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Auricular Acupressure in the Prevention of Postoperative Nausea and Emesis: a randomized controlled trial.

Abstract

Introduction: Successful antiemesis contributes significantly to quality, safety, and patient satisfaction. Patients undergoing general anesthesia often experience postoperative nausea and vomiting (PONV). Acupressure offers a side effect-free alternative to common first-line antiemetics. Because the patient may perceive needle acupuncture as uncomfortable, acupressure is a desirable alternative for the prevention of PONV.

Methods: This study was a randomized, prospective, double-blinded clinical trial investigating the effect of acupressure in patients with a history of PONV and motion sickness. The three auricular acupressure points chosen were shen men, point zero, and the subcortex point. Rescue treatment for PONV with 4 mg intravenous ondansetron was used if the patient reported persistent nausea. A blinded observer recorded antiemetic rescue data, and postoperative analgesic use was recorded over 24 hours. Nausea, vomiting, and retching were assessed in the post-anesthesia care unit (PACU).

Results: Using univariate analysis, we ruled out the null hypothesis of equal means as a function of intervention group (p = 0.001). Pair-wise comparisons revealed a difference between placebo and test groups (p = 0.000) and also sham and test groups (p = 0.033) where age (p = 0.048) and gender (p = 0.003) were significant covariates.

Discussion: Our data reveal that auricular acupressure significantly decreases nausea during the PACU stay and within the 24 hours postoperatively. It is not clear whether the intervention decreases nausea as a primary effect or as a secondary result by decreasing narcotic requirements. Also, perception of nausea may be in part subjective. This is evidenced by our results in which subjects who received sham points fared better than the placebo subjects.

Patients undergoing general anesthesia often experience postoperative nausea and vomiting (PONV). Despite the utilization of newer anesthetic agents and antiemetics, such as 5-HT3 antagonists, the incidence of PONV remains between 20% and 70%. (1) PONV causes undue distress on patients and can lead to increased costs in the ambulatory surgery setting by increasing lengths of stay and unplanned admissions. Protracted retching and vomiting can lead to more severe sequelae, including wound tension, pulmonary aspiration, and fluid and electrolyte imbalances. PONV negatively affects the patient experience. In multiple surveys, patients have named the avoidance of nausea and vomiting as their number one concern, outranking pain, death, myocardial infarction, and stroke. (2,3) Stimulation of acupuncture points, including Pericardium-6 (P6), decreases postoperative emesis. (4-6) Arnberger and coworkers concluded that intraoperative P6 stimulation was comparable in efficacy to that of commonly used antiemetic drugs. (7,8) Because the awake patient may perceive needle acupuncture as uncomfortable, acupressure is a desirable alternative for the prevention of PONV. Like acupuncture, acupressure offers an essentially side effect-free alternative to mainstream antiemetics, such as 5-hydroxytryptamine-3 antagonists, metoclopramide, and droperidol. It is not known to cause any of the rare but serious reactions of these medications, including anaphylaxis, bronchospasm, QT prolongation, or extrapyramidal symptoms. Auricular acupressure is also devoid of reactions that are more common, though less threatening, including headache, fatigue, urinary retention, and constipation.

Causes of PONV can be divided into four main categories: 1. patient characteristics, including age, gender, BMI, history of motion sickness and previous PONV, anxiety, and gastroparesis; 2. anesthetic technique, including general versus regional anesthesia and anesthetic agents chosen; 3. surgical factors, including type of surgery and duration of surgery; 4. postoperative factors, including pain, dizziness, ambulation, oral intake, and opioid use. (9) We hypothesize that acupressure is superior to placebo or sham in preventing PONV. To test our hypothesis, we performed a randomized, prospective, double-blinded clinical trial investigating the benefits of auricular acupressure compared to sham points or placebo using a reduction in nausea postoperatively as the primary outcome after general anesthesia for knee arthroscopy patients at high-risk for PONV

Materials and Methods

The charts of patients presenting for a knee arthroscopy deemed to be at high risk for PONV and in whom a non-TIVA, "standard" general anesthetic was chosen were screened for participation in this study. Those patients meeting the inclusion-exclusion criteria (Table 1), were asked to participate in the study through written consent. No patient refused participation. After informed consent was obtained, we randomized a total of 150 patients using a computer-generated randomization schedule to one of three groups: auricular acupressure point intervention group (N = 50), sham point group (N = 47), and placebo group (N = 53) (Fig. 1). IRB approval was obtained to perform this study.

The acupressure was performed preoperatively. The external pinnae were swabbed bilaterally with alcohol to remove superficial dirt and oil for optimal adhesive application. Subjects in the first two groups received the placement of three 24 karat gold-plated surgical steel pellets per ear for a total of six pellets. The pellets (Accu-Patch[R] Pellets, 1.2 mm ball, Lhasa OMS, Inc., Weymouth, MA) were covered with tan, nontransparent, hypoallergenic tape (0.3 inch diameter). The three auricular acupressure points chosen were 1. the shen men located on the triangular fossa, superior to the origin of the superior and inferior crus of the antihelix, 2. point zero, which is midpoint between the crus of the helix and the conchal fossa, and 3. the subcortex point centered on the antitragus. The sham point pellets were located 5 mm away from the real points. The placebo group only received the nontransparent adhesive but no pellets.

The patient proceeded with the knee arthroscopy under general anesthesia. The general anesthetic was standardized. The following agents were available for induction, maintenance, and reversal: midazolam, fentanyl, propofol, sevoflurane, rocuronium, glycopyrrolate, and neostigmine. In the post-anesthesia care unit (PACU), rescue treatment for PONV with 4 mg IV ondansetron was used if the patient reported persistent nausea for 30 minutes or if two or more episodes of vomiting occurred within 2 hours without reports of nausea. Postoperatively, the patients received standardized narcotic prescriptions from their surgeons for pain management. The patients were followed for up to 24 hours via telephone. The follow-up survey collected data on the following: nausea and vomiting, acupressure pellet compliance, and pain assessment.

Results

Our study consisted of 150 subjects randomized into three groups: intervention (N = 50), sham (N = 47), and placebo (N = 53). To provide a more continuous metric, we formed a composite by adding the PACU and 24-hour nausea scores. Using univariate analysis, we ruled out the null hypothesis of equal means as a function of intervention group (p = 0.001). Pairwise comparisons showed a difference between placebo and test groups (p = 0.000) and also interventions sham and test groups (p = 0.033). Using ANOVA and multiple comparisons, we found that there was significantly less nausea in the intervention group as compared to placebo both in PACU and within a 24 hour period post-discharge. The number of episodes of emesis was insignificantly different among the test, sham, and placebo groups. The duration of time that the subjects spent in PACU was not significantly different among the three groups (Table 2).

Discussion

Our data reveal that auricular acupressure significantly decreases nausea during the PACU stay and within the 24 hours after discharge from PACU; however, the number of episodes of emesis was not significantly different among the intervention, sham, and placebo groups. The duration of time that the subjects spent in PACU was not significantly different among the three groups. In addition to the patient being physiologically ready for discharge, many other external factors influence patient discharge time and PACU stay. The time at which a patient is discharged can be affected by the availability of an escort, the availability of a discharge nurse to sign out a patient, whether the surgeon wishes to see the patient before discharge, whether the prescription for the patient is ready, and transportation issues. Because there are so many factors other than patient readiness, it is not surprising that there were no statistically significant findings among the groups for length of PACU stay.

Patients undergoing general anesthesia often experience PONV. (1,2) Even with the utilization of newer anesthetic agents and antiemetics, such as 5-HT3 antagonists, the incidence of PONV remains between 20% and 70%. (10) PONV causes undue distress on patients and can lead to increased costs in the ambulatory surgery setting by increasing lengths of stay and unplanned admissions. Protracted retching and vomiting can lead to more severe sequelae, including wound tension, pulmonary aspiration, and fluid and electrolyte imbalances. Patient satisfaction is negatively impacted by a postoperative course complicated by nausea and vomiting.

The new methods of compensating providers for patient care, including the Federal Government's Value Based Purchasing (VBP) program, include patient experience metrics in their compensation calculations. (11) PONV negatively effects patient satisfaction following surgery. (2,3) Thus, decreasing or eliminating PONV can positively impact how patients perceive their surgical experience and lead to higher patient satisfaction scores. This has the potential to result in greater reimbursement to institutions and other providers. Additionally, the complexity and volume of ambulatory surgery is increasing. PONV can lead to delays in discharge and even unscheduled admissions. These unanticipated events increase the cost of care and are being monitored by health care payers. (12) Auricular acupressure can potentially decrease the likelihood of these events and increase the value of care we provide. Increasing the value of care we provide is essential to remain competitive in the current and future health care environment. (13)

Potential limitations of our study and areas requiring further research include the effect of acupressure on patients undergoing other types of surgery. We do not know whether the benefits of acupressure will be observed in patients undergoing longer, more complex surgical procedures. These procedures, including ligament reconstructions and open procedures, are associated with longer operative times and increased potential for PONV. It is also unclear whether acupressure can help patients who are not at high risk for PONV. Future studies can include a cost-benefit analysis exploring whether PACU stay was shorter and whether fewer antiemetics and analgesics were employed. It would also be interesting to investigate whether these techniques can be applied to a pediatric population and patients undergoing surgeries known to be emetogenic such as head and neck, gynecologic, and urologic procedures.

Conclusion

Auricular acupressure is an attractive means of preventing PONV because most patients are receptive to it, the beads can be applied easily, and it is inexpensive. Our data show that there is a statistically significant difference in the number of episodes of nausea both in the PACU and within 24 hours of discharge. No significant difference was found between the incidences of emesis among the three groups. This was likely because there were too few episodes of emesis overall.

Disclosure Statement

None of the authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.

References

(1.) Greif R, Laciny S, Rapf B, et al. Supplemental oxygen reduces the incidence of postoperative nausea and vomiting. Anesthesiology. 1999 Nov;91(5):1246-52.

(2.) Hocking G, Weightman WM, Smith C, et al. Measuring the quality of anaesthesia from a patient's perspective: development, validation, and implementation of a short questionnaire. Br J Anaesth. 2013 Dec;111(6):979-89.

(3.) Eberhart LH, Morin AM, Wulf H, Geldner G. Patient preferences for immediate postoperative recovery. Br J Anaesth. 2002 Nov;89(5):760-1.

(4.) Fan CF, Tanhui E, Joshi S, et al. Acupressure treatment for prevention of postoperative nausea and vomiting. Anesth Analg. 1997 Apr;84(4):821-5.

(5.) Gieron C, Wieland B, von der Laage D, Tolksdorf W. [Acupressure in the prevention of postoperative nausea and vomiting]. Anaesthesist. 1993 Apr;42(4):221-6.

(6.) Dundee JW, Ghaly RG. Does the timing of P6 acupuncture influence its efficacy as a postoperative antiemetic? Br J Anaesth. 1989 Nov;63(5):630.

(7.) Arnberger M, Stadelmann K, Alischer P, et al. Monitoring of neuromuscular blockade at the P6 acupuncture point reduces the incidence of postoperative nausea and vomiting. Anesthesiology. 2007 Dec;107(6):903-8.

(8.) Boehler M, Mitterschiffthaler G, Schlager A. Korean hand acupressure reduces postoperative nausea and vomiting after gynecological laparoscopic surgery. Anesth Analg. 2002 Apr;94(4):872-5.

(9.) Watcha MF, White PF. Postoperative nausea and vomiting. Its etiology, treatment, and prevention. Anesthesiology. 1992 Jul;77(1):162-84.

(10.) Capili B, Anastasi JK, Geiger JN. Adverse event reporting in acupuncture clinical trials focusing on pain. Clin J Pain. 2010 Jan;26(1):43-8.

(11.) VanLare JM, Conway PH. Value-based purchasing--national programs to move from volume to value. N Engl J Med. 2012 Jul 26;367(4):292-5.

(12.) Kocher RP, Adashi EY. Hospital readmissions and the Affordable Care Act: paying for coordinated quality care. JAMA. 2011 Oct 26;306(16):1794-5.

(13.) Porter ME. What is value in health care? N Engl J Med. 2010 Dec 23;363(26):2477-81.

Cynthia L. Feng, M.D., M.P.A., Jovan Popovic, M.D., Richard P. Kline, M.S., Ph.D., M.A., Jung T. Kim, M.D., Rafael Matos, Sarah Lee, and Joseph A. Bosco, III, M.D.

Cynthia L. Feng, M.D., M.P.A., Jovan Popovic, M.D., Richard P. Kline, M.S., Ph.D., M.A., Jung T. Kim, M.D., Rafael Matos, Sarah Lee, Department of Anesthesiology, and Joseph A. Bosco, III, M.D., Department of Orthopaedic Surgery, New York University School of Medicine, New York, New York.

Correspondence: Joseph A. Bosco, III, M.D., Department of Orthopaedics, New York University School of Medicine, 333 East 38th Street, New York, New York 10016; joseph.bosco@nyumc.org.

Caption: Figure 1 Flow diagram of the study group.
Table 1 Inclusion and Exclusion Criteria

Inclusion                            Exclusion

1. Informed consent                  1. Neurological deficit in ears
   had been signed                      or operative extremity
2. ASA Physical Status               2. Active infection at site of
   Classification of I or II            pellet placement
3. Undergoing non-TIVA               3. Allergy to adhesive
   general anesthesia
4. Undergoing elective knee          4. Diabetes
   arthroplasty
5. Nonsmoker for at least the        5. Pregnancy or lactation
   previous 12 consecutive months
6. History of motion sickness or     6. Chronic opioid analgesic or
   postoperative nausea or vomiting     drug abuse
7. Available 24 hours after          7. Unstable cardiovascular, renal,
   emergence for follow-up              or hepatic diseases
                                     8. Inability to cooperate or
                                        understand/follow instructions
                                     9. Has persistent/recurrent
                                        nausea or vomiting
                                     10. Has received medication with
                                         known or potential antiemetic
                                         activity within the 24-hour
                                         period prior to receiving study
                                         drug. This includes, but is not
                                         limited to phenothiazines,
                                         butyrophenones, hydroxyzine,
                                         lorazepam, cannabinoids,
                                         metoclopramide, corticosteroids
                                         (with the exception of topical
                                         steroids for skin disorder and
                                         inhaled steroids for
                                         respiratory disorders),
                                         trimethobenzamide, monoamine
                                         oxidase inhibitors, lithium,
                                         and 5-HT3 receptor antagonists.

Table 2 Nausea for Placebo, Sham, and Test Groups

                                      Mean        Standard
                                      Difference  Error     Significance

Nausea, mean #      Placebo  Sham      0.933      0.508     0.192
episodes, PACU               Test      1.563      0.503     0.007
                    Sham     Placebo  -0.933      0.508     0.192
                             Test      0.630      0.518     0.537
                    Test     Placebo  -1.563      0.503     0.007
                             Sham     -0.630      0.518     0.537
Nausea, mean #      Placebo  Sham      0.615      0.339     0.199
episodes, 24 hours           Test      1.329      0.333     0.000
                    Sham     Placebo  -0.615      0.339     0.199
                             Test      0.714      0.343     0.113
                    Test     Placebo  -1.329      0.333     0.000
                             Sham     -0.714      0.343     0.113
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Article Details
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Author:Feng, Cynthia L.; Popovic, Jovan; Kline, Richard P.; Kim, Jung T.; Matos, Rafael; Lee, Sarah; Bosco,
Publication:Bulletin of the NYU Hospital for Joint Diseases
Article Type:Report
Date:Apr 1, 2017
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