Aromatherapy Versus Oral Ondansetron for Antiemetic Therapy Among Adult Emergency Department Patients: A Randomized Controlled Trial

Inhaled Isopropyl Alcohol for the Treatment of Nausea and Vomiting in a Patient Receiving Palliative Care: A Case Report

Nausea and vomiting are distressing symptoms experienced by many patients receiving palliative care for serious illness. Common pharmacologic management strategies include 5-HT3 receptor antagonists, antipsychotics, antihistamines, and antimuscarinic agents; however, these agents incur risks of adverse effects. One of the most worrisome risks of commonly used antiemetics is prolonging the QT interval and the associated risk of torsades de pointes. To avoid the dangers of pharmacologic treatment of nausea and vomiting, previous studies in emergency medicine and postoperative settings suggest that inhaled isopropyl alcohol is an inexpensive, safe, and effective nonpharmacologic intervention. This case report highlights the successful use of inhaled isopropyl alcohol for managing nausea and vomiting in a patient with heart failure receiving palliative care.

Nonpharmacological Nursing Interventions in Postoperative Nausea and Vomiting: A Systematic Review

PURPOSE

This study aims to assess the impact of nonpharmacological nursing interventions on postoperative nausea and vomiting (PONV).

DESIGN

This is a systematic review.

METHODS

MEDLINE, Web of Science, ScienceDirect, Tübitak-ULAKBİM, and TRDizin databases were searched for the following search terms, including "Postoperative Nausea and Vomiting," "Nurse," "Nursing," and "Nonpharmacological Interventions" to identify nonpharmacological nursing interventions for PONV. A systematic review of English and Turkish articles published in the period between January 1, 2012 and June 1, 2023 was conducted. The PICOT-SD method was used to determine the compatibility of the pieces with the eligibility criteria.

FINDINGS

Fifty-eight of 3,874 articles obtained from databases fulfilled the eligibility criteria. This study demonstrated that acupuncture, aromatherapy, the oral intake of ginger, listening to music, education, and visits to patients decreased the incidence of nausea and vomiting and increased the quality of life. Additionally, it was found that patients' quality of life tended to improve along with reductions in postoperative complications.

CONCLUSIONS

The results of this study support previous findings in the literature and demonstrate that nonpharmacological nursing interventions help reduce and prevent PONV. Based on our results, we suggest that nonpharmacological nursing interventions can be employed for the management of PONV in patients undergoing surgery.

Isopropyl alcohol inhalation versus 5-HT3 antagonists for treatment of nausea: a meta-analysis of randomised controlled trials

PURPOSE

Nausea is a common and unpleasant sensation for which current therapies such as serotonin (5-HT3) antagonists are often ineffective, while also conferring a risk of potential adverse events. Isopropyl alcohol (IPA) has been proposed as a treatment for nausea. We aimed to compare IPA with 5-HT3 antagonists for the treatment of nausea across all clinical settings.

METHODS

MEDLINE, EMBASE, PubMed, CENTRAL and CINAHL were searched from inception to 17 July 2023 for randomised controlled trials (RCTs) comparing inhaled IPA and a 5-HT3 antagonist for treatment of nausea. Severity and duration of nausea, rescue antiemetic use, adverse events and patient satisfaction were the outcomes sought. Risk of bias (RoB) was assessed using Cochrane RoB 2. Random-effects model was used for meta-analysis. Combination of meta-analyses and narrative review was used to synthesise findings. The evidence was appraised using GRADE.

RESULTS

From 1242 records, 4 RCTs were included with 382 participants. Participants receiving IPA had a significantly lower mean time to 50% reduction in nausea (MD - 20.06; 95% CI - 26.26, - 13.85). Nausea score reduction at 30 min was significantly greater in the IPA group (MD 21.47; 95% CI 15.47, 27.47). IPA led to significantly reduced requirement for rescue antiemetics (OR 0.60; 95% CI 0.37, 0.95; p = 0.03). IPA led to no significant difference in patient satisfaction when compared with a 5-HT3 antagonist. The overall GRADE assessment of evidence quality ranged from very low to low.

CONCLUSION

IPA may provide rapid, effective relief of nausea when compared with 5-HT3 antagonists.

Isopropyl alcohol inhalation for the treatment of nausea in adult emergency department patients: a systematic review and meta-analysis

BACKGROUND

Nausea and vomiting is a common ED chief complaint. However, randomised trials comparing antiemetic agents to placebo have not demonstrated superiority. This systematic review investigates the efficacy of inhaled isopropyl alcohol (IPA) compared with usual care or placebo in adults presenting to the ED with nausea and vomiting.

METHODS

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, other relevant trial registries, journals, and conference proceedings up to September 2022. Randomised controlled trials using IPA to treat adult ED patients with nausea and vomiting were included. The primary outcome was change in severity of nausea, measured by a validated scale. A secondary outcome was vomiting during the ED stay. We used a random-effects model for the meta-analysis, and assessed certainty of evidence using the Grades of Recommendation, Assessment, Development and Evaluation system.

RESULTS

Two trials comparing inhaled IPA to saline placebo and including a total of 195 patients were pooled for meta-analysis of the primary outcome. A third study comparing a group receiving inhaled IPA and oral ondansetron to another group receiving inhaled saline placebo and oral ondansetron did not qualify for the original registered protocol, but was included in a secondary analysis. All studies were judged to be at low or unclear risk of bias. The pooled mean difference for the primary analysis was a reduction in reported nausea of 2.18 on a 0-10 scale (95% confidence interval (CI) 1.60 to 2.76), favouring IPA over placebo, where the minimum clinically significant difference was defined as 1.5. The evidence level was graded as moderate, due to imprecision from low patient numbers. Only the study included in the secondary analysis assessed the secondary outcome of vomiting, and did not find a difference between intervention and control.

CONCLUSION

This review suggests that IPA likely has a modest effect in reducing nausea in adult ED patients, compared with placebo. Larger multicentre trials are needed, as the evidence is limited by few trials and patients.

PROSPERO REGISTRATION NUMBER

CRD42022299815.

Droperidol versus ondansetron for nausea treatment within the emergency department

OBJECTIVE

A randomised single-blind trial was undertaken in an adult ED population, comparing the effectiveness of droperidol 2.5 mg IV with ondansetron 8 mg IV for the treatment of nausea and vomiting.

METHODS

Patients were randomly allocated to receive droperidol (n = 60) or ondansetron (n = 60). Patients rated their nausea severity on a Visual Analogue Scale (VAS) immediately before and 30 min after drug administration. The primary outcome was of symptom improvement, defined by a VAS change ≥-8 mm 30 min post-treatment. Mean VAS change and percentage experiencing desired effect were secondary outcomes compared.

RESULTS

Of 120 study patients, 60 (50%) received droperidol or ondansetron. Symptom improvement occurred in 93% (56 of 60) and 87% (52 of 60), respectively (P = 0.362). Mean VAS change was -38 mm and -29 mm, respectively (P = 0.031). Percentage of patients indicating desired effect was 85% and 63%, respectively (P = 0.006). Additional antiemetics were required for 16% and 37% of subjects, respectively (P = 0.006).

CONCLUSION

There was no statistically significant difference in the primary outcome of symptom improvement between droperidol and ondansetron. Secondary outcomes which favour droperidol warrant further exploration.

Inhalation of Isopropyl Alcohol for the Management of Nausea and Vomiting: A Systematic Review

Background: The use of inhaled isopropyl alcohol (IPA) has been proposed as a therapeutic intervention for the relief of nausea in various settings. The objective of this systematic review was to evaluate the existing evidence for the use of inhaled IPA in the management of nausea and vomiting. Methods: We performed a literature search on Medline, EMBASE, Web of Science, Scopus, CINAHL, PsycInfo, and Cochrane Library databases before November 2021. The following concepts were searched using subject headings and keywords as needed "aromatherapy," "alcohol," "ethylic alcohol," "ethanol," "isopropyl alcohol," "emesis," "chemotherapy-induced," "pregnancy," "hyperemesis gravidarum," "motion sickness," "emetics," "antiemetics," "inhalation," and "inhale." Searches were not limited to a specific language. The bibliographies of identified articles were also manually searched. Two authors independently assessed the included studies for risk of bias. Results: Thirteen randomized controlled trials out of 158 studies identified met the inclusion criteria, with a total of 1253 participants. Twelve studies were conducted in the postoperative anesthesia care unit and two studies were performed in the emergency department setting. Four studies were double blinded, one was single blind, and eight were open label. Three studies assessed the use of inhaled IPA for prevention, whereas 10 studies evaluated its use in the treatment of nausea and vomiting. Seven studies reported IPA to be more effective, four studies reported no difference, and two studies reported IPA to be ineffective. Participant satisfaction was high overall, regardless of intervention received. No adverse effects were reported. The overall quality of evidence was low. Conclusion: There is a lack of strong evidence to support the use of inhaled IPA in the management of nausea and vomiting. Additional trials are warranted to confirm this finding and to further explore the use of inhaled IPA in various populations and settings.

Aromatherapy in Palliative Care: A Single-Institute Retrospective Analysis Evaluating the Effect of Lemon Oil Pads against Nausea and Vomiting in Advanced Cancer Patients

Simple Summary

Palliative care aims to improve the quality of life for patients with serious illnesses by improving symptoms. Many patients with advanced diseases suffer from nausea and vomiting. In addition to evidenced-based treatments, patients with advanced diseases often seek for complementary and integrative therapies. Aromatherapy is commonly used to alleviate the various symptoms of palliative care patients and is well accepted by both patients and their caregivers. We retrospectively evaluated the efficacy of using lemon oil pads against nausea and vomiting in our palliative care unit and found a positive effect against nausea and vomiting in this patient group.

Abstract

Aromatherapy is regularly used in the University Hospital Krems’s palliative care unit. In a retrospective analysis, we investigated whether there were improvements in nausea and vomiting in patients with advanced cancers over a time span of 24 months. Data collection used the medical records of patients who were institutionally approved to receive routine aroma applications for alleviating nausea and vomiting. The efficacy of using lemon oil pads was tested with one-dimensional chi-squared tests. Sixty-six patients received 222 applications of lemon oil on cotton pads; no data were available for 17 applications. The adequate relief of nausea and vomiting was reported for 149 (73%) applications, whereas no symptom control was seen for 56 (27%) applications. For the 56 applications without symptom control, first- and second-line rescue medications were successful in 53 and 3 cases, respectively. The use of aromatherapy with lemon oil pads against nausea and vomiting was feasible for 73% of all applications. All patients who did not benefit from aromatherapy had effective symptom control with a rescue medication. Large randomized prospective trials are necessary to evaluate the benefit of the use of lemon oil pads against nausea and vomiting in patients with advanced cancer.

Translation of novel antiemetic to sub-Saharan Africa using diffusion of innovation framework

OBJECTIVE

Studies indicate inhaled isopropyl alcohol (IIA) is effective or superior to ondansetron for adult patients. Although quick-acting and low cost, it cannot be assumed this remedy is suitable for adoption in all settings. We explored how an innovative antiemetic remedy studied in the United States translates to a sub-Saharan Africa clinic/hospital setting using Rogers' Diffusion of Innovation Framework.

DESIGN

Qualitative design with purposive sampling.

SAMPLE

Health care staff (n = 11) providing and community members (n = 22) accessing health care services in a sub-Saharan Africa clinic/hospital.

MEASUREMENTS

Semi-structured interviews with coding and identification of themes via deductive content analysis using Rogers' Diffusion of Innovation Framework.

RESULTS

Nausea and vomiting was a common complaint, with malaria the most common etiology. Participants emphasized treatment of etiology over symptomatic treatment and described previous aromatherapy use. IIA advantages included administration route, quick-acting, self-administration, portable, available, and easy trialability. Participants expressed concerns regarding use of term "alcohol" as potentially offensive to others.

CONCLUSION

Use of Rogers' Diffusion of Innovation framework identified barriers and facilitators to translation of a novel antiemetic remedy for sub-Saharan Africa clinic/hospital settings. Evaluating clinical innovations from perspectives of relative advantage, compatibility, complexity, trialability, and observability enhances adoption of innovations within clinical settings.

Battlefield Acupuncture Versus Standard Pharmacologic Treatment of Low Back Pain in the Emergency Department: A Randomized Controlled Trial

BACKGROUND

Battlefield acupuncture (BFA) offers a novel analgesic option that avoids the need for pharmacologic interventions with problematic side effect profiles.

OBJECTIVE

To compare BFA with standard pharmacologic interventions to treat patients in the emergency department (ED) with low back pain.

METHODS

We conducted a nonblinded randomized controlled trial of a convenience sample of adults presenting to an urban tertiary care ED with a chief complaint of low back pain. We randomized subjects to undergo either BFA or the control arm in which they received standard pharmacologic therapies at the discretion of their treating clinician. The primary outcome was mean pain reduction measured on a 100-mm visual analogue scale (VAS) from enrollment to 30-40 min postintervention. Secondary outcomes included the Back Pain Functional Scale (BPFS; scores range from 0-60) measured at 30-40 min postintervention and again at 48-72 h postintervention.

RESULTS

We enrolled 52 subjects with 26 randomized to each arm. The mean decrease in pain VAS was 33.4 mm among patients undergoing BFA vs. 21.5 mm in the control arm (effect size difference 12.0 mm [95% confidence interval {CI} 0.1-23.8 mm]). The median improvement in the BPFS score at 48-72 h postintervention was 12.0 among patients undergoing BFA vs. 8.0 in the control arm (effect size difference 4 [95% CI -9.0 to 16.0]). There were no adverse events.

CONCLUSIONS

BFA shows promise for further study as an alternative to standard pharmacologic interventions among adults presenting to the ED with low back pain. © 2021 Elsevier Inc.

Effectiveness of Inhaled Aromatherapy on Chemotherapy-Induced Nausea and Vomiting: A Systematic Review

Background: Chemotherapy-induced nausea and vomiting (CINV) are among the most common and feared side effects of cancer treatments. Their presence has a negative impact on the quality of life and morbidity associated with the disease. Despite increasingly effective antiemetic treatments, 40% of cancer patients experience CINV during the acute or delayed phase of their treatment. This distressing experience lived through by a large number of people makes it a priority in the improvement of cancer patients and a daily concern for nurses in cancer care units. In an attempt to alleviate this problem, the idea of using aromatherapy as supportive care has led the authors to research the knowledge available on this subject. Objective: The purpose of this systematic review was to examine the existing scientific evidence regarding the effectiveness of respiratory aromatherapy on CINV in addition to standard treatment compared with their recommended management in people with cancer. Design: Systematic review. Methods: This review was conducted according to the preferred reporting items for systematic reviews and meta-analyses guidelines and queried six databases (PubMed, Scopus, Cochrane Database, Embase, CINAHL, and Google Scholar). An analysis of the risk of bias using the Cochrane "Risks of Bias" tools and a qualitative synthesis of the results of the studies were carried out. Results: Eleven studies were included, nine in adults and two in children. Seven out of nine studies showed statistically significant results in adults with either direct or dry inhalation. Four out of seven alleviated both nausea and vomiting thanks to peppermint, ginger essential oil; three decreased nausea only with chamomilla, ginger or cardamom essential oil. Atmospheric diffusion and the use of inhaled aromatherapy in children did not show any benefit. Conclusions: Results appear promising for the use of direct inhaled aromatherapy in the management of CINV. However, most of the studies found the women concerned suffered from gynecologic cancers and had certain methodological limitations. Indeed, small samples and a wide variety of interventions were studied (different essential oils, number of drops of essential oils used, method of administration, etc.), making it impossible so far to generalize these results. Studies with a more robust methodology and larger samples will make it possible to confirm the potential usefulness of this complementary treatment.

Olfactory Distraction for Management of Nausea in Palliative Care Patients

Nausea is one of the most common and debilitating symptoms Palliative Care patients experience. This can be caused by the life-limiting illness itself, its complications, or its treatments. While there are many options for management, including anti-emetics and motility agents, patients may develop refractory nausea or even intolerance to these treatments. Drug interactions, sedation, extrapyramidal effects, serotonin syndrome, and prolonged QT intervals with risk factors for Torsades de Pointes may all preclude use of these medications. Olfactory distraction using alcohol swabs has supporting literature in the emergency care setting as a means of alleviating nausea in a safe and effective way. We present a case series of 3 patients admitted to a Northwell facility who were referred to the Palliative Care consult service for severe nausea. The patients had nausea of varying etiology and were successfully managed with inhalation of alcohol swabs. This is the first case series that looks into applying this intervention to the Palliative Care population as an easy-to-use, readily-available, and safe method to manage nausea.

Implementation of isopropyl alcohol (IPA) inhalation as the first-line treatment for nausea in the emergency department: practical advantages and influence on the quality of care

Background

Nasal inhalation of isopropyl alcohol (IPA) seems an effective anti-emetic for the symptomatic treatment of nausea in the emergency department (ED) compared to conventional anti-emetics (Ondansetron and Metoclopramide). However, it is not yet known what the practical consequences are related to the use of IPA in the ED.

Objectives

The purpose of this study was to assess the practical implications for patient care associated with IPA use and to evaluate the viability of permanent implementation of IPA inhalation as a first-line therapy for nausea in the ED.

Methods

We conducted a prospective, single-center implementation study comparing ED-based care for nauseated patients before (n=106) and after (n=104) the introduction of IPA. We evaluated the treatment process and cost and assessed implementation using a survey based on recommended implementation outcome measures.

Results

Comparing baseline phase to implementation phase, we found a significant increase in the percentage of patients receiving nausea treatment (66.0% versus 97.1%; p<0.001) and a reduction in time to treatment initiation (7 versus 1 min, p<0.001). Additionally, IPA introduction was associated with a decrease in the administration of conventional anti-emetics (0.52 versus 0.23 administrations per patient, p<0.001) and a notable drop in treatment cost (€1.33 versus €0.67 per patient). Nurses were content with IPA implementation and regarded definitive implementation as feasible and sustainable.

Conclusion

Implementation of IPA as the first-line nausea treatment in the ED can increase the quality of care and improve care efficiency. Definitive implementation of IPA as a first-line treatment in the ED is both viable and practically feasible.

Trial registration

NTR, NL7717, Registered on March 23, 2018 - Retrospectively registered

Supplementary Information

The online version contains supplementary material available at 10.1186/s12245-021-00334-z.

Isopropyl alcohol nasal inhalation for nausea in the triage of an adult emergency department

OBJECTIVES

Nausea and vomiting (N&V) are among the most common complaints in the emergency department (ED). However, low acuity is assigned to most of these patients at the triage, and waiting for long hours without medication decreases patient safety and satisfaction. We aimed to compare the inhalation of isopropyl alcohol (IPA) with placebo (P) to treat nausea at the triage area of an ED.

METHODS

In this prospective, randomized and placebo-controlled trial, we used a convenience sample of consecutive adult (ages 18-65) patients presented to the triage area of the ED with the complaint of N&V, and we randomized them to inhale IPA or P embedded gauzes. We used an 11-point (0-10) numeric rating scale (NRS) to evaluate the degree of N&V before the inhalation, at the baseline, and at 2, 4 and 10 min after the inhalation.

RESULTS

We randomized 118 patients (IPA, n = 62; P, n = 56, intent-to-treat), three patients left the ED without being seen, and 115 patients completed the study. IPA and P groups were similar according to age, sex, comorbidities, and vital signs. We found that patients in the IPA group had significantly lower mean NRS starting with the 2nd minute (robust two-way mixed ANOVA between-subjects, p = 0.008). We also observed a significant within-subjects effect in the IPA group. The mean NRS value was decreased at each consecutive time point in the IPA group (all pairwise comparisons, p < 0.001).

CONCLUSION

In this study, IPA was significantly more effective than P for N&V at the triage. Moreover, patients in the IPA group had less need for rescue treatment.

Patient-reported Outcome Measures in Emergency Care Research: A Primer for Researchers, Peer Reviewers, and Readers

Patient-reported outcomes (PROs) are of increasing importance in clinical research because they capture patients' experience with well-being, illness, and their interactions with health care. Because PROs tend to focus on specific symptoms (e.g., pain, anxiety) or general assessments of patient functioning and quality of life that offer unique advantages compared to traditional clinical outcomes (e.g., mortality, emergency department revisits), emergency care researchers may benefit from incorporation of PRO measures into their research design as a primary or secondary outcome. Patients may also benefit from the ability of PROs to inform clinical practice and facilitate patient decision making, as PROs are obtained directly from the lived experience of other patients with similar conditions or health status. This review article introduces and defines key terminology relating to PROs, discusses reasons for utilizing PROs in clinical research, outlines basic psychometric and practical assessments that can be used to select a specific PRO measure, and highlights examples of commonly utilized PRO measures in emergency care research.