Evidence for the efficacy of acupressure for preventing post-operative nausea and vomiting: an ongoing debate:

Research hotspots and trends on acupuncture therapy on vomiting from 1990 to 2022: A bibliometric analysis

OBJECTIVES

Acupuncture treatment (AT) is commonly utilized for vomiting; however, limited bibliometric analyses exist in this area. Employing a bibliometric approach, we conducted a comprehensive review spanning three decades to assess the research landscape, advancements, and emerging trends in AT for vomiting.

METHODS

We collected the related literature data from the Web of Science Core Collection (WOSCC) from 1990 to 2022. VOSviewer and R studio were used to perform the bibliometric analysis of AT on vomiting. The status of authors, countries, affiliations, annual publications, keywords, and journals were analyzed accordingly.

RESULTS

The earliest relevant paper was published in 1990. Streitberger, K was the most productive author (7 records) and had significant influence (225 reference times, H-Index = 7). The United States had the highest publication count (224 records) and received the most recognition (9719 reference times, H-Index = 52). MEDICINE had the highest number of outputs (34 records), while ANESTHESIA AND ANALGESIA was the most cited journal (1045 reference times). The institution with the most works was Chengdu University of Traditional Chinese Medicine (CDUTCM) (13 records), and the University of California, Los Angeles received the most citations (1252 reference times). Recent and future research hotspots included AT for postoperative vomiting and post-chemotherapy vomiting. Systematic reviews and meta-analyses were the predominant study types.

CONCLUSIONS

The current status and development prospects of AT for vomiting are shown in this study. In addition, this article provides valuable ideas and potential directions for future research activities.

Preventing nausea and vomiting in women undergoing regional anesthesia for cesarean section: challenges and solutions

BACKGROUND

Intraoperative nausea and vomiting (IONV) or postoperative nausea and vomiting (PONV) affecting women undergoing regional anesthesia for cesarean section is an important clinical problem since these techniques are used widely. There are burdens of literature about IONV/PONV and several in parturient and cesarean. However, it needs more attention. The underlying mechanisms of IONV and PONV in the obstetrical setting mainly include hypotension due to sympathicolysis during neuraxial anesthesia, bradycardia owing to an increased vagal tone, the visceral stimulation via the surgical procedure and intravenously administered opioids.

METHODS

Given the high and even increasing rate of cesarean sections and the sparse information on the etiology, incidence and severity of nausea and vomiting and the impact of prophylactic measures on the incidence of PONV/IONV, this article aims to review the available information and provide pragmatic suggestions on how to prevent nausea and vomiting in this patient cohort. Current literature and guidelines were identified by electronic database searching (MEDLINE via PubMed and Cochrane database of systematic reviews) up to present, searching through reference lists of included literature and personal contact with experts.

DISCUSSION AND CONCLUSION

Taking into account the current guidelines and literature as well as everyday clinical experience, the first step for decreasing the incidence of IONV and PONV is a comprehensive management of circulatory parameters. This management includes liberal perioperative fluid administration and the application of vasopressors as the circumstances require. By using low-dose local anesthetics, an additional application of intrathecal or spinal opioids or hyperbaric solutions for a sufficient controllability of neuraxial distribution, maternal hypotension might be reduced. Performing a combined spinal-epidural anesthesia or epidural anesthesia may be considered as an alternative to spinal anesthesia. Antiemetic drugs may be administered restrainedly due to off-label use in pregnant women for IONV or PONV prophylaxis and may be reserved for treatment.

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.

Acupuncture versus Usual Care for Postoperative Nausea and Vomiting in Children after Tonsillectomy/Adenoidectomy: A Pragmatic, Multicentre, Double-Blinded, Randomised Trial

Objectives

To investigate the effect of a standardised acupuncture on nausea and vomiting in children after tonsillectomy with or without adenoidectomy when possible placebo effects were precluded.

Methods

A pragmatic, multicentre, double-blinded, randomised controlled trial. The study was conducted over 10 months in 2012–2013 at three ambulatory clinics. Two hundred and eighty-two children, age 1–11 years, American Society of Anesthesiologists grade ≤II, were included. To equalise expectancy effects, all parents were told that their child would receive acupuncture. However, children were randomly allocated to perioperative bilateral needling acupuncture at PC6, depth 7 mm, mean time 17 min (SD 5–45) during anaesthesia plus usual care, or to usual care only. The regional ethics committee approved this approach. Primary endpoints were nausea and vomiting 24 h postoperatively.

Results

This study did not demonstrate any effect of acupuncture (95% CI) compared with standard care. The overall vomiting in the acupuncture and usual-care groups was 44.2% and 47.9%, respectively. Nausea was experienced by 31.7% in the acupuncture group and by 32.6% in the usual-care group. The test power was acceptable for comparisons of vomiting.

Conclusions

The findings suggest that when controlling for possible placebo effects standardised PC6 acupuncture needling during anaesthesia without further stimulation of PC6 is not effective in reducing nausea and vomiting in children after tonsillectomy with or without adenoidectomy. Future studies should investigate acupuncture treatment which balances adequate dose and technique and a feasible, child-friendly acupuncture treatment.

Trial Registration Number

ClinicalTrials.gov NCT01729052.