Acupoint Stimulation for Postoperative Nausea and Vomiting

By Carmen Tamayo, MD

Although postoperative nausea and vomiting (PONV) is less common now than when ether and cyclopropane were commonly used anesthetics, the overall incidence is about 30%, with up to 70% of high-risk patients experiencing PONV.1 Risk factors include being female, being a nonsmoker, having a history of motion sickness or PONV, and use of postoperative opioids.1 Type of surgery also affects risk: PONV is quite common after craniotomy, ear, nose and throat procedures, major breast procedures, strabismus surgery, laparoscopy, and laparotomy.1 Nitrous oxide, volatile inhalational agents, and intra-operative opioids also increase risk. PONV can lead to aspiration, dehydration, electrolyte disturbances, and disruption of the surgical site. PONV increases treatment costs and may be associated with increased anxiety, dissatisfaction with the surgical experience, and anticipatory nausea in the future.2 Although PONV rarely causes medically serious complications, patients feel that avoiding PONV is more important than avoiding postoperative pain.1

Acupuncture point stimulation has been assessed to prevent nausea and vomiting of various etiologies, including PONV. A MEDLINE search (1966-2002) of prospective randomized controlled trials of acupuncture or acupressure for nausea or emesis, supplemented by my own files, identified 23 trials of acupoint stimulation for postoperative nausea and vomiting in adults (see Table). Pediatric trials will not be covered here. Sixteen of 23 trials found a benefit for acupuncture stimulation for nausea and/or vomiting. Five trials were negative, and two trials reported mixed results.

Acupuncture points (or acupoints) can be stimulated by needles, pressure, heat, or transcutaneous electrical stimulation (TENS) devices. At least 11 trials tested acupressure bands, which are elastic bracelets with a button that presses on the P6 point, which is two thumb-widths proximal to the distal wrist crease, between the flexor carpi radialis and palmaris longus tendons. Acupressure band trials are easily controlled by misplacing the band on the wrist so that it doesn’t stimulate the P6 point; alternatively, a placebo band, lacking a button, may be used. All but two trials applied stimulation at the P6 acupoint; the Boehler trial tested acupressure "seeds" taped to a Korean hand acupressure point (K9, on the middle phalanx of the fourth finger), and the Kotani trial tested acupuncture at the bladder meridian point (about 2.5 cm from the spinal vertebrae).

No serious adverse events have been associated with acupressure bands; occasional wrist swelling has been noted. Several studies in which the bands were placed prior to anesthesia noted that the bands did not interfere with the insertion of intravenous lines into the same arm. Adverse events following acupuncture are rare (see Alternative Therapies in Women’s Health, July 2002).

Acupuncture and/or acupressure appear to be effective for PONV. Different methods of stimulating P6 (acupuncture, acupressure, electroacupuncture) appear to be equally effective, and all treatments appear to be benign.

Clinical trials of acupoint stimulation for PONV have used diverse populations and techniques. The wide variation in type of surgery, type of anesthesia, timing of administration of acupuncture or acupressure, duration of treatment, and duration of the study make it difficult to compare techniques and timing.

Future research evaluating acupoint stimulation should improve the quality of the existing evidence. Nevertheless, women undergoing surgery may consider acupressure bands, or other forms of acupoint stimulation, as a safe alternative or adjunct to pharmacological agents for preventing PONV.

Dr. Tamayo is Director, Division of Complementary and Alternative Medicine, Foresight Links Corp. in London, Ontario, Canada.

References

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4. Kotani N, et al. Preoperative intradermal acupuncture reduces postoperative pain, nausea and vomiting, analgesic requirement, and sympathoadrenal responses. Anesthesiology 2001;95:349-356.

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