Recent advances in the non-pharmacological management of postoperative nausea and vomiting

D. J. Rowbotham*

University Division of Anaesthesia, Critical Care Pain and Pain, University of Leicester, Victoria Building, Leicester Royal Infirmary, Leicester LE1 5WW, UK

* E-mail: djr8{at}le.ac.uk

Keywords: acupuncture ; vomiting, nausea, postoperative


    Introduction
 Top
 Introduction
 Acupressure wristbands
 Acustimulation
 Acupuncture injections
 Electroacupuncture
 Korean hand acupressure
 Conclusions
 References
 
Acupuncture is available worldwide for the treatment of many conditions and complaints. In recent years, clinical and laboratory investigations have been conducted in an attempt to provide an evidence-base in support of this technique. Although in some cases the quality of the data is poor, systematic reviews have been published describing the use of acupuncture in chronic pain (e.g. back, neck, arthritis, headache, fibromyalgia), weight reduction, addiction, temporomandibular joint disorders, asthma, smoking cessation, emesis, stroke, and tinnitus.18 The nature, quality, and implications of the data are often fiercely debated. However, it is generally accepted that there is clear evidence that acupuncture can be effective for nausea and vomiting associated with pregnancy, chemotherapy, and the postoperative period.6 18 21 23

The mechanism of action of acupuncture is still uncertain. It may be that low frequency stimulation of the skin activates A-ß and A-{delta} fibres, which may influence neurotransmission in the dorsal horn or higher centres. The endogenous opioid system is probably involved; 25 yr ago, increased concentrations of ß-endorphins were reported in human cerebrospinal fluid after acupuncture in patients with chronic pain.11 There is evidence to suggest that different frequencies of stimulation are associated with the release of specific opioids.16 For example, 2 Hz stimulation releases enkephalin, ß-endorphin, and endomorphin; 100 Hz stimulation releases dynorphin. Perhaps part of the mechanism of action in nausea and vomiting is explained by the fact that acupuncture has been shown to inhibit gastric acid secretion and normalize gastric dysrrhythmia.27

The evidence-base for acupuncture at the traditional Chinese P6 point for the prevention of PONV has been reviewed by Lee and Done;21 their findings have recently been updated on the Cochrane Database of Systematic Reviews.22 Data pooled from relatively well-designed studies investigating the various methods of P6 acupuncture administration show that it is effective in the prevention of PONV. The size of the effect is comparable with antiemetic drugs. After analysing 26 trials, the relative risk compared with sham treatment for nausea, vomiting and need for escape antiemesis was 0.72, 0.71, and 0.76, respectively. There was a suggestion that P6 acupuncture is more effective against nausea compared with vomiting.

A major attraction of acupuncture is its favourable side-effect profile compared with pharmacological intervention. Adverse events have been described in a prospective survey of 32 000 administrations of acupuncture by doctors and physiotherapists;37 only 43 significant events were reported (14 per 10 000 treatments). None of these events were considered as serious; the most common were fainting, needle allergy, exacerbation of symptoms, needle lost or left in place, needle site pain (2 weeks maximum), drowsiness/lethargy, headache, and anxiety. Another, almost identical, survey of 34 000 treatments demonstrated a similar adverse event profile with an incidence of 13 per 10 000.25 However, these reports are concerned with acupuncture delivered in general and specialist practice; not in the perioperative period where acupuncture may be given to unconscious patients with significant co-morbidities, for example diabetics, the immunocompromised. Some serious, and occasionally fatal, complications have been reported, including pneumothorax, necrotizing fasciitis, abscess formation, hepatitis, nerve injury, and vessel damage.10 20 26 29 31 34

The evidence suggests that acupuncture should be considered when attempting to prevent PONV. However, manual acupuncture requires specialist training and is labour intensive and time-consuming; it may not be practical in many units. This article reviews recent work investigating the efficacy of acupuncture delivered by techniques, which could be applied relatively easily in many patients.


    Acupressure wristbands
 Top
 Introduction
 Acupressure wristbands
 Acustimulation
 Acupuncture injections
 Electroacupuncture
 Korean hand acupressure
 Conclusions
 References
 
Data on the efficacy of wristbands that apply constant simple pressure on the P6 point (acupressure) are available. Urological endoscopic surgery can be associated with a high risk of PONV and the effect of wristbands applied at the P6 point have been compared with placebo in 200 patients undergoing internal ureterotomy, cysto/panendoscopy, double J-stenting, ureterorenoscopy, percutaneous nephrostomy, or cystolithopaxy.1 Patients with a previous history of PONV and travel sickness were excluded. The wristbands were applied 30 min before surgery and the incidence of PONV was observed for 24 h. However, the wristbands were removed 6 h post operation. Twenty-five per cent of the acupressure group experienced PONV compared with 29% of the placebo group (not significant). Despite the fact that there was no prospective power analysis in this study and the retrospective calculation is unclear, it seems likely that this study did fail to show a difference; however, it is a pity that the wristbands were removed after only 6 h and that there were no data showing the incidence of PONV during this period when treatment was being applied.

The same investigators went on to investigate PONV after laparoscopic cholecystectomy in a study of improved design.2 Wristbands applied 30 min before surgery at P6 were compared with placebo and ondansetron 4 mg. There was a low incidence of PONV and no differences between the groups at 6–24 h after surgery; however, in the first 6 h (when the wristbands were applied), there was a significant and very similar beneficial effect of the wristbands and ondansetron 4 mg compared with placebo (incidence of PONV 10, 8, and 44%, respectively; P<0.05).

Alkaissi and workers have published two studies investigating acupressure administered by a Sea-Band® in women undergoing minor gynaecological surgery. The first study3 involved only 20 patients per group and the placebo stimulation group seemed to have an antiemetic effect as well as the active stimulation group. Their second study4 was larger and multi-centre; it involved 410 women and the data were analysed using regression techniques to account for confounding variables. A complete response (no PONV) was more likely in the active group compared with those receiving no acupressure (67 vs 54%; P<0.05). Unfortunately, this study was not fully blinded.


    Acustimulation
 Top
 Introduction
 Acupressure wristbands
 Acustimulation
 Acupuncture injections
 Electroacupuncture
 Korean hand acupressure
 Conclusions
 References
 
Transcutaneous electrical stimulation is used routinely in many acute and chronic pain situations; there are considerable data with respect to its efficacy for this indication.33 38 Similar technology can be used to stimulate acupuncture points (acustimulation). Acustimulation was described initially in pregnancy-induced nausea and vomiting where it was found to be effective.14 To date, the most investigated commercially available acustimulation device is the ReliefBand®. It is a portable battery powered (lithium coin cells) device that is worn on the wrist like a watch.42 Two electrodes contact the skin with the aid of the application of electroconductive gel. The nature of the stimulation can be varied; a typical setting is 25 mA at 31 Hz.

One of the first reports elucidating the efficacy of acustimulation for PONV was a multicentre study of 221 patients undergoing laparoscopic cholecystectomy under standardized anaesthesia.42 The device was applied 10 min before the end of surgery and remained in situ for 9 h. Patients were randomized into three groups: (i) active ReliefBand® at P6; (ii) sham ReliefBand® at P6; and (iii) sham ReliefBand® on the dorsum of the wrist away from any recognized acupuncture sites (designated placebo). The results were somewhat inconclusive, probably because of the multi-centre design, inadequate patient numbers, and the use of a low output setting on the device. There was a significantly decreased (P<0.05) incidence of moderate-severe nausea for up to 9 h after surgery in the active treatment group compared with the sham and placebo groups (5–11, 16–38, and 15–26%, respectively). However, there were no differences in the incidence of vomiting and the need for escape medication.

A more controlled, better designed, single-centre study compared the efficacy (alone and combined with ondansetron 4 mg) of acustimulation (ReliefBand® for 72 h) with ondansetron 4 mg in 120 patients undergoing plastic surgery.39 There was no doubt that, compared with ondansetron alone, the combination of acustimulation and ondansetron significantly reduced the incidence of nausea (20 vs 50%), vomiting (nil vs 20%) and need for rescue analgesia (10 vs 37%). Also, the ability to resume a normal diet within 24 h, quality of recovery, and patient satisfaction were significantly superior in the combined group. There was a trend for acustimulation to be better than ondansetron 4 mg alone but statistical significance was not reached. The study was powered to detect a 25% difference between groups and provides convincing evidence for the prophylactic antiemetic effect of acustimulation.

The vast majority of the literature with respect to PONV is concerned with prophylaxis. Studies investigating the treatment of episodes of PONV are difficult to design and perform. For example, a high proportion of patients recruited to these studies will not develop PONV and therefore not be randomized into the treatment groups. Furthermore, many believe that the use of placebo for PONV studies is unethical and standardized anaesthesia will often include a prophylactic antiemetic; both these factors reduce the recruitment rate further.

However, there are data to support the use of acustimulation for the treatment of established PONV. A well-designed study compared acustimulation (ReliefBand®), ondansetron 4 mg and the combination of both techniques for the treatment of PONV in patients undergoing day-case surgery with general anaesthesia.12 It was powered to detect a reduction in the need for a second intervention by 30%; 221 patients were recruited and 90 developed PONV. Unfortunately, antiemetic prophylaxis with metoclopramide 10 mg or droperidol 0.625 mg was given; however, there were no differences in the treatment groups in this respect. Combination of acustimulation and ondansetron was clearly superior to acustimulation alone (complete response rate 73 vs 40%; P<0.01). Response rates with acustimulation alone compared with ondansetron were not significantly different but there was a trend for acustimulation to be inferior to ondansetron (40 vs 57%).


    Acupuncture injections
 Top
 Introduction
 Acupressure wristbands
 Acustimulation
 Acupuncture injections
 Electroacupuncture
 Korean hand acupressure
 Conclusions
 References
 
Acupuncture points may be stimulated by the injection of mild irritants; this may be particularly useful if the use of indwelling needles is difficult or inappropriate, for example in children.

The use of dextrose 50% injected at the P6 point for prophylaxis of PONV in children undergoing general anaesthesia and surgery has been described.36 Investigators used 0.2 ml of dextrose 50% injected at P6 and sham locations at the end of surgery before reversal of anaesthesia. This technique was compared with the efficacy of droperidol 10 µg kg–1 in 190 children aged 7–16 yr undergoing day-case surgery. The study design was complicated (randomized, double-blind, sham placebo-controlled) but it was clear that P6 injections were effective. For example, the incidence of PONV in the post-anaesthetic care unit (PACU) was significantly lower in the acupoint group compared with the sham group (32 vs 56%; P<0.03); it was also better than the droperidol group, but not significantly so (32 vs 46%). Other measures, including need for rescue therapy, showed a similar pattern and logistic regression models excluded effects of other confounding variables. After 24 h, there were no differences between the groups but data were affected considerably by use of escape medication by this time.

The effect of 0.2 ml of glucose 30% injection has been compared with droperidol 20 µg kg–1 and placebo in 120 adults undergoing gynaecological laparoscopy.40 Both acupuncture injections and droperidol had a significant effect on PONV compared with placebo.

Local complications of this technique are of potential concern, particularly in small children. In the paediatric study described above,36 there were no complaints of pain or local irritation and no signs of median nerve damage (the solution was injected above the palmar aponeurosis; the median nerve lies below this structure). The authors stated that they were not aware of any case report describing median nerve damage using this technique. However, median nerve damage is possible with acupuncture. For example, a foreign body resulting from the fracture of an acupuncture needle has caused median nerve neuropathy, which resolved when it was removed.34 If injection of dextrose 50% was adopted for general and frequent use, it would not be too surprising if median nerve damage was reported. There will be no warning of injection deep to the palmar aponeurosis (median nerve pain) in the anaesthetized patient.


    Electroacupuncture
 Top
 Introduction
 Acupressure wristbands
 Acustimulation
 Acupuncture injections
 Electroacupuncture
 Korean hand acupressure
 Conclusions
 References
 
Acupuncture can be administered by passing a small electric current through a needle inserted at an acupuncture point and another needle acting as a skin surface electrode. Needles can be laid flat against the skin and taped in position. This technique has been used extensively in many branches of medicine, including chronic pain,9 but work on PONV has been limited to date.

One of the first studies originated in Taiwan and was published in 1989; it described 100 patients undergoing gynaecological laparoscopy,17 and compared electroacupuncture with a control group and prochlorperazine 5 mg. The incidence of emesis was the same in both active groups (12%), and this was significantly less than in the control group (44%; P<0.05).

More recently, its efficacy has been investigated in a study of 120 children undergoing tonsillectomy with and without adenoidectomy.30 The incidence of overall PONV was significantly lower in the active group compared with control (63 vs 93%: P<0.001; numbers needed to treat 3.3). The effect on overall PONV was primarily as a result of a difference in the incidence of nausea (60 vs 85%: P<0.01); there was no significant difference in the likelihood of vomiting.

Electroacupuncture has recently been compared with ondansetron 4 mg in women undergoing major breast surgery.15 Electrical stimulation was applied 30–60 min before induction of anaesthesia and continued until the end of surgery. There was a clear effect of both active groups; for example, the complete response rate (no nausea, vomiting, or rescue medication) was greater in the acupuncture (73%) and ondansetron groups (52%) at 24 h compared with placebo (38%; P<0.006). The incidence of nausea at 2 h was significantly less in the acupuncture group (19%) compared with the ondansetron (40%) and placebo group (79%; P<0.0001). Other studies using electrical stimulation of acupuncture needles have reduced some or all elements of PONV.24 35


    Korean hand acupressure
 Top
 Introduction
 Acupressure wristbands
 Acustimulation
 Acupuncture injections
 Electroacupuncture
 Korean hand acupressure
 Conclusions
 References
 
Korean hand acupuncture is a new technique that does not utilize traditional Chinese acupuncture points such as P6; it was first described by a Korean physician in the 1970s.41 We are aware of this in the context of PONV initially because of the work of Schlager and colleagues.7 32 The Korean hand acupuncture point K-K9 is equivalent to the Chinese acupuncture point P6 but it is situated on the palmar aspect of the middle phalanx of the fourth finger (Fig. 1). This point can be stimulated by the use of Korean acupressure discs that are secured to the area by the use of adhesive tape. Schlager and colleagues32 investigated the efficacy of this technique in children after strabismus surgery. In a well-designed, appropriately powered study, disc stimulation of the K-K9 point was compared with placebo (tape only) in 50 children. The incidence of vomiting was significantly lower in the active group (20 vs 68%; P=0.001). The same team went on to confirm their findings in a study investigating the efficacy after laparoscopic gynaecological surgery.8 On this occasion, Korean acupressure at K-K9 was applied using a 2-mm diameter acupressure seed kept in place by adhesive tape. The incidence of nausea (40 vs 70%; P=0.006) and vomiting (23 vs 50%; P=0.007) was significantly less in the active group.



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Fig 1 Traditional Chinese and Korean hand acupuncture points used for PONV. Chinese P6: located three patient's finger breadth proximal to the proximal flexor palmar crease, between the tendons of the flexor carpi radialis and palmaris longus. Korean hand acupressure point K-K9: palmar aspect of the middle phalanx of the fourth finger. Korean hand acupressure point K-D2: dorsum of the lateral aspect of the distal phalanx of the index finger.

 
Korean workers have investigated the efficacy of Korean hand acupuncture in preventing PONV after abdominal hysterectomy in 160 patients.19 This study utilized a capsaicin plaster to provide stimulation to another Korean hand acupuncture point (K-D2). This is situated on the dorsum of the lateral aspect of the distal phalanx of the index finger (Fig. 1). Efficacy at this point was compared with placebo and also Chinese acupuncture point P6. The incidence of vomiting when using the K-D2 point (22%) and the P6 point (26%) was significantly less than the control group (57%; P<0.001). The need for rescue therapy was also significantly less in both active groups. Recently, the same group have reported a significant effect of Korean hand acupuncture (point K-A20) in reducing the incidence and severity of sore throat after abdominal hysterectomy.28

The relationship between motion sickness and PONV is well established.13 The efficacy of Korean hand acupuncture in preventing motion sickness has been demonstrated in patients undergoing ambulance transfer to hospital for treatment of minor trauma.5 On arrival at hospital, there was a significant increase in nausea scores in both active and sham groups but the scores were significantly less in the active group (25 vs 83 mm; P<0.01).


    Conclusions
 Top
 Introduction
 Acupressure wristbands
 Acustimulation
 Acupuncture injections
 Electroacupuncture
 Korean hand acupressure
 Conclusions
 References
 
There is considerable evidence that acupuncture applied at the traditional Chinese acupuncture point P6 is effective at preventing PONV with very few side-effects. Furthermore, the effect compares favourably with antiemetic drugs. Some acupuncture techniques are not time-consuming and do not need to be administered by specially trained personnel. There are sufficient data to support the widespread use of acupuncture at P6 for PONV. This would enable the assessment of efficacy and safety in large numbers of patients and possibly enhance the perioperative experience of many.

To date, published data on Korean hand acupressure are very impressive and this simple technique may find a place in clinical practice. However, further investigations are required.


    References
 Top
 Introduction
 Acupressure wristbands
 Acustimulation
 Acupuncture injections
 Electroacupuncture
 Korean hand acupressure
 Conclusions
 References
 
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2 Agarwal A, Bose N, Gaur A, Singh U, Gupta MK, Singh D. Acupressure and ondansetron for postoperative nausea and vomiting after laparoscopic cholecystectomy. Can J Anaesth 2002; 49: 554–60[Abstract/Free Full Text]

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5 Bertalanffy P, Hoerauf K, Fleischhackl R, et al. Korean hand acupressure for motion sickness in prehospital trauma care: a prospective, randomized, double-blinded trial in a geriatric population. Anesth Analg 2004; 98: 220–3[Abstract/Free Full Text]

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9 Casimiro L, Brosseau L, Milne S, Robinson V, Wells G, Tugwell P. Acupuncture and electroacupuncture for the treatment of RA. Cochrane Database Systematic Rev 2002; 3: Cd003788

10 Cho YP, Jang HJ, Kim JS, Kim YH, Han MS, Lee SG. Retroperitoneal abscess complicated by acupuncture: case report. J Korean Med Sci 2003; 18: 756–7[ISI][Medline]

11 Clement-Jones V, McLoughlin L, Tomlin S, Besser GM, Rees LH, Wen H. Increased beta-endorphin but not metenkephalin levels in human cerebrospinal fluid after acupuncture stimulation for recurrent pain. Lancet 1980; 2: 946–8[CrossRef][ISI][Medline]

12 Coloma M, White PF, Ogunnaike BO, et al. Comparison of acustimulation and ondansetron for the treatment of established postoperative nausea and vomiting. Anesthesiology 2002; 97: 1387–92[CrossRef][ISI][Medline]

13 Eberhart LHJ, Hogel J, Seeling W, Staack AM, Geldner G, Georgieff M. Evaluation of three risk scores to predict postoperative, nausea and vomiting. Acta Anaesthesiol Scand 2000; 44: 480–8[CrossRef][ISI][Medline]

14 Evans AT, Samuels SN, Marshall C, Bertolucci LE. Supression of pregnancy-induced nausea and vomiting with sensory afferent stimulation. J Reprod Med 1993; 38: 603–6[ISI][Medline]

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16 Han JS. Acupuncture and endorphins. Neurosci Lett 2004; 361: 258–61[CrossRef][ISI][Medline]

17 Ho RT, Jawan B, Fung ST, Cheung HK, Lee JH. Electro-acupuncture and postoperative emesis. Anaesthesia 1989; 45: 327–9[ISI]

18 Kaptchuk TJ. Acupuncture: theory, efficacy, and practice. Ann Intern Med 2002; 136: 374–83[Abstract/Free Full Text]

19 Kim KS, Koo MS, Jeon JW, Park HS, Seung IS. Capsicum plaster at the Korean hand acupuncture point reduces postoperative nausea and vomiting after abdominal hysterectomy. Anesth Analg 2002; 95: 1103–7[Abstract/Free Full Text]

20 Lao L, Hamilton GR, Fu J, Berman BM. Is acupuncture safe? A systematic review of case reports. Altern Therap Health Med 2003; 9: 72–83[ISI]

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24 Lin JG, Lob MW, Wen YR, Hsieh CL, Tsai SK, Sun WZ. The effect of high and low frequency electroacupuncture in pain after lower abdominal surgery. Pain 2002; 99: 509–14[CrossRef][ISI][Medline]

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31 Saw A, Kwan MK, Sengupta S. Necrotising fasciitis: a life-threatening complication of acupuncture in a patient with diabetes mellitus. Singapore Med J 2004; 45: 180–2[Medline]

32 Schlager A, Boehler M, Puhringer F. Korean hand acupressure reduces postoperative vomiting in children after strabismus surgery. Br J Anaesth 2000; 85: 267–70[Abstract/Free Full Text]

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34 Southworth SR, Hartwig RH. Foreign body in the median nerve: a complication of acupuncture. J Hand Surg 1990; 15: 111–2

35 Stener-Victorin E, Waldenstrom U, Wikland M, Nilsson L, Hagglund L, Lundeberg T. Electro-acupuncture as a peroperative analgesic method and its effects on implantation rate and neuropeptide Y concentrations in follicular fluid. Hum Reprod 2003; 18: 1454–60[Abstract/Free Full Text]

36 Wang SM, Kain ZN. P6 acupoint injections are as effective as droperidol in controlling early postoperative nausea and vomiting in children. Anesthesiology 2002; 97: 359–66[CrossRef][ISI][Medline]

37 White A, Hayhoe S, Hart A, Ernst E. Adverse events following acupuncture: prospective survey of 32 000 consultations with doctors and physiotherapists. Br Med J 2001; 323: 485–6[Free Full Text]

38 White PF, Li S, Chiu JW. Electroanalgesia: its role in acute and chronic pain management. Anesth Analg 2001; 92: 505–13[Abstract/Free Full Text]

39 White PF, Issioui T, Hu J, et al. Comparative efficacy of acustimulation (ReliefBand) versus ondansetron (Zofran) in combination with droperidol for preventing nausea and vomiting. Anesthesiology 2002; 97: 1075–81[CrossRef][ISI][Medline]

40 Yang LC, Jawan B, Chen CN, Ho RT, Chang KA, Lee JH. Comparison of P6 acupoint injection with 50-percent glucose in water and intravenous droperidol for prevention of vomiting after gynecological laparoscopy. Acta Anaesthesiol Scand 1993; 37: 192–4[ISI][Medline]

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Cost effectiveness of non-pharmacological management of postoperative nausea and vomitingin low risk
Anwar K Rashid
British Journal of Anaesthesia, 29 Jun 2005 [Full text]

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