, NK₁ receptor antagonists, corticosteroids, antihistamines, and anticholinergics. No language restrictions were applied. Abstract publications were excluded.

DATA COLLECTION AND ANALYSIS

A review team of 11 authors independently assessed trials for inclusion and risk of bias and subsequently extracted data. We performed pair-wise meta-analyses for drugs of direct interest (amisulpride, aprepitant, casopitant, dexamethasone, dimenhydrinate, dolasetron, droperidol, fosaprepitant, granisetron, haloperidol, meclizine, methylprednisolone, metoclopramide, ondansetron, palonosetron, perphenazine, promethazine, ramosetron, rolapitant, scopolamine, and tropisetron) compared to placebo (inactive control). We performed network meta-analyses (NMAs) to estimate the relative effects and ranking (with placebo as reference) of all available single drugs and combinations. Primary outcomes were vomiting within 24 hours postoperatively, serious adverse events (SAEs), and any adverse event (AE). Secondary outcomes were drug class-specific side effects (e.g. headache), mortality, early and late vomiting, nausea, and complete response. We performed subgroup network meta-analysis with dose of drugs as a moderator variable using dose ranges based on previous consensus recommendations. We assessed certainty of evidence of NMA treatment effects for all primary outcomes and drug class-specific side effects according to GRADE (CINeMA, Confidence in Network Meta-Analysis). We restricted GRADE assessment to single drugs of direct interest compared to placebo.

MAIN RESULTS

We included 585 studies (97,516 randomized participants). Most of these studies were small (median sample size of 100); they were published between 1965 and 2017 and were primarily conducted in Asia (51%), Europe (25%), and North America (16%). Mean age of the overall population was 42 years. Most participants were women (83%), had American Society of Anesthesiologists (ASA) physical status I and II (70%), received perioperative opioids (88%), and underwent gynaecologic (32%) or gastrointestinal surgery (19%) under general anaesthesia using volatile anaesthetics (88%). In this review, 44 single drugs and 51 drug combinations were compared. Most studies investigated only single drugs (72%) and included an inactive control arm (66%). The three most investigated single drugs in this review were ondansetron (246 studies), dexamethasone (120 studies), and droperidol (97 studies). Almost all studies (89%) reported at least one efficacy outcome relevant for this review. However, only 56% reported at least one relevant safety outcome. Altogether, 157 studies (27%) were assessed as having overall low risk of bias, 101 studies (17%) overall high risk of bias, and 327 studies (56%) overall unclear risk of bias. Vomiting within 24 hours postoperatively Relative effects from NMA for vomiting within 24 hours (282 RCTs, 50,812 participants, 28 single drugs, and 36 drug combinations) suggest that 29 out of 36 drug combinations and 10 out of 28 single drugs showed a clinically important benefit (defined as the upper end of the 95% confidence interval (CI) below a risk ratio (RR) of 0.8) compared to placebo. Combinations of drugs were generally more effective than single drugs in preventing vomiting. However, single NK₁ receptor antagonists showed treatment effects similar to most of the drug combinations. High-certainty evidence suggests that the following single drugs reduce vomiting (ordered by decreasing efficacy): aprepitant (RR 0.26, 95% CI 0.18 to 0.38, high certainty, rank 3/28 of single drugs); ramosetron (RR 0.44, 95% CI 0.32 to 0.59, high certainty, rank 5/28); granisetron (RR 0.45, 95% CI 0.38 to 0.54, high certainty, rank 6/28); dexamethasone (RR 0.51, 95% CI 0.44 to 0.57, high certainty, rank 8/28); and ondansetron (RR 0.55, 95% CI 0.51 to 0.60, high certainty, rank 13/28). Moderate-certainty evidence suggests that the following single drugs probably reduce vomiting: fosaprepitant (RR 0.06, 95% CI 0.02 to 0.21, moderate certainty, rank 1/28) and droperidol (RR 0.61, 95% CI 0.54 to 0.69, moderate certainty, rank 20/28). Recommended and high doses of granisetron, dexamethasone, ondansetron, and droperidol showed clinically important benefit, but low doses showed no clinically important benefit. Aprepitant was used mainly at high doses, ramosetron at recommended doses, and fosaprepitant at doses of 150 mg (with no dose recommendation available). Frequency of SAEs Twenty-eight RCTs were included in the NMA for SAEs (10,766 participants, 13 single drugs, and eight drug combinations). The certainty of evidence for SAEs when using one of the best and most reliable anti-vomiting drugs (aprepitant, ramosetron, granisetron, dexamethasone, ondansetron, and droperidol compared to placebo) ranged from very low to low. Droperidol (RR 0.88, 95% CI 0.08 to 9.71, low certainty, rank 6/13) may reduce SAEs. We are uncertain about the effects of aprepitant (RR 1.39, 95% CI 0.26 to 7.36, very low certainty, rank 11/13), ramosetron (RR 0.89, 95% CI 0.05 to 15.74, very low certainty, rank 7/13), granisetron (RR 1.21, 95% CI 0.11 to 13.15, very low certainty, rank 10/13), dexamethasone (RR 1.16, 95% CI 0.28 to 4.85, very low certainty, rank 9/13), and ondansetron (RR 1.62, 95% CI 0.32 to 8.10, very low certainty, rank 12/13). No studies reporting SAEs were available for fosaprepitant. Frequency of any AE Sixty-one RCTs were included in the NMA for any AE (19,423 participants, 15 single drugs, and 11 drug combinations). The certainty of evidence for any AE when using one of the best and most reliable anti-vomiting drugs (aprepitant, ramosetron, granisetron, dexamethasone, ondansetron, and droperidol compared to placebo) ranged from very low to moderate. Granisetron (RR 0.92, 95% CI 0.80 to 1.05, moderate certainty, rank 7/15) probably has no or little effect on any AE. Dexamethasone (RR 0.77, 95% CI 0.55 to 1.08, low certainty, rank 2/15) and droperidol (RR 0.89, 95% CI 0.81 to 0.98, low certainty, rank 6/15) may reduce any AE. Ondansetron (RR 0.95, 95% CI 0.88 to 1.01, low certainty, rank 9/15) may have little or no effect on any AE. We are uncertain about the effects of aprepitant (RR 0.87, 95% CI 0.78 to 0.97, very low certainty, rank 3/15) and ramosetron (RR 1.00, 95% CI 0.65 to 1.54, very low certainty, rank 11/15) on any AE. No studies reporting any AE were available for fosaprepitant. Class-specific side effects For class-specific side effects (headache, constipation, wound infection, extrapyramidal symptoms, sedation, arrhythmia, and QT prolongation) of relevant substances, the certainty of evidence for the best and most reliable anti-vomiting drugs mostly ranged from very low to low. Exceptions were that ondansetron probably increases headache (RR 1.16, 95% CI 1.06 to 1.28, moderate certainty, rank 18/23) and probably reduces sedation (RR 0.87, 95% CI 0.79 to 0.96, moderate certainty, rank 5/24) compared to placebo. The latter effect is limited to recommended and high doses of ondansetron. Droperidol probably reduces headache (RR 0.76, 95% CI 0.67 to 0.86, moderate certainty, rank 5/23) compared to placebo. We have high-certainty evidence that dexamethasone (RR 1.00, 95% CI 0.91 to 1.09, high certainty, rank 16/24) has no effect on sedation compared to placebo. No studies assessed substance class-specific side effects for fosaprepitant. Direction and magnitude of network effect estimates together with level of evidence certainty are graphically summarized for all pre-defined GRADE-relevant outcomes and all drugs of direct interest compared to placebo in http://doi.org/10.5281/zenodo.4066353.

AUTHORS' CONCLUSIONS

We found high-certainty evidence that five single drugs (aprepitant, ramosetron, granisetron, dexamethasone, and ondansetron) reduce vomiting, and moderate-certainty evidence that two other single drugs (fosaprepitant and droperidol) probably reduce vomiting, compared to placebo. Four of the six substance classes (5-HT₃ receptor antagonists, D₂ receptor antagonists, NK₁ receptor antagonists, and corticosteroids) were thus represented by at least one drug with important benefit for prevention of vomiting. Combinations of drugs were generally more effective than the corresponding single drugs in preventing vomiting. NK₁ receptor antagonists were the most effective drug class and had comparable efficacy to most of the drug combinations. 5-HT₃ receptor antagonists were the best studied substance class. For most of the single drugs of direct interest, we found only very low to low certainty evidence for safety outcomes such as occurrence of SAEs, any AE, and substance class-specific side effects. Recommended and high doses of granisetron, dexamethasone, ondansetron, and droperidol were more effective than low doses for prevention of vomiting. Dose dependency of side effects was rarely found due to the limited number of studies, except for the less sedating effect of recommended and high doses of ondansetron. The results of the review are transferable mainly to patients at higher risk of nausea and vomiting (i.e. healthy women undergoing inhalational anaesthesia and receiving perioperative opioids). Overall study quality was limited, but certainty assessments of effect estimates consider this limitation. No further efficacy studies are needed as there is evidence of moderate to high certainty for seven single drugs with relevant benefit for prevention of vomiting. However, additional studies are needed to investigate potential side effects of these drugs and to examine higher-risk patient populations (e.g. individuals with diabetes and heart disease).

Management strategies for the treatment and prevention of postoperative/postdischarge nausea and vomiting: an updated review

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. The routine use of opioid analgesics for perioperative pain management is a major contributing factor to both PONV and PDNV after surgery. PONV and PDNV can delay discharge from the hospital or surgicenter, delay the return to normal activities of daily living after discharge home, and increase medical costs. The high incidence of PONV and PDNV has persisted despite the introduction of many new antiemetic drugs (and more aggressive use of antiemetic prophylaxis) over the last two decades as a result of growth in minimally invasive ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major surgical procedures (e.g. enhanced recovery protocols). Pharmacologic management of PONV should be tailored to the patient’s risk level using the validated PONV and PDNV risk-scoring systems to encourage cost-effective practices and minimize the potential for adverse side effects due to drug interactions in the perioperative period. A combination of prophylactic antiemetic drugs with different mechanisms of action should be administered to patients with moderate to high risk of developing PONV. In addition to utilizing prophylactic antiemetic drugs, the management of perioperative pain using opioid-sparing multimodal analgesic techniques is critically important for achieving an enhanced recovery after surgery. In conclusion, the utilization of strategies to reduce the baseline risk of PONV (e.g. adequate hydration and the use of nonpharmacologic antiemetic and opioid-sparing analgesic techniques) and implementing multimodal antiemetic and analgesic regimens will reduce the likelihood of patients developing PONV and PDNV after surgery.

The Effect of Acupressure at PC6 and REN12 on Vomiting in Patients Undergoing Inguinal Hernia Repair: A Double-Blind Randomized Clinical Trial

BACKGROUND

Inguinal hernia surgery is one of the most commonly performed surgeries with complications such as postoperative nausea and vomiting (PONV).

AIM

This study aimed to evaluate the effect of acupressure at PC6 and REN 12 points on vomiting of patients undergoing inguinal hernia repair.

MATERIAL AND METHODS

This is a double-blind, randomised clinical trial performed on 60 patients undergoing inguinal hernia repair. Using permutation blocks, patients were allocated in two groups (acupressure at PC6 and REN12 points). After the surgery and full patient consciousness, acupressure was applied on PC6 and REN 12 points separately in each group for 5 minutes; 2, 4 and 6 hours later, acupressure was repeated on those points. Two hours after each acupressure, frequency and severity of vomiting were determined.

RESULTS

The results showed that there was no significant difference between the frequency of vomiting before the intervention and 2 hours after the intervention in the two intervention groups (P ≥ 0.05). Additionally, none of the two intervention groups experienced vomiting at 4, 6, and 8 hours after the intervention.

CONCLUSION

It seems that acupressure at PC6 and REN 12 points are not effective in reducing the frequency and severity of vomiting in patients after inguinal hernia surgery.

Randomized trial of acupuncture with antiemetics for reducing postoperative nausea in children

BACKGROUND

Postoperative nausea and vomiting (PONV) is common after tonsillectomy in children. There is evidence that perioperative acupuncture at the pericardium 6 (P6) point is effective for preventing PONV in adults. Our goal was to determine if intraoperative acupuncture at the P6 point, in addition to usual antiemetics, is more effective than antiemetics alone in preventing PONV in children.

METHODS

In a randomized double-blind trial, 161 children age 3 through 9 years undergoing tonsillectomy with or without adenoidectomy were randomized to either bilateral acupuncture at P6 plus antiemetics (n = 86) or antiemetics only (n = 75). All participants received ondansetron 0.15 mg/kg and dexamethasone 0.25 mg/kg, up to 10 mg. The presence of nausea, retching, emesis and administration of additional antiemetics were recorded during phases I and II of PACU recovery. Follow-up calls occurred on postoperative day 1 (POD 1).

RESULT

During phase I and II recovery, the incidence of PONV was significantly less with acupuncture than without (7.0% vs 34.7%, RR: 0.2, 95% CI: 0.09-0.46; P < 0.001). The difference in PONV was driven by less nausea in the acupuncture group (5.0% vs 24.0%), with no difference in vomiting between the two groups. In the first 24 hours, PONV occurred in 36.1% with acupuncture and 49.3% without; these values did not differ significantly (P = 0.09).

CONCLUSIONS

Children receiving acupuncture plus antiemetic therapy had less risk of developing nausea during phase I and II recovery, but there was no difference in PONV on POD 1. Acupuncture may reduce nausea in the PACU, even when combined with antiemetics.

The Effect of Timing of Pc.6 Acupuncture on Post-Operative Vomiting following Major Gynaecological Surgery

We have studied whether the antiemetic effect of PC.6 (Neiguan) acupuncture at the wrist in preventing post-operative nausea and vomiting is affected by the timing of its administration in fifty patients undergoing major gynaecological surgery. Patients were randomly assigned to receive PC.6 acupuncture either five minutes before induction of anaesthesia (Group 1), five minutes after induction of anaesthesia (Group 2) or when awake in the recovery room post-operatively (Group 3). There were no significant differences in emetic sequelae amongst the three groups, with respective incidences of vomiting of 29%, 24% and 25% within the first 6 hours post-operatively. In order to have an 80% power of detecting a difference between groups of the magnitude found, over 3600 patients would need to be studied. We conclude that general anaesthesia does not affect the antiemetic action of PC.6 acupuncture.

Some Problems Encountered in the Scientific Evaluation of Acupuncture Antiemesis

The production of a medical research paper is beset with problems from inception to publication. If the subject involves acupuncture, the problems can seem surprisingly great even for an established university research department.

Most acupuncture reports from China are anecdotal in nature and reviewing the Western literature shows that difficulty in definition of techniques has allowed invasive and non-invasive acupuncture to be used interchangeably, with consequent inaccuracy in the reported results. Because of the physical nature of the treatment, not all accepted criteria for clinical trials are achievable and ethical committees may therefore be reluctant to grant approval. Even publication has been made difficult by scepticism from peer reviewers, although a more enlightened attitude is now gaining ground.

If acupuncture is to become an accepted treatment, scientific evaluation by experienced research teams and perseverance in gaining publication for the results is vital.

Can Acupuncture have Specific Effects on Health? A Systematic Review of Acupuncture Antiemesis Trials

The effects of acupuncture on health are generally hard to assess. Stimulation of the P6 acupuncture point is used to obtain an antiemetic effect and this provides an excellent model to study the efficacy of acupuncture. Thirty-three controlled trials have been published worldwide in which the P6 acupuncture point was stimulated for treatment of nausea and/or vomiting associated with chemotherapy, pregnancy, or surgery. P6 acupuncture was equal or inferior to control in all four trials in which it was administered under anaesthesia; in 27 of the remaining 29 trials acupuncture was statistically superior. A second analysis was restricted to 12 high-quality randomized placebo-controlled trials in which P6 acupuncture point stimulation was not administered under anaesthesia. Eleven of these trials, involving nearly 2000 patients, showed an effect of P6. The reviewed papers showed consistent results across different investigators, different groups of patients, and different forms of acupuncture point stimulation. Except when administered under anaesthesia, P6 acupuncture point stimulation seems to be an effective antiemetic technique. Researchers are faced with a choice between deciding that acupuncture does have specific effects, and changing from 'Does acupuncture work?' to a set of more practical questions; or deciding that the evidence on P6 antiemesis does not provide sufficient proof, and specifying what would constitute acceptable evidence.

Effectiveness of P6 acupoint electrical stimulation in preventing postoperativenausea and vomiting following laparoscopic surgery

BACKGROUND/AIM

The effects of pericardium 6 (P6) electrical stimulation in patients at risk of postoperative nausea and vomiting (PONV) following laparoscopic surgery were evaluated.

MATERIALS AND METHODS

Eighty patients for laparoscopic surgery with at least one of the determined risks (nonsmoker, female, previous PONV/motion sickness, or postoperative opioid use) were randomized into either an active or sham group. At the end of surgery, Reletex electrical acustimulation was placed at the P6 acupoint. The active group had grade 3 strength and the sham group had inactivated electrodes covered by silicone. It was worn for 24 h following surgery. PONV scores were recorded.

RESULTS

The active group had significantly shorter durations of surgery and lower PONV incidence over 24 h (35.1% versus 64.9%, P = 0.024) and this was attributed to the lower incidence of nausea (31.4% versus 68.6%, P = 0.006). The overall incidence of vomiting was not significantly different between the groups, but it was higher in the sham group of patients with PONV risk score 3 (23.9%, P = 0.049).

CONCLUSION

In patients at high risk for PONV, P6 acupoint electrical stimulation lowers the PONV incidence by reducing the nausea component. However, this reduction in nausea is not related to increasing PONV risk scores.

The efficacy of P6 acupressure with sea-band in reducing postoperative nausea and vomiting in patients undergoing craniotomy: a randomized, double-blinded, placebo-controlled study

BACKGROUND

Postoperative nausea and vomiting (PONV) is a multifactorial problem after general anesthesia. Despite antiemetic prophylaxis and improved anesthetic techniques, PONV still occurs frequently after craniotomies. P6 stimulation is described as an alternative method for preventing PONV. The primary aim of this study was to determine whether P6 acupressure with Sea-Band could reduce postoperative nausea after elective craniotomy. Secondary aims were to investigate whether the frequency of vomiting and the need for antiemetics could be reduced.

METHODS

In this randomized, double-blinded, placebo-controlled study, patients were randomized into either a P6 acupressure group (n=43) or a sham group (n=52). Bands were applied unilaterally at the end of surgery, and all patients were administered prophylactic ondansetron. Postoperative nausea was evaluated with a Numerical Rating Scale, 0 to10, and the frequency of vomiting was recorded for 48 hours.

RESULTS

We found no significant effect from P6 acupressure with Sea-Band on postoperative nausea or vomiting in patients undergoing craniotomy. Nor was there any difference in the need for rescue antiemetics. Altogether, 67% experienced PONV, and this was especially an issue at >24 hours in patients recovering from infratentorial surgery compared with supratentorial surgery (55% vs. 26%; P=0.014).

CONCLUSIONS

Unilateral P6 acupressure with Sea-Band applied at the end of surgery together with prophylactic ondansetron did not significantly reduce PONV or the need for rescue antiemetics in patients undergoing craniotomy. Our study confirmed that PONV is a common issue after craniotomy, especially after infratentorial surgery.

Stimulation of the wrist acupuncture point PC6 for preventing postoperative nausea and vomiting

BACKGROUND

Postoperative nausea and vomiting (PONV) are common complications following surgery and anaesthesia. Antiemetic drugs are only partially effective in preventing PONV. An alternative approach is to stimulate the PC6 acupoint on the wrist. This is an update of a Cochrane review first published in 2004, updated in 2009 and now in 2015.

OBJECTIVES

To determine the effectiveness and safety of PC6 acupoint stimulation with or without antiemetic drug versus sham or antiemetic drug for the prevention of PONV in people undergoing surgery.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library, Issue 12, 2014), MEDLINE (January 2008 to December 2014), EMBASE (January 2008 to December 2014), ISI Web of Science (January 2008 to December 2014), World Health Organization Clinical Trials Registry, ClinicalTrials.gov, and reference lists of articles to identify additional studies. We applied no language restrictions.

SELECTION CRITERIA

All randomized trials of techniques that stimulated the PC6 acupoint compared with sham treatment or drug therapy, or combined PC6 acupoint and drug therapy compared to drug therapy, for the prevention of PONV. Interventions used in these trials included acupuncture, electro-acupuncture, transcutaneous electrical acupoint stimulation, transcutaneous nerve stimulation, laser stimulation, capsicum plaster, acu-stimulation device, and acupressure in people undergoing surgery. Primary outcomes were the incidences of nausea and vomiting after surgery. Secondary outcomes were the need for rescue antiemetic therapy and adverse effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and assessed the risk of bias domains for each trial. We used a random-effects model and reported risk ratio (RR) with associated 95% confidence interval (95% CI). We used trial sequential analyses to help provide information on when we had reached firm evidence in cumulative meta-analyses of the primary outcomes, based on a 30% risk ratio reduction in PONV.

MAIN RESULTS

We included 59 trials involving 7667 participants. We rated two trials at low risk of bias in all domains (selection, attrition, reporting, blinding and other). We rated 25 trials at high risk in one or more risk-of-bias domains. Compared with sham treatment, PC6 acupoint stimulation significantly reduced the incidence of nausea (RR 0.68, 95% CI 0.60 to 0.77; 40 trials, 4742 participants), vomiting (RR 0.60, 95% CI 0.51 to 0.71; 45 trials, 5147 participants) and the need for rescue antiemetics (RR 0.64, 95% CI 0.55 to 0.73; 39 trials, 4622 participants). As heterogeneity among trials was substantial and there were study limitations, we rated the quality of evidence as low. Using trial sequential analysis, the required information size and boundary for benefit were reached for both primary outcomes.PC6 acupoint stimulation was compared with six different types of antiemetic drugs (metoclopramide, cyclizine, prochlorperazine, droperidol. ondansetron and dexamethasone). There was no difference between PC6 acupoint stimulation and antiemetic drugs in the incidence of nausea (RR 0.91, 95% CI 0.75 to 1.10; 14 trials, 1332 participants), vomiting (RR 0.93, 95% CI 0.74 to 1.17; 19 trials, 1708 participants), or the need for rescue antiemetics (RR 0.87, 95% CI 0.65 to 1.16; 9 trials, 895 participants). We rated the quality of evidence as moderate, due to the study limitations. Using trial sequential analyses, the futility boundary was crossed before the required information size was surpassed for both primary outcomes.Compared to antiemetic drugs, the combination of PC6 acupoint stimulation and antiemetic therapy reduced the incidence of vomiting (RR 0.56, 95% CI 0.35 to 0.91; 9 trials, 687 participants) but not nausea (RR 0.79, 95% CI 0.55 to 1.13; 8 trials, 642 participants). We rated the quality of evidence as very low, due to substantial heterogeneity among trials, study limitations and imprecision. Using trial sequential analysis, none of the boundaries for benefit, harm or futility were crossed for PONV. The need for rescue antiemetic was lower in the combination PC6 acupoint stimulation and antiemetic group than the antiemetic group (RR 0.61, 95% CI 0.44 to 0.86; 5 trials, 419 participants).The side effects associated with PC6 acupoint stimulation were minor, transient and self-limiting (e.g. skin irritation, blistering, redness and pain) in 14 trials. Publication bias was not apparent in the contour-enhanced funnel plots.

AUTHORS' CONCLUSIONS

There is low-quality evidence supporting the use of PC6 acupoint stimulation over sham. Compared to the last update in 2009, no further sham comparison trials are needed. We found that there is moderate-quality evidence showing no difference between PC6 acupoint stimulation and antiemetic drugs to prevent PONV. Further PC6 acupoint stimulation versus antiemetic trials are futile in showing a significant difference, which is a new finding in this update. There is inconclusive evidence supporting the use of a combined strategy of PC6 acupoint stimulation and antiemetic drug over drug prophylaxis, and further high-quality trials are needed.

Narrative Review of Perioperative Acupuncture for Clinicians

Acupuncture is one of the oldest forms of the natural healing arts. The exact mechanisms of action are unknown at this time; however, current theories to explain the benefits experienced after acupuncture include Traditional Chinese Medicine and Western medicine concepts. Acupuncture may improve the quality of perioperative care and reduce associated complications. Perioperative acupuncture is apparently effective in reducing preoperative anxiety, postoperative nausea and vomiting, and postoperative pain. The Pericardium-6 (P-6; Nei Guan), Yintang (Extra 1), and Shenmen acupuncture points are the most studied and effective acupuncture points in reducing preoperative anxiety, postoperative nausea and vomiting, and postoperative pain experiences. Intraoperatively administered acupuncture may reduce immunosuppression in patients and lessen intraoperative anesthetic requirements, although the clinical usefulness of acupuncture in the intraoperative period remains inconclusive. Perioperative acupuncture is a promising intervention, but additional studies are needed to further understand and define acupuncture's role throughout the perioperative period and determine its clinical usefulness. The purpose of this article is to provide a brief clinical review concerning acupuncture and its application for common issues that occur in the perioperative period.

Nausea control by needling at acupuncture point Neiguan (PC6) during an intraoral impression-taking procedure

The objective of this study was to evaluate the effectiveness of acupuncture point PC6 (Neiguan) in controlling nausea during intraoral impression taking. This study was conducted in Piracicaba, São Paulo, Brazil. The sample consisted of 33 adult volunteers with nausea, who were randomly divided into control and study groups, and treated with nonpenetrating sham acupuncture and real acupuncture, respectively, at acupoint PC6. The two groups had two maxillary impressions taken, one prior to acupuncture and the other after acupuncture. The nausea assessment was made using the visual analog scale, Gagging Severity Index (GSI), and Gagging Prevention Index. Volunteers' expectation that nausea would be reduced through acupuncture was also assessed. For statistical analysis, we used the t test and the Spearman correlation (p < 0.05). When assessed by Gagging Severity Index/Gagging Prevention Index, nausea was reduced in the real acupuncture group (p < 0.01). In the visual analog scale assessment, similar reductions of nausea were noted in both groups (p > 0.05). No correlation existed between the expected and the actual reductions in nausea. Our results indicate that acupoint PC6 was effective for controlling nausea during the maxillary impression-taking procedure. Patients' expectation did not influence the results.

Acupuncture in preventing postoperative nausea and vomiting: efficacy of two acupuncture points versus a single one

Despite recent advances in anesthesiology and postoperative care, postoperative nausea and vomiting are common complaints. Although acupuncture techniques have received attention in anesthesiology, the ideal technique and selection of the most appropriate acupuncture points are still under debate. This study compared the efficacy of two simultaneous acupuncture points with that of a single point in the prevention and treatment of postoperative nausea and vomiting following general anesthesia through a double-blind, randomized, controlled trial involving 227 surgical patients undergoing general anesthesia who were randomly assigned into two groups. The first group received acupuncture by stimulation only on the PC6 point (single group), and the second group underwent concomitant stimulation of the PC6 and the L14 acupuncture points (combined group) during surgery under general anesthesia. The prevalences of postoperative nausea and vomiting were compared between the two groups. No significant differences were observed between the two groups (p>0.05). Of 115 patients in the combined group, 80 (69.6%) complained about nausea and vomiting compared with 96 (85.7%) in the single group, a significantly lower proportion (p<0.05). Our findings favor a combination of PC6 and LI4 stimulation for the treatment of postoperative nausea and vomiting.

Sedating pediatric dental patients by oral ketamine with alternating bi-lateral stimulation of eye movement desensitization and minimizing adverse reaction of ketamine by acupuncture and Bi-Digital O-Ring Test

Ketamine, besides being an anesthetic agent, is also a strong analgesic that can be especially useful for painful procedures. Vivid dreams and nightmare, considered as undesirable side effects of ketamine, are rarely encountered when administrated orally, making it one of the most desirable oral sedative for children because it partially protects the pharyngeal-laryngeal reflex. Besides, if used in recommended dosage, it does not suppress the cardiopulmonary function as most other sedatives do. Ketamine's bronchodilator effect makes it a good sedative for children with asthma, allergies, and hay fever. Alternating bi-lateral stimulation (ABLS) of eye movement desensitization, applying pre-operatively before ketamine was found to reduce the post-operative violent emergence and behavioral problems. Acupressure at P 6 (Neikuan) acupoint helps to decrease nausea and vomiting episodes by ketamine. 36 patients with history of unmanageable behavior were sedated with ketamine 3mg/kg and ABLS. To prevent possible adverse reaction, Bi-Digital O-Ring Test (BDORT) were used to test all patients. ABLS significantly decreased tearful separation from parent. It took 15 to 20 minutes for ketamine to take effect, peak effect took 20 to 25 minutes. Working time ranged from 20 to 40 minutes. Post-operative recovery was more pleasant when ABLS was combined with ketamine, acupuncture/acupressure not only prevented vomiting and BDORT safeguard the patients from unpredictable untoward side effects but also promoting calmness.

A Randomized Clinical Trial of the Efficacy of KID21 Point (Youmen) Acupressure on Nausea and Vomiting of Pregnancy

BACKGROUND

Nausea and vomiting in pregnancy is a common complaint of nearly 50-80% of pregnant women. The problem begins around the 4th weeks of pregnancy and often stays up to the 12th weeks and may continue to the 16th week in a few patients.

OBJECTIVES

The aim of our study is to determine the effect of acupressure (on KID21 point) on nausea and vomiting of pregnancy.

MATERIALS AND METHODS

This single blind clinical trial study was performed on 80 women with nausea and vomiting in the first trimester of pregnancy. Women were randomly divided to two groups; study group with the acupressure on KID21 point and the placebo group with pressure on sham acupressure for 20 minutes per day in four consecutive days. The intensity of nausea was assessed by visual Analogue scale (VAS) and vomiting frequency was evaluated by counting during these four days. Then the results compared with each other.

RESULTS

The intensity of nausea and vomiting between two groups on the fourth day was shown differences (P<0.001).

CONCLUSIONS

Acupressure on KID21 point is more effective than sham acupressure in reduction of nausea and vomiting in pregnancy.

Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting

BACKGROUND

Postoperative nausea and vomiting (PONV) are common complications following surgery and anaesthesia. Drugs to prevent PONV are only partially effective. An alternative approach is to stimulate the P6 acupoint on the wrist. This is an update of a Cochrane review first published in 2004.

OBJECTIVES

To determine the efficacy and safety of P6 acupoint stimulation in preventing PONV.

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library, Issue 3, 2008), MEDLINE (January 1966 to September 2008), EMBASE (January 1988 to September 2008), ISI Web of Science (January 1965 to September 2008), the National Library of Medicine publication list of acupuncture studies, and reference lists of articles.

SELECTION CRITERIA

All randomized trials of techniques that stimulated the P6 acupoint compared with sham treatment or drug therapy for the prevention of PONV. Interventions used in these trials included acupuncture, electro-acupuncture, transcutaneous nerve stimulation, laser stimulation, capsicum plaster, an acu-stimulation device, and acupressure in patients undergoing surgery. Primary outcomes were the risks of nausea and vomiting. Secondary outcomes were the need for rescue antiemetic therapy and adverse effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted the data. We collected adverse effect information from the trials. We used a random-effects model and reported relative risk (RR) with associated 95% confidence intervals (95% CI).

MAIN RESULTS

We included 40 trials involving 4858 participants; four trials reported adequate allocation concealment. Twelve trials did not report all outcomes. Compared with sham treatment P6 acupoint stimulation significantly reduced: nausea (RR 0.71, 95% CI 0.61 to 0.83); vomiting (RR 0.70, 95% CI 0.59 to 0.83), and the need for rescue antiemetics (RR 0.69, 95% CI 0.57 to 0.83). Heterogeneity among trials was moderate. There was no clear difference in the effectiveness of P6 acupoint stimulation for adults and children; or for invasive and noninvasive acupoint stimulation. There was no evidence of difference between P6 acupoint stimulation and antiemetic drugs in the risk of nausea (RR 0.82, 95% CI 0.60 to 1.13), vomiting (RR 1.01, 95% CI 0.77 to 1.31), or the need for rescue antiemetics (RR 0.82, 95% CI 0.59 to 1.13). The side effects associated with P6 acupoint stimulation were minor. There was no evidence of publication bias from contour-enhanced funnel plots.

AUTHORS' CONCLUSIONS

P6 acupoint stimulation prevented PONV. There was no reliable evidence for differences in risks of postoperative nausea or vomiting after P6 acupoint stimulation compared to antiemetic drugs.

[Effects of the Nei-Guan acupressure by wrist band on postoperative nausea and vomiting after middle ear surgery]

PURPOSE

This study was to identify the effects of Nei-Guan acupressure using a wrist band on postoperative nausea and vomiting after middle ear surgery.

METHODS

The study design was a nonequivalent control group non-synchronized posttest design. Forty patients were assigned into two groups of 20 patients, the wrist band group and the control group. In the wrist band group, acupressure was applied with a wrist band on the P6 point at both wrists from 30 min before to 24 hr after anesthesia.

RESULTS

The 1st hypothesis 'Applied wrist band groups will have a greater reduction in the nausea & vomiting grades by INVR than the control group' was accepted (t=2.303, p=.028). The 2nd hypothesis 'The Applied wrist band groups will have a greater reduction in the occurrence of nausea & vomiting than the control group' was partly accepted. The 3rd hypothesis 'The applied wrist band group will have a greater reduction in injection of antiemetics for 24 hr. post anesthesia than the control group' was rejected.

CONCLUSION

Acupressure on the P6 point using a wrist band is effective to alleviate nausea for middle ear surgery patients.

Metaanalysis of Acustimulation Effects on Postoperative Nausea and Vomiting in Children

OBJECTIVE

Using metaanalysis, we sought to determine acustimulation (AS) effects on postoperative nausea and vomiting (PONV) in children.

METHODS

Metaanalyses were performed on various acupoint AS effects including acupressure, acupuncture, laser acupuncture, and electrical stimulation (ETS) on PONV in children. On-line databases were searched for randomized controlled trials (RCTs) from 1966 through May 2005. In addition, the reference lists of reviewed papers were scanned for additional trials. The identified RCTs were evaluated for methodological quality using the Quality Reporting of Meta-analyses (QUOROM) guidelines, and results were pooled using the fixed-effects model.

RESULTS

Twelve RCTs were pooled for the outcomes of 24-hour PONV including 12 trials for vomiting and two trials for nausea. Compared with the control groups, all AS modalities reduced vomiting (RR = 0.69, 95% CI: 0.59-0.80, P < .0001) and nausea (RR = 0.59, 95% CI: 0.46-0.76, P < .0001). Acupressure (two trials) and acupuncture (six trials) modalities were effective in reducing vomiting (P < .005); however, ETS (two trials) did not show significant effects in reducing the vomiting (P = .118) in children. Compared with the controls, medications (three trials) reduced vomiting (RR = 0.42, 95% CI: 0.22-0.7, P = .0056). There were no differences between the medication and AS treatments (three trials) in reducing vomiting (RR = 1.25, 95% CI: 0.54-2.93, P = .6025).

CONCLUSIONS

This metaanalysis demonstrated that acupressure and acupuncture are effective treatment modalities to reduce postoperative vomiting in children. Acupuncture treatment is as effective as medications to reduce vomiting in children. Acupuncture had the greatest impact on reducing vomiting when compared with acupressure and ETS in children.

Metaanalyses of Acustimulations: Effects on Nausea and Vomiting in Postoperative Adult Patients

OBJECTIVE

Using metaanalysis to examine the effects of acustimulations on nausea and vomiting symptoms (NVS) in postoperative adult populations.

METHODS

Metaanalyses of effects of various acupoints stimulations (AS) (including acupuncture, acupressure, and electrical stimulation) on NVS in postoperative adult populations were performed. Thirty-three quality randomized controlled trials (RCT) published over the past three decades were identified by evaluating the quality of randomization and treatment methods, and results were pooled using a fixed effects model.

RESULTS

Twenty-four trials were pooled for nausea, 29 trials for vomiting, and 19 trials for rescue antiemetics, with AS compared with placebo or controls. Two additional trials did not have control groups but compared AS to medication groups. Compared with the controls, AS (all modalities) reduced nausea (relative risk [RR] = 0.60, 95% confidence interval [CI]: 0.54-0.67, P < .0001), vomiting (RR = 0.51, 95% CI: 0.45-0.57, P < .0001), and use of rescue antiemetics (RR = 0.63, 95% CI: 0.54-0.74, P < 0001). All AS modalities were effective in reducing NVS. Korean hand acupressure stimulations (two trials) had the best impact on reducing vomiting. There were no significant differences on pooled RRs for nausea (five trials) and vomiting (eight trials) between medication and AS groups, but medication groups had increased use of rescue antiemetics (two trials, RR = 2.27, 95% CI: 1.48-3.49, P = .0002). There was a placebo effect when compared with controls in reducing nausea (four trials, RR = 0.67, 95% CI: 0.50-0.90, P = .0069) and vomiting (three trials, RR = 0.39, 95% CI: 0.19-0.80, P = .0106).

CONCLUSIONS

This metaanalysis demonstrated that AS is just as effective as medications in reducing NVS and that acupressure is just as effective as acupuncture or electrical stimulation in reducing NVS for postoperative adult populations.

Acupressure for intrathecal narcotic-induced nausea and vomiting after caesarean section

In this randomized double-blind trial we investigated the effect of acupressure on the incidence of nausea and vomiting after caesarean section under spinal anaesthesia with added intrathecal morphine. Parturients wore either acupressure or placebo wristbands during surgery and postoperatively for at least 10 h. There was no significant difference overall between the two groups in the incidence of intra- or postoperative nausea or vomiting/retching. Demand for antiemetic medication was also similar in the two groups. However, in the sub-group of parturients who gave a previous history of postoperative nausea or vomiting, there was a statistically significant reduction in both postoperative nausea and vomiting/retching in the acupressure group. Further investigations are needed to see whether acupressure may be an effective non-pharmacological, non-invasive treatment for a common problem in this sub-group of patients.

Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting

BACKGROUND

Postoperative nausea and vomiting (PONV) are common complications following surgery and anaesthesia. Drug therapy to prevent PONV is only partially effective. An alternative approach is to stimulate a P6 acupoint on the wrist. Although there are many trials examining this technique, the results are conflicting.

OBJECTIVES

To determine the efficacy and safety of P6 acupoint stimulation in preventing PONV.

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library, Issue 1, 2003), MEDLINE (January 1966 to January 2003), EMBASE (January 1988 to January 2003) and the National Library of Medicine publication list of acupuncture studies up to and including January 2003. Reference lists of retrieved papers and reviews were consulted for additional references.

SELECTION CRITERIA

All randomized trials of techniques that stimulated the P6 acupoint compared with: sham treatment or drug therapy for the prevention of PONV. Interventions used in these trials included acupuncture, electro-acupuncture, transcutaneous nerve stimulation, laser stimulation, acustimulation device and acupressure.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed methodological quality and extracted the data. Primary outcomes were incidences of nausea and vomiting. Secondary outcomes were the need for rescue antiemetic therapy and adverse effects. A random effects model was used and relative risk (RR) with associated 95% confidence intervals (95% CI) are reported. Egger's test was used to measure the asymmetry of the funnel plot.

MAIN RESULTS

Twenty-six trials (n = 3347) were included, none of which reported adequate allocation concealment. There were significant reductions in the risks of nausea (RR 0.72, 95% CI 0.59 to 0.89), vomiting (RR 0.71, 95% CI 0.56 to 0.91) and the need for rescue antiemetics (RR 0.76, 95% CI 0.58 to 1.00) in the P6 acupoint stimulation group compared with the sham treatment, although many of the trials were heterogeneous. There was no evidence of difference in the risk of nausea and vomiting in the P6 acupoint stimulation group versus individual antiemetic groups. However, when different antiemetics were pooled, there was significant reduction in the risk of nausea but not vomiting in the P6 acupoint stimulation group compared with the antiemetic group (RR 0.70, 95% CI 0.50 to 0.98; RR 0.92, 95% CI 0.65 to 1.29 respectively). The side effects associated with P6 acupoint stimulation were minor. There was some evidence of asymmetry of the funnel plot.

REVIEWERS' CONCLUSIONS

This systematic review supports the use of P6 acupoint stimulation in patients without antiemetic prophylaxis. Compared with antiemetic prophylaxis, P6 acupoint stimulation seems to reduce the risk of nausea but not vomiting.

Comparison of acupressure bands and droperidol for reducing post-operative nausea and vomiting in gynecologic surgery patients

The purpose of this study was to evaluate the effectiveness of acupressure bands, droperidol, and the combined modalities, administered preoperatively, in reducing PONV in inpatient gynecologic patients. One hundred and forty-three patients were randomized to one of four groups: droperidol and acupressure bands, droperidol and placebo bands, placebo drug and acupressure bands, or placebo drug and placebo bands. Overall, during their hospital stay, 69% of the women experienced PONV and 45% experienced vomiting at some time. Although droperidol was most effective the day of surgery, neither acupressure bands or droperidol were effective in reducing PONV.

Placebo controls in randomized trials of acupuncture

Considerable intellectual and practical effort has been expended on designing and evaluating placebo controls in acupuncture studies. Somewhat less attention has been paid to the question: Why use a placebo in a randomized trial of acupuncture? This is partly because placebo controls have generally been seen as an inherent part of randomized trial methodology. As a result, most acupuncture trials have included a placebo-control group. A large number of different placebo techniques have been used in these trials. The design and choice of placebo techniques has typically depended on purely theoretical considerations, without empirical validation of physiological inactivity and psychological credibility. Principles can be developed for deciding whether to use placebo or another form of control in a randomized trial. These include issues of ethics, practicality and methodology. Such principles apply regardless of the intervention; they can and should be applied to acupuncture research.

The efficacy of acupressure to prevent nausea and vomiting in post-operative patients

BACKGROUND

Post-operative nausea and vomiting is a common complication following general anaesthesia. Traditional Chinese medicine indicates that acupressure therapy may reduce nausea and vomiting in certain ailments.

AIM(S) OF THE STUDY

The aim of this study was to examine the effect of stimulating two acupressure points on prevention of post-operative nausea and vomiting.

DESIGN AND METHODS

A randomized block experimental design was used. The Rhodes Index of Nausea, Vomiting and Retching (INVR) questionnaire was used as a tool to measure incidence. To control the motion sickness variable, the subjects who underwent functional endoscopic sinus surgery (FESS) under general anaesthesia were randomly assigned to a finger-pressing group, a wrist-band group, and a control group. There were 150 subjects in total with each group consisting of 50 subjects. The acupoints and treatment times were similar in the finger-pressing group and wrist-band pressing group, whereas only conversation was employed in the control group.

RESULTS

Significant differences in the incidence of the post-operative nausea and vomiting were found between the acupressure, wrist-band, and control groups, with a reduction in the incidence rate of nausea from 73.0% to 43.2% and vomiting incidence rate from 90.5% to 42.9% in the former. The amount of vomitus and the degree of discomfort were, respectively, less and lower in the former group.

CONCLUSION

In view of the total absence of side-effects in acupressure, its application is worthy of use. This study confirmed the effectiveness of acupressure in preventing post-operative nausea and vomiting.

Korean hand acupressure reduces postoperative nausea and vomiting after gynecological laparoscopic surgery

To investigate the effectiveness of prophylactic Korean hand acupressure in the prevention of postoperative vomiting in women scheduled for minor gynecological laparoscopic surgery, we conducted a double-blinded, randomized, placebo-controlled study. In one group (n = 40), acupressure was performed 30 min before the induction of anesthesia by using special acupressure seeds, which were fixed onto the Korean hand acupuncture point K-K9 and remained there for at least 24 h. The second group (n = 40) functioned as the Placebo group. The treatment groups did not differ with regard to demographics, surgical procedure, or anesthetic administered. In the Acupressure group, the incidence of nausea and vomiting was significantly less (40% and 22.5%) than in the Placebo group (70% and 50%). We conclude that Korean hand acupressure of the acupuncture point K-K9 is an effective method for reducing postoperative nausea and vomiting in women after minor gynecological laparoscopic surgery.

IMPLICATIONS

This randomized study was performed to investigate the antiemetic effect of the Korean hand acupuncture point K-K9. Acupressure of K-K9 reduces the incidence of postoperative nausea and vomiting in female patients after minor gynecological laparoscopic surgery.

The effects of acupressure on the incidence of postoperative nausea and vomiting in postsurgical patients

Postoperative nausea and vomiting (PONV) is one of the most common postoperative complications. Aside from pharmacological interventions, other complementary healing modalities have been introduced to assist patients in decreasing PONV and improving postoperative outcomes. This study examined acupressure as a potentially holistic and safe complement to the more traditional approach of using drugs to prevent and/or relieve nausea and vomiting in the postoperative patient. Acupressure involves constant pressure (without puncture of the skin) on the Nei Guan acupuncture points through the use of a British product called Sea-Bands (Sea Band UK Ltd, Leics, England). These bands are made of elasticated fabric, with a small round plastic button inside. A quasi-experimental research design was used to examine the effects of unilateral and bilateral application of acupressure on 157 patients who are prone to PONV: postgynecological, postplastic, and posturological surgery patients. The incidence of PONV was determined through retrospective chart reviews. The hypothesis was that there would be a difference in the incidence of PONV between 5 groups: group 1 (Sea-Bands with acupressure on both wrists), group 2 (Sea-Bands with acupressure on one wrist), group 3 (wristband without acupressure on both wrists), group 4 (wristband without acupressure on one wrist), and group 5 (no wristband). This hypothesis was examined by using a one-way analysis of variance (ANOVA); it was not supported. Neither unilateral nor bilateral application of acupressure significantly affected the incidence of nausea and vomiting. These findings must be viewed with caution, however, because power analysis showed low effect sizes and an inadequate sample size. Further research is recommended with a larger sample size. This study has made perianesthesia nurses more aware of other complementary modalities to assist patients with nausea and vomiting.

Prevention and treatment of postoperative nausea and vomiting

Pain, nausea and vomiting are frequently listed by patients as their most important perioperative concerns. With the change in emphasis from an inpatient to outpatient hospital and office-based medical/surgical environment, there has been increased interest in the 'big little problem' of postoperative nausea and vomiting (PONV). Currently, the overall incidence of PONV is estimated to be 25 to 30%, with severe, intractable PONV estimated to occur in approximately 0.18% of all patients undergoing surgery. PONV can lead to delayed postanaesthesia care unit (PACU) recovery room discharge and unanticipated hospital admission, thereby increasing medical costs. The aetiology and consequences of PONV are complex and multifactorial, with patient-, medical- and surgery-related factors. A thorough understanding of these factors, as well as the neuropharmacology of multiple emetic receptors [dopaminergic, muscarinic, cholinergic, opioid, histamine, serotonin (5-hydroxy-tryptamine; 5-HT)] and physiology [cranial nerves VIII (acoustic-vestibular), IX (glossopharyngeal) and X (vagus), gastrointestinal reflex] relating to PONV are necessary to most effectively manage PONV. Commonly used older, traditional antiemetics for PONV include the anticholinergics (scopolamine), phenothiazines (promethazine), antihistamines (diphenhydramine), butyrophenones (droperidol) and benzamides (metoclopramide). These antiemetics have adverse effects such as dry mouth, sedation, hypotension, extrapyramidal symptoms, dystonic effects and restlessness. The newest class of antiemetics used for the prevention and treatment of PONV are the serotonin receptor antagonists (ondansetron, granisetron, tropisetron, dolasetron). These antiemetics do not have the adverse effects of the older, traditional antiemetics. Headache and dizziness are the main adverse effects of the serotonin receptor antagonists in the dosages used for PONV. The serotonin receptor antagonists have improved antiemetic effectiveness but are not as completely efficacious for PONV as they are for chemotherapy-induced nausea and vomiting. Older, traditional antiemetics (such as droperidol) compare favourably with the serotonin receptor antagonists regarding efficacy for PONV prevention. Combination antiemetic therapy improves efficacy for PONV prevention and treatment. In the difficult-to-treat PONV patient (as in the chemotherapy patient), suppression of numerous emetogenic peripheral stimuli and central neuroemetic receptors may be necessary. This multimodal PONV management approach includes use of: (i) multiple different antiemetic medications (double or triple combination antiemetic therapy acting at different neuroreceptor sites); (ii) less emetogenic anaesthesia techniques; (iii) adequate intravenous hydration; and (iv) adequate pain control.

The use of nonpharmacologic techniques to prevent postoperative nausea and vomiting: a meta-analysis

We assessed the efficacy of nonpharmacologic techniques to prevent postoperative nausea and vomiting (PONV) by systematic review. These studies included acupuncture, electroacupuncture, transcutaneous electrical nerve stimulation, acupoint stimulation, and acupressure. Of the 24 randomized trials retrieved by a search of articles indexed on the MEDLINE and EMBASE databases (1980-1997), 19 were eligible for meta-analysis. The primary outcomes were the incidence of nausea, vomiting, or both 0-6 h (early efficacy) or 0-48 h (late efficacy) after surgery. The pooled relative risk (RR) and numbers needed to treat (NNT) were calculated. In children, no benefit was found. Some results in adults were significant. Nonpharmacologic techniques were similar to antiemetics in preventing early vomiting (RR = 0.89 [95% confidence interval 0.47-1.67]; NNT = 63 [10-infinity]) and late vomiting (RR = 0.80 [0.35-1.81]; NNT = 25 [5-infinity]) in adults. Nonpharmacologic techniques were better than placebo at preventing early nausea (RR = 0.34 [0.20-0.58]; NNT = 4 [3-6]) and early vomiting in adults (RR = 0.47 [0.34-0.64]; NNT = 5 [4-8]). Nonpharmacologic techniques were similar to placebo in preventing late vomiting in adults (RR = 0.81 [0.46-1.42]; NNT = 14 [6-infinity]). Using nonpharmacologic techniques, 20%-25% of adults will not have early PONV compared with placebo. It may be an alternative to receiving no treatment or first-line antiemetics.

IMPLICATIONS

This systematic review showed that nonpharmacologic techniques were equivalent to commonly used antiemetic drugs in preventing vomiting after surgery. Nonpharmacologic techniques were more effective than placebo in preventing nausea and vomiting within 6 h of surgery in adults, but there was no benefit in children.

Pc.6 Acupressure for Dental Nausea: A Prospective Randomised Double Blind Clinical Trial with Crossover, Part 2

This reports the second part of a single-centre, prospective, randomised, double-blind clinical trial with crossover. It has aimed to assess whether PC.6 acupressure could reduce nausea related to maxillary dental impression taking.

The selection criterion was a self registration of nausea greater than 33% of a 100mm visual analogue scale (VAS) following an initial maxillary impression (control) in patients referred for treatment. Exclusion criteria were: current medication with a secondary emetic or anti-emetic effect, prior knowledge of PC.6 acupressure, a recent history of nausea, and the first trimester of pregnancy. Twenty three entered the trial and 18 completed.

The test involved a second and third impression with prior application of finger pressure on either PC.6 or a dummy point on the forearm The initial point was chosen by the patient, leaving the other point to be pressed subsequent to crossover. The mean level of nausea was recorded by patients after PC.6 acupressure and also after pressure at a dummy point. These recordings were then compared.

The sample consisted of 6 males and 12 females, and the mean age was 14.74 years. The mean difference in nausea between PC.6 acupressure and pressure at the dummy point was −0.39mm % of the VAS (SD 40.48mm %). The 95% Confidence Interval was −20.52 and 19.74mm %, and the difference was not significant. Three and a half minutes of PC.6 acupressure did not significantly reduce nausea experienced with a maxillary impression, compared with pressure at the dummy point, in this small sample: both showed a mean reduction of 50% on the control figure.

Nonpharmacologic treatment of postoperative nausea

Nausea is the most common postoperative complication of anesthesia. Appropriately applied acupressure offers a safe and cost-effective nursing approach to the prevention of this problem. This study tested the effect of acupressure on the incidence of postoperative nausea in same-day surgery patients.

METHODS

Ninety outpatient surgery patients were randomly assigned to one of three groups. The treatment group (n = 30) received bilateral elastic bands designed to exert pressure on the appropriate location on the distal aspect of the wrist during the perioperative period. The placebo group (n = 30) had elastic bands incapable of acupressure placed on their wrists. The control group (n = 30) received routine nursing and medical interventions for nausea and vomiting. Antiemetics were prescribed by the anesthesiologist and administered to patients in all three groups if nausea persisted and/or emesis occurred. The incidences of nausea or vomiting were tabulated separately for operating room, PACU phase I, and PACU phase II, and compared using Fisher's Exact Test.

RESULTS

The incidence of nausea and vomiting did not differ overall in the OR or PACU phase I. However, in PACU phase II the incidence was 10% in the treatment group, 20% in the placebo group, and 50% in the control group (overall, P = .0001). Treatment wrist bands reduced the incidence of nausea and vomiting as compared with the control group (P = .0001), as did the placebo wrist bands (P = .0033). The numerical trend suggests that the incidence is reduced by half. The incidence of nausea can be significantly reduced by the use of placebo and suggests that further reduction can be obtained by using acupressure.

Effect of P-6 acupressure on prevention of nausea and vomiting after epidural morphine for post-cesarean section pain relief

BACKGROUND

Nausea and vomiting are important side effects following administration of epidural morphine for post-Cesarean section pain relief. Stimulation of the P-6 (Neiguan) acupoint is a traditional Chinese acupuncture modality used for antiemetic purpose; it has been found to be effective. The aim of this study was to evaluate the antiemetic effect of P-6 acupressure in parturients given epidural morphine for post-Cesarean section pain relief.

METHOD

In a randomized, double-blind and controlled trial, sixty parturients receiving epidural morphine for post-Cesarean section pain relief were investigated. Parturients were allocated to receive the acupressure bands or placebo bands on the P-6 acupoint bilaterally before the administration of spinal anesthesia and were observed over a 48-hour study period.

RESULTS

The incidence of nausea and vomiting was significantly decreased from 43% and 27% in the control group, to 3% and 0% in the acupressure group, respectively (P < 0.05).

CONCLUSION

The results demonstrate that prophylactic use of acupressure bands bilaterally on the P-6 acupoint can significantly reduce incidence of nausea and vomiting after epidural morphine for post-Cesarean section pain relief.

Efficacy of P6 acupressure in the treatment of nausea and vomiting during pregnancy

OBJECTIVE

Our purpose was to investigate the efficacy of P6 acupressure in reducing or relieving symptoms of nausea with or without vomiting and retching during pregnancy.

STUDY DESIGN

Symptomatic pregnant volunteers (n=161) participated in a 7-day community-based clinical trial. All participants were assigned to one of three groups (i.e., P6 acupressure, placebo [acupressure bands inappropriately placed], or control) on the basis of a process of blocked randomization. Data were analyzed by error bar charts and analysis of variance of difference scores.

RESULTS

Of 161 women, 149 (92.5%) completed the protocol. Irrespective of group assignment, participants reported significant decreases in nausea (p<0.0009) and vomiting or retching (p<0.0009). However, there was no differential treatment effect as a result of acupressure.

CONCLUSION

There was no apparent medical benefit from the use of P6 acupressure. Our findings differ from other recently published studies that did not include a control group.

Problems That Patients Feel are Appropriate to Discuss with Their GPs

A descriptive study was performed to discover what problems patients felt it appropriate to discuss with their general practitioner, their use of alternative therapies, and any questions they wished their doctor had asked them in the past. Demographic data was recorded including Church attendance.

Data was collected using an original questionnaire distributed to two groups of patients; 150 consecutive patients attending the surgery (surgery group) and 220 randomly selected from the adult age-sex register (home group). Chi-squared analysis was performed.

A broad range of subjects appropriate to a general practice consultation was found (from influenza to spiritual problems). Prior use of homeopathy and hypnosis was widespread. Multiple attenders were more likely to be church attenders. Men in the surgery group were most likely to discuss marital, relationship and spiritual problems.

Qualitative data from open questions demonstrated patients' concerns with consultation time and the exploration of feelings.

Acupressure wrist bands to relieve nausea and vomiting in hospice patients: do they work?

This study assessed the effects of acupressure wrist bands on the nausea and vomiting of terminally ill patients. Using a single subject experimental design, six hospice patients were exposed to three conditions: An acupressure wrist band; A placebo wrist band; A no wrist band condition. Patients and their caregivers rated nausea and vomiting during the treatment. Despite some difficulty obtaining complete data, the results of this preliminary test indicate that acupressure wrist bands were not effective in reducing nausea and vomiting in this small sample of hospice patients.