Use of a disposable acupressure device as part of a multimodal antiemetic strategy for reducing postoperative nausea and vomiting. Anesth Analg. 2012;115:31-37. [PMID: 22504214 DOI: 10.1213/ANE.0b013e3182536f27]

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.

A Scoping Review of Measures Utilized to Assess Patient Satisfaction with Acupuncture Treatments Within Randomized Controlled Trials

Objective

Patient satisfaction is an increasing priority for health care facilities in ensuring reimbursement for services, high-quality access to care, and transparent communication. Cumulatively, these metrics guide patient-centered care and facilitate optimal service delivery. The purpose of this scoping review was to evaluate measures of patient satisfaction with acupuncture treatments.

Materials and Methods

This scoping review was guided by the Arksey and O'Malley methodological framework. Analysis was performed based on the multidimensional hierarchical model of perceived service-quality conceptual framework. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement was used to organize included publications and to display search processes in a flow diagram. An academic reference librarian conducted a literature search, using electronic databases that included PubMed,® Cumulative Index to Nursing and Allied Health Literature, EMBASE,® and Web of Science.

Results

A total of 384 publications were initially identified and screened; 26 met the eligibility criteria and were included in the synthesis. Discrepancies in the use of patient-satisfaction measures among studies were found in only 1 study demonstrating holistic assessment.

Conclusions

There is a need for consistent measurement of patient satisfaction with acupuncture treatments. Future studies may evaluate development of a satisfaction tool to measure patient satisfaction with acupuncture treatments comprehensively.

The effects of acupressure on postoperative nausea and vomiting among patients undergoing laparoscopic surgery: A meta-analysis of randomized controlled trials

BACKGROUND AND OBJECTIVE

Laparoscopic surgery is one of the most commonly performed surgeries in general surgery, with fewer side effects and rapid recovery. Postoperative nausea and vomiting (PONV) remains the main challenge that confronts the prognosis of this minimally invasive surgery. We aimed to evaluate the effect of acupressure, a nonpharmacological non-invasive method, on the incidence of nausea and vomiting following laparoscopic surgery within the early phase (first six hours postoperatively) and the extended phase (for at least 24 h postoperatively).

METHODS

We searched PubMed, Cochran, Scopus, Web of Science, Google scholar, and Wiley for randomized controlled trials that evaluated the effect of acupressure on PONV in patients undergoing laparoscopy. Data were extracted and analyzed in a random model, and pooled risk ratios (RRs) with their respective 95% confidence intervals (CIs) were calculated.

RESULTS

Eleven trials were included in the meta-analysis, comprising 941 patients. Most of the included patients were females undergoing gynecological laparoscopy or laparoscopic cholecystectomy. Acupressure significantly lowered the incidence of nausea and vomiting, within the early phase (RR = 0.62, 95% CI [0.44 to 0.88]; p = 0.008), (RR = 0.5, 95% CI [0.30 to 0.84]; p = 0.008), and the extended phase (RR = 0.65, 95% CI [0.52 to 0.83]; p = 0.0003), (RR = 0.44, 95% CI [0.32 to 0.61]; p < 0.00001), respectively. Moreover, acupressure significantly reduced the need for rescue antiemetic drugs in both phases (p < 0.05).

CONCLUSION

Acupressure is an effective procedure for reducing nausea, vomiting, and the need for antiemetic drugs after laparoscopic surgery.

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.

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.

[Risk factors for nausea and vomiting after adolescent idiopathic scoliosis surgery]

OBJECTIVE

To explore risk factors for postoperative nausea and vomiting (PONV) that requires intervention with medications during adolescent idiopathic scoliosis (AIS) surgery.

METHODS

We analyzed the data of 986 patients with AIS (including 156 male and 830 female patients) undergoing scoliosis surgery through a posterior approach between December, 2012 and January, 2016 in Nanjing Drum Tower Hospital. The data were collected from the patients including ASA grade, body mass index (BMI), Cobb angle, preoperative respiratory and cardiovascular diseases, operation time, type of anesthesia, quantity of intraoperative liquid infusion, blood loss, urine volume, the lowest MAP and CVP, intraoperative fentanyl consumption, and intraoperative administration of dexmedetomidine, dexamethasone, ondansetran and droperidol. The incidence of PONV in 48 h following the surgery, hemoglobin variation after operation (ΔHb), postoperative analgesia, times of use and types of antiemetic drugs, and postoperative hospital stay were recorded for all the patients. The potential risk factors of PONV within 48 h were analyzed using univariate analysis and multivariate logistic regression.

RESULTS

Of the 986 patients analyzed, 151 (15.3%) experienced PONV within 48 h following surgeries for AIS. Multivariate logistic regression analysis suggested that an high intraoperative fentanyl dose (> 0.65 mg; OR=9.303, 95% CI: 2.373-8.622, P < 0.001), an obvious ΔHb (> 28.5 g/L; OR=1.107, 95% CI: 1.060-1.157, P < 0.001), and postoperative analgesia with fentanyl (OR=11.671, 95% CI: 2.381-11.284, P < 0.001) were risk factors for PONV. Intraoperative administration of dexmedetomidine (OR=0.027, 95% CI: 0.006-0.123, P=0.002) and dexamethasone combined with ondansetron (OR=0.241, 95%CI: 0.066-0.886, P=0.032) were protective factors against PONV.

CONCLUSIONS

A high-dose intraoperative fentanyl consumption, a marked ΔHb, and postoperative analgesia with fentanyl are risk factors for PONV while intraoperative administration of dexmedetomidine and dexamethasone combined with ondansetron are protective factors against PONV following surgeries for AIS.

Anti-emetic Drugs for Prophylaxis of Postoperative Nausea and Vomiting After Craniotomy: An Updated Systematic Review and Network Meta-Analysis

Background: There is uncertainty about the effect of antiemetic drugs (AED) for the prophylaxis of postoperative nausea and vomiting (PONV) after craniotomy. In this study, we assessed the effectiveness and safety of AED for PONV.

Methods and Findings: We searched online databases including the Cochrane Library, PubMed, Wiley, Elsevier Science Direct, Ovid LWW, and Springer for publications from 1985 to June 2018. Adults undergoing craniotomy with the prophylactic use of at least one AED were included. The primary outcomes were the incidence of postoperative nausea (PON) and postoperative vomiting (POV) during the first and second day. A total of 1,433 participants from 17 clinical trials were enrolled in this Network Meta-Analysis (NMA). Compared to placebo, ramosetron was the most effective treatment for PON 24 h after surgery (OR = 0.063, 95% Crl: 0.006–0.45), with a 69.2% probability. On the other hand, for POV, droperidol was the best treatment during the first 2 h with a 71.1% probability (OR = 0.029, 95% Crl: 0.003–0.25); while fosaprepitant was the most effective treatment at 0–24 h (OR = 0.027, 95% Crl: 0.007–0.094; 66.9% probability) and 0–48 h (OR = 0.036, 95% Crl: 0.006–0.18; 56.6% probability). Besides, ramosetron showed a significantly higher incidence of complete response (OR = 29. 95% Crl: 1.4–6.5e + 02), as well as lower requirement for rescue AED (OR = 0.022, 95% Crl: 0.001–0.2). Granisetron was associated with the lowest incidence of headache and excessive sedation.

Conclusions: Compared with placebo, ramosetron appears to be the best prophylactic treatment for PON 24 h after craniotomy, with higher complete responses. Fosaprepitant appears to be the most effective prophylaxis option for POV on the first 0–24 and 0–48 h. Both may be better applied in combination with perioperative dexamethasone. These findings may guide clinicians to provide improved pharmacological prophylaxis for PONV after craniotomy with fewer adverse effects.

Efficacy of external nasal nerve block following nasal surgery : A randomized, controlled trial

BACKGROUND

Pain is the major determinant factor which affects the quality of recovery and postoperative agitation following nasal surgery with the patient under general anesthesia. Our objectives were to test the hypothesis that an external nasal nerve block will decrease pain intensity, decrease drug consumption, decrease the incidence of postoperative emergence agitation and improve quality of recovery.

MATERIAL AND METHODS

In this study 100 adult patients who were scheduled for elective external nasal surgery with the patient under general anesthesia and nasal packing on each side, received external nasal nerve blocks postoperatively for 24 h with saline (group I) or 2% xylocaine (group II) with 1:200,000 epinephrine. Postoperative pain was measured at the postanesthesia care unit (PACU) utilizing a visual analog scale (VAS). Narcotics consumption was also measured. Emergence agitation and quality of recovery were also assessed.

RESULTS

Pain scores were statistically significant between both groups. Requirements of equivalent morphine doses in the PACU were lower in group II (block) than group I (control) with a significant P value <0.001. Group II (block) patients required significantly less intraoperative fentanyl than group I (control) patients (p = 0.001). Group II (block) showed higher scores in pain dimension of QoR-40 in comparison with group I (P <0.001). The incidence of emergence agitation was lower in group II (block) than in group I (control, 24% vs. 48%, P = 0.012).

CONCLUSION

External nasal nerve block is an effective technique for reducing postoperative pain, drug consumption and quality of recovery. It also reduces emergence agitation. The effects are mainly due to profound analgesia and effective pain control that lead to decreased drug usage and reduced discomfort.

A Systematic Review and Meta-Analysis of Acupressure for Postoperative Gastrointestinal Symptoms among Abdominal Surgery Patients

Postoperative ileus is a common and often life-threatening gastrointestinal complication with few management methods available for patients. Integrating acupressure into perioperative care promises to bring benefits into preventing postoperative ileus. This systematic review and meta-analysis aims to evaluate the efficacy of acupressure in identifying the signs and symptoms of postoperative ileus among patients undergoing abdominal surgery. The MEDLINE, EMBASE, Web of Science, CINAHL, China Journal Net and Wanfang databases were searched for high-quality RCTs using keywords such as acupressure, postoperative ileus, abdominal surgery, etc. A total of six studies ([Formula: see text]) were included in this review and meta-analysis. The quality of the literature was found to be uniformly moderate by the Effective Public Health Practice Project (EPHPP) assessment tool. The results of meta-analyses revealed that acupressure could significantly reduce risks for postoperative nausea (OR 0.52, 95% CI 0.39–0.70, [Formula: see text]) and vomiting (OR 0.54, 95% CI 0.39–0.75, [Formula: see text]) compared with the control group, without significant heterogeneity among studies. Meta-analysis of the need for antiemetic drugs suggested that the OR was 0.39 (95% CI 0.20–0.78, [Formula: see text]) with significant heterogeneity among studies. Our results suggested that acupressure might be effective in reducing the incidence of postoperative nausea and vomiting and the need for antiemetic drugs among patients undergoing abdominal surgery. Considering the substantial risk of bias in the articles included, future high-quality RCTs with a rigorous methodology are desirable to provide solid evidence. Furthermore, other signs and symptoms of postoperative ileus should be explored in future.

An update on the management of postoperative nausea and vomiting

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. PONV and PDNV can delay discharge and recovery and increase medical costs. The high incidence of PONV has persisted in part because of the tremendous growth in ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major operations. Pharmacological management of PONV should be tailored to the patients' risk level using the PONV and PDNV scoring systems to minimize the potential for these adverse side effects in the postoperative period. A combination of prophylactic antiemetic drugs should be administered to patients with moderate-to-high risk of developing PONV in order to facilitate the recovery process. Optimal management of perioperative pain using opioid-sparing multimodal analgesic techniques and preventing PONV using prophylactic antiemetics are key elements for achieving an enhanced recovery after surgery. Strategies that include reductions of the baseline risk (e.g., adequate hydration, use of opioid-sparing analgesic techniques) as well as a multimodal antiemetic regimen will improve the likelihood of preventing both PONV and PDNV.

Contemporary acupressure therapy: Adroit cure for painless recovery of therapeutic ailments

Since time immemorial, complementary and alternative medicines (CAM) have played a significant role in human health care. CAM is known to have a strong reputation and reliability within every culture to provide basic health care treatment for patients. CAM acts as a better therapeutic option in human being for treating various diseases and improving quality of life with apt consideration to the economic aspects. Acupressure, one of the known CAM, originated in ancient China is based on the principal of acupoints activation across the meridians which correct the imbalance between Qi. Activation of specific points on the meridians is known to facilitate reduction of pain at the local sites. It also reduces the pain from other body parts. This review outlines various types, devices and mechanisms involved in the acupressure treatment.

Effects of P6 stimulation on postoperative nausea and vomiting in laparoscopic cholecystectomy patients

PURPOSE

Postoperative nausea and vomiting (PONV) remains one of the most common postsurgical complications after anesthesia and surgery. Pericardium 6 (P6) stimulation is believed to prevent PONV and is a potential adjunctive treatment with pharmacologic agents. The purpose of this study was to compare the effects of P6 stimulation on PONV occurrence to a control group not receiving the P6 stimulation in sequential female patients undergoing laparoscopic cholecystecomy at a community hospital in central Florida between November 2010 and March 2013.

DESIGN

This study is a double-blinded randomized controlled trial.

METHODS

PONV was measured on admission to the postanesthesia care unit (PACU), at 30 and 60 minutes, at discharge from the PACU to home and at two points at home up to 6 hours and between 6 and 24 hours.

FINDINGS

Of the 56 total patients, those in the P6 group (n = 26) had statistically significant lower incidence of PONV, 0%, vs 14.3% in the control group (n = 27; P < .05) on admission to the PACU, but at all other time points, there was no significant difference in PONV. Thirty-one percent of the patients in the P6 group had PONV in PACU or at home compared with 51.9% in the control group.

CONCLUSIONS

The results of the study demonstrate that the use of P6 stimulation in the perioperative arena is clinically meaningful; however, more research is needed with a larger sample size.

Comparing Effects of Two Different Types of Nei-Guan Acupuncture Stimulation Devices in Reducing Postoperative Nausea and Vomiting

PURPOSE

To compare the effects of a relief band using transcutaneous electrical nerve stimulation with a wrist band using acupressure on the Nei-Guan acupuncture point to relieve postoperative nausea and vomiting (PONV) in patients who had undergone gynecologic surgery.

DESIGN

A double-blinded randomized controlled trial.

METHODS

In total, 54 patients scheduled for gynecologic surgery under general anesthesia were included in this study. Assessments of PONV were performed 0, 2, 6, and 24 hours after discharge from the postanesthesia care unit. The severity of PONV was measured using the Rhodes' Index of Nausea, Vomiting and Retching and by recording the frequency of patient-requested antiemetic administration that is used to treat severe cases of PONV.

FINDINGS

The relief band reduced the severity of PONV and the need for antiemetic administration within the first 24 hours postsurgery.

CONCLUSIONS

The results of this study support the use of a relief band when compared with a wrist band and with a control group to reduce PONV in women after gynecologic surgery.

Increasing Access to Auricular Acupuncture for Postoperative Nausea and Vomiting

PURPOSE

Postoperative nausea and vomiting (PONV) affects more than 30% of surgical patients. Auricular acupuncture (AA) has been shown to decrease the incidence of PONV in select populations.

DESIGN

An evidence-based quality improvement project made AA available to all adult surgical patients, and the results were recorded in a database. A retrospective between-groups analysis of 210 database entries was conducted, of those 25 receiving AA.

FINDINGS

More risk factors for PONV were present in the AA group (P < .001). Both groups experienced a less-than-expected rate of PONV. Similar rates were shown between groups for PONV, postanesthesia care unit length of stay, and opioid consumption. Patient satisfaction was 96% with AA. The AA group was treated with less antiemetic medication (P < .001), yet PONV rates remained similar.

CONCLUSIONS

A multimodal approach treating patients at risk for PONV is recommended. Administration of multiple antiemetics may result in unnecessary cost or unfavorable side effects when effective and less costly alternatives exist. AA is a viable treatment for PONV, considering cost and patient satisfaction.

A decade of offering a Healing Enhancement Program at an academic medical center

An increased focus has been given to improving the patient experience in health care. This focus has included placing value in a patient-centric, holistic approach to patient care. In the past decade, the Healing Enhancement Program was developed at 1 large medical center to address this focus through implementation of such integrative medicine services as massage, acupuncture, and music therapy to holistically address the pain, anxiety, and tension that hospitalized patients often experience. We describe the development and growth of this program over the past decade.

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.

Dexamethasone alone vs in combination with transcutaneous electrical acupoint stimulation or tropisetron for prevention of postoperative nausea and vomiting in gynaecological patients undergoing laparoscopic surgery

BACKGROUND

Postoperative nausea and vomiting (PONV) is commonly reported after surgery and anaesthesia. We compared the effects of combinations of electrical acupoint stimulation or tropisetron with dexamethasone with the effects of dexamethasone alone, for inhibition of PONV in gynaecological patients undergoing laparoscopic surgery.

METHODS

We randomized 157 patients undergoing elective gynaecological laparoscopic surgery under general anaesthesia into the following three groups: acupoint stimulation+dexamethasone (Group Acu, n=53), tropisetron+dexamethasone (Group Trp, n=53), and dexamethasone alone (Group Dxm, n=51). The incidence of nausea, vomiting, and need for rescue antiemetics was recorded 2, 6, 24, and 48 h after surgery.

RESULTS

We found significant differences in the incidence of PONV during 24 h after surgery between the combination therapy groups and the dexamethasone-alone group (P=0.021). In the first 24 h, 28% of patients in Group Acu, 26% of patients in Group Trp, and 50% of patients in Group Dxm experienced nausea, vomiting, or both. The incidence of 24 h PONV in Group Acu was significantly lower than that in Group Dxm (P=0.048; odds ratio 0.389; 95% CI 0.170-0.891). The incidence of 24 h PONV in Group Trp was also significantly lower than that in Group Dxm (P=0.042; odds ratio 0.359; 95% CI 0.157-0.819). There was no significant difference between Group Acu and Group Trp (P=0.857). The need for antiemetic rescue medication was similar in the three groups. All groups expressed similar patient satisfaction.

CONCLUSIONS

Combined with dexamethasone, electrical acupoint stimulation or tropisetron is more effective in PONV prophylaxis than dexamethasone alone in gynaecological patients undergoing laparoscopic surgery.

CLINICAL TRIAL REGISTRATION

NCT 02096835.

Sham Acupressure Controls Used in Randomized Controlled Trials: A Systematic Review and Critique

OBJECTIVES

To explore the commonly utilized sham acupressure procedures in existing acupressure trials, and to assess whether different types of sham interventions yield different therapeutic outcomes, and, as far as possible, to identify directions for the future development of an adequate sham acupressure method.

METHODS

Randomized controlled trials comparing true acupressure with sham interventions were included. Thirteen electronic databases were adopted to locate relevant studies from inception to July 3, 2014. Meanwhile, eight Chinese journals on complementary and alternative medicine were manually searched to locate eligible articles. In addition, eligible studies listed in the reference lists of the included papers and other related systematic reviews on acupressure were also screened to further search any potentially eligible trials. Methodological quality of the included studies was evaluated using the risk of bias assessment tool developed by the Cochrane Back Review Group. Descriptive analysis was adopted to summarize the therapeutic outcomes.

RESULTS

Sixty-six studies with 7265 participants were included. Methodological quality of the included trials was generally satisfactory. Six types of sham acupressure approaches were identified and "non-acupoint" stimulation was the most frequently utilized sham point while an acupressure device was the most commonly used approach for administering sham treatments. Acupressure therapy was a beneficial approach in managing a variety of health problems and the therapeutic effect was found to be more effective in the true acupressure groups than that in the sham comparative groups. No clear association could be identified between different sham acupressure modalities and the reported treatment outcomes.

CONCLUSIONS

A great diversity of sham acupressure controls have been used in clinical practice and research. A solid conclusion whether different sham alternatives are related to different treatment outcomes cannot be derived because of significant clinical heterogeneity among the analyzed trials. Non-acupoints are generally recommended but the definite locations should be identified with caution. For studies using single sham acupoints on hands or legs, it is suggested to apply identical acupressure devices on the same acupoint as in the active intervention without any stimulation. While for studies on pain, stimulation of sham acupoints should be avoided.

Transversus abdominis plane infiltration for laparoscopic gastric banding: A pilot study

AIM: To estimate an effect size for the transversus abdominis plane (TAP) infiltration on quality of recovery in patients undergoing laparoscopic gastric band surgery.

METHODS: The pilot study was a randomized, double blinded, placebo controlled trial. Patients undergoing laparoscopic gastric band surgery were randomized to receive a bilateral TAP infiltration with 20 mL of 0.5% ropivacaine or saline. The evaluated outcomes included quality of recovery-40 (QoR-40) at 24 h, postoperative opioid consumption and pain. Data was examined using the Mann-Whitney U test.

RESULTS: Nineteen subjects were recruited. There was a positive trend favoring the TAP infiltration group in global QoR-40 scores at 24 h after surgery, median [interquartile range (IQR)] of 175.5 (170-189) compared to 170 (160-175) in the control group (P = 0.06). There also a positive trend toward a lower cumulative opioid consumption in the TAP infiltration group, median (IQR) of 7.5 (2.5-11.5) mg iv morphine equivalents compared to 13 (7-21.5) in the control group (P = 0.07). Correlation analysis (Spearman’s Rho) demonstrated an inverse relationship between 24 h cumulative opioid consumption and global QoR-40 scores, -0.49 (P = 0.03).

CONCLUSION: The use of multimodal analgesic techniques to reduce opioid related side effects is particularly desirable in morbidly obese patients undergoing gastric reduction surgery. The TAP infiltration seems to have a clinically important effect in reducing postoperative opioid consumption and improve quality of recovery after laparoscopic gastric band surgery in morbid obese patients. Future studies to confirm the beneficial effects of the TAP infiltration in these patients are warranted.

A physiological perspective for utility or futility of alcohol-based hand rub gel against nausea-vomiting: is it P-6 acupoint or transnasal aroma?

Nausea-vomiting is a common and unpleasant phenomenon with numerous underlying mechanisms and pathways that are not always well elucidated. In clinical practice, refractory nausea-vomiting is encountered in several settings. Antiemetic medications may reduce these symptoms but are not always effective in all patients. In the absence of a well-defined optimal strategy for management of nausea-vomiting, the search for better approaches to treat this distressing symptom continues. One of the alternative treatment approaches is a compounded formulation called ABHR gel that is comprised of multiple antiemetic medications and has been shown to be useful for symptomatic relief in some patients with refractory nausea-vomiting. It has been suggested that alternative mechanisms should be explored to explain the perceived efficacy of ABHR gel, because transdermal absorption leading to nil-to-minimal or subtherapeutic blood concentrations of active ingredients does not explain the role of ABHR gel in the treatment of nausea-vomiting. In the current paper, we discuss possible mechanisms that may explain ABHR transdermal gel's efficacy. Compounded ABHR transdermal gel formulation's efficacy in antagonizing nausea-vomiting that has been recently questioned may be explained by alternative mechanisms mediated through the P-6 acupoint stimulation and facial-nasal, cooling-related counterstimulation.