You are on page 1of 4

British Journal of Anaesthesia 82 (3): 387–90 (1999

)

Acupressure and the prevention of nausea and vomiting after
laparoscopy
D. Harmon1*, J. Gardiner1, R. Harrison2 and A. Kelly3

1Department of Anaesthesia and 2Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin,
Ireland. 3Department of Community Health and General Practice, Trinity College, Dublin, Ireland
*To whom correspondence should be addressed at: Department of Anaesthesia, Beaumont Hospital, Beaumont Road,
Dublin 9, Ireland

The efficacy of currently available antiemetics remains poor. Concern with their side effects
and the high cost of the newer drugs has led to renewed interest in non-pharmacological
methods of treatment. We have studied the efficacy of acupressure at the P6 point in the
prevention of nausea and vomiting after laparoscopy, in a double-blind, randomized, controlled
study of acupressure vs placebo. We studied 104 patients undergoing laparoscopy and dye
investigation. The anaesthetic technique and postoperative analgesia were standardized. Failure
of treatment was defined as the occurrence of nausea and/or vomiting within the first 24 h
after anaesthesia. The use of acupressure reduced the incidence of nausea or vomiting from
42% to 19% compared with placebo, with an adjusted risk ratio of 0.24 (95% CI 0.08–0.62;
P50.005). Other variables were similar between groups.
Br J Anaesth 1999; 82: 387–90
Keywords: vomiting, nausea, acupressure; vomiting, incidence; surgery, laparoscopy
Accepted for publication: November 9, 1998

In 1848, 1 yr after the introduction of general anaesthesia studies comparing acupuncture and acupressure in the
in Great Britain, John Snow published an article on the prevention of PONV.
phenomenon of postoperative nausea and vomiting The potential side effects of acupuncture include nerve
(PONV).1 Since that time, repeated efforts have been made damage,12 13 pneumothorax14 and infectious disease trans-
to reduce the incidence and intensity of this problem. mission.15 These side effects are rare and possibly only
However, Rowbotham, in his review of the management of relevant to patients with diabetes mellitus or those with
PONV, concluded that the efficacy of currently available risk factors for endocarditis.16 There are only relative
antiemetics remains poor.2 These drugs also cause a variety contraindications with the sterile needles used in modern
of side effects, such as dystonic reactions, restlessness and day practice. In contrast, there are no reported adverse
tachycardia. effects of acupressure in the literature. Acupressure has
Postoperative emetic symptoms are influenced by many thus far not been studied after gynaecological surgery and
factors and these must be carefully controlled when studying holds the potential for being a simpler but effective therapy.
PONV.3 An important influence is the type of surgery.4
Laparoscopy for diagnostic and therapeutic gynaecological
purposes is associated with a 36–60% incidence of PONV.5 Patients and methods
Acupressure, a non-invasive type of acupuncture, has After obtaining approval from the Hospital Ethics and
been reported as a potential non-pharmacological method Research Committee, and written informed consent, we
of preventing nausea and vomiting. In acupressure, manual conducted a prospective, randomized, double-blind study.
stimulation is applied, unlike acupuncture where the skin The study was planned with a power of 0.9 to detect a 20%
is pierced with a needle. Studies have shown that acupressure difference in the incidence of PONV, with a significance
can decrease nausea caused by morning sickness,6 general level of 0.05. This required recruitment of 104 patients.
anaesthesia7 and chemotherapy.8 But other studies of this We studied ASA I–II patients, aged 19–43 yr, under-
technique have had unfavourable results, including those going laparoscopy and dye investigation at the Rotunda
of Yentis and Bissonnette9 and Lewis and colleagues.10 Hospital. This procedure was part of a series of infertility
Acupuncture has been shown to be effective in the preven- investigations. Criteria for exclusion included obesity (BMI
tion of PONV in patients undergoing laparoscopic gynaeco- .35 kg m–2), diabetes mellitus and a previous history of
logical procedures.11 There are no randomized, controlled PONV. Patients with diabetes mellitus are predisposed to

© British Journal of Anaesthesia

1 h before operation.v.v. The groups were comparable in solpadeine 500 mg 6 hourly) as required. To examine the severity carpi radialis and palmaris longus 2 ‘cun’ (a cun is a Chinese of nausea and vomiting. IR5irregular Leicestershire. They were similar and nurses were informed that an antiemetic should be between groups. Patients were allocated randomly to either an acupressure Acupressure (n552) Control (n552) or control group.5 mg. was prescribed We studied 104 patients: 52 in the acupressure group and with simple analgesics (mefenamic acid 500 mg 6 hourly/ 52 in the control group. for pain relief in the Results recovery room.05 was chosen. measurement equal to the width of the interphalangeal joint mild. wrist bands were placed with pressure at a non. Vomiting and retching were not of the thumb) from the distal wrist crease. acupressure bands (Sea band UK Ltd.285. P350. nausea was classified as none. Diclofenac 100 mg Initially. The acupressure group whether nausea. respectively.3–0. severe (. retching or vomiting had occurred. Postop. The latter was categorized into three groups. In the acupressure group. Ondansetron 4 mg age. Anaesthesia was Patient characteristics in the two groups were assessed induced with thiopental 0. and maintained with 0–1.5 mg and glycopyrrolate 0. Patients were told that a form of Duration (min)3 20 (5) 21 (5) acupuncture (using wrist bands instead of needles) may reduce the incidence of postoperative sickness and we were investigating the most appropriate site for this to be placed. Bands removed and control of nausea/vomiting was estimated using a before the end of anaesthesia helped the double-blind aspect logistic regression model controlled for opioid and duration of the study and maintained the simplicity of the technique. 10 (19%) allocation. All procedures were carried out by experienced surgeons.18 All patients received fentanyl i.v. of anaesthesia. All patients received Statistical analysis diazepam 10 mg. episodes over 24 h: none. and prochlorperazine 12. Menstrual phase Postop. Patients and vomiting are shown in Table 2. Data were compared using the unpaired t test (P150.v. No antiemetic medication was given before or during operation. These results demonstrated a statistically significant 388 .3 mg kg–1. At the three compared with 22 (42%) in the control group. they 3. moderate (3–5) or acupoint site. In the acupressure group. Control (27/19/6) 11 11 The treatment point P6 (Nei-Guan) is the number 6 meridian point in the pericardium channel. nausea. F5Follicular. UK) were placed on the right forearm. wrist bands Acupressure (27/21/4) 14 8 were placed with the plastic bead positioned at the P6 point. Kitching and Nagle19 as none. peripheral vascular disease and were therefore excluded Table 1 Patient characteristics and duration of surgery (mean (SD or range)). immediately before induction of anaesthesia. Acupressure bands were removed 20 min after sure and control groups.m. Neuromuscular block was vomiting and then separately for nausea and vomiting. given in the presence of intolerable nausea or vomiting.m.17 In the control distinguished and severity was classified by the number of group. P250. provided by atracurium 0. Then the odds ratio for acupressure induction of anaesthesia. In Figure 1.20 At the end of the 24-h period. patients with neostigmine 2.197) because of the risk of blood flow impairment to the digits. i. moderate or severe. and at 2 and 24 h after data are not stratified for variables which may influence the operation). with prior the association between nausea and vomiting in the acupres- consent. (F/L/IR) opioid simple analgesia pressure band has an adjustable strap with a spherical plastic bead attached to it. Pethidine 1 mg kg–1 i. Comparison between 1.5). times (in the recovery room.5 mg i. The incidence of nausea and vomiting at three patients had nausea/vomiting in the first 24 h after operation times during the first 24 h was determined. 1). an anaesthetist blinded to the therapy registered incidence of nausea or vomiting. patient charts Anaesthesia was administered by different anaesthetists were assessed for antiemetic and analgesic requirements.5 mg kg–1 i. retching/vomiting. it is located on the anterior surface of the forearm between the tendons of the extensor were recorded as having vomiting. mild (0–2). L5luteal.5% enflurane and groups was performed for overall nausea.. Multivariate analysis of the data is presented in Table If a patient experienced both nausea and vomiting. Randomization was conducted by com- Age (yr)1 33 (19–41) 32 (27–43) puter and the code was sealed until arrival of the patient in Weight (kg)2 62 (10) 64 (9) the operating theatre. Pearson’s chi-square test was used to investigate rectally was given at the end of the procedure. Residual neuromuscular block was antagonized in all A significance level of 0. In both groups. Harmon et al. compared with the control group (P5 0. retching and 60% nitrous oxide in oxygen.5 µg kg–1 i. The had a significantly lower incidence of nausea and vomiting results were scored in a manner similar to that of Allen. before emergence. The acu. Table 2 Distribution of patients and risk factors. weight and duration of surgical procedure (Table 1).011) (Fig. The incidence of postoperative nausea and/or vomiting Both patients and nurses were unaware of patient group is shown in Figure 1.0837. were prescribed for The incidence of risk factors for postoperative nausea PONV in the recovery room and ward. using a standardized technique. and fentanyl using the unpaired Student’s t test.

P50. oscopy in our study is similar to other studies.24 0. type of surgery.28 0.005 been highlighted.33 administration of opioids.005).07–1.17–0. Severe 0 0 Up to 70% of patients report emetic symptoms as the Antiemetic (1 dose) 3 9 postoperative outcome they would most like to avoid. Important Fig 1 Incidence of nausea/vomiting in the acupressure and control groups at the three times. including also a statistically significant reduction in nausea in the age. it is important that studies evaluating PONV are ments in both groups are shown in Table 4.26 Acupressure Table 3 Odds ratio (95% confidence interval) of efficacy of acupressure in studies which did not report favourable results9 10 applied preventing nausea/vomiting after laparoscopy. The standard control Duration (1–15 min) 1 – – in acupuncture research is ‘sham’ acupuncture.00 0. Fan and colleagues. a mechanism as it is not clinically effective if the nerve protective effect of acupressure in preventing nausea per- supply is disrupted. after adjustment for opioid and duration of anaesthesia. Addi- tional problems with ‘sham’ acupuncture occur in patients Table 4 Severity of nausea and vomiting.79 0.005).09 1. acupressure was Vomiting n547 n547 applied simultaneously with induction of anaesthesia and None 44 41 removed before emergence to overcome some of these Mild 2 4 Moderate 1 1 problems.32 Yet patients are often reassured that the reduction in nausea and vomiting in the acupressure group latest available antiemetic medications will be administered.22–1.65 0.35–11. Blinding is also affected by patient experience.22 It is a protective effect of acupressure. and antiemetic requirements.88 0.4 0. There were no carefully designed to avoid bias.23 Most studies indicate the efficacy of acupressure or acupuncture at the P6 meridian. had a maximal effect in the first hour. Acupuncture has the potential to Nausea only n544 n539 elicit very powerful non-specific effects. There was Many factors influence the incidence of PONV. simple stimulation by inserting the needle may (201 min) 4.59 0.34 acupressure group compared with controls (P50.08– reported increased beta-endorphin concentrations in human 0.08–0. P values were computed controlling for the other variables presented the importance of applying the technique before the emetic stimulus. Statistical analysis of acupressure treatment components of this treatment include the timing of stimula- for postoperative nausea and vomiting: chi-square test55. n5number of patients who have experienced acupuncture therapy. history of PONV35 and phase of the menstrual cycle.7 Belluomini and colleagues6 and Al-Sadi. Score is the maximum reported score over 24 h.02). sex. adjusted risk ratio of 0. P50. with an adjusted risk ratio of 0. tion24 and correct point location.41 of acupuncture for analgesia research. Mild 4 11 Almost 100% of patients treated with sham acupuncture Moderate 3 5 Severe 0 0 may respond positively.28 (95% CI 0. Peripheral nerve stimulation is an integral part of the When nausea and vomiting were analysed separately. P50.36 37 Severity of nausea and vomiting and antiemetic require- Therefore. as was demon- strated previously by Dundee and colleagues.40 0. but the wide confidence 389 .5 We were able to demonstrate the effectiveness of P6 acupressure in Discussion reducing nausea and vomiting after laparoscopy. Odds ratios were derived from a logistic regression the technique after induction of anaesthesia.02).08–0.30 In our study.21 Clement-Jones and colleagues sisted.56.23.011.29 Such a physiological mechanism does not exist for nausea and vomiting.25 P6 manual stimulation absolute difference 23% and 95% confidence interval 0.62 0.02 Vomiting 0.39–13.24 (95% CI 0. Acupuncture has been shown to enhance gastric motility.70 0.59 research.23 on the gate control theory of pain.27 28 Many of these are relevant to the use No opioid vs opioid 0. Experienced patients are able to identify the feeling of ‘chi’ if the needle Acupressure Control is placed appropriately. it raises expecta- None 37 25 tions and involves sensation in addition to time and empathy. Newman and Julious11 found this technique to be effective. ative.08–0. In analgesia (15–20 min) 1. it is not justified to use antiemetics routinely before operation.79. Acupressure and the prevention of nausea and vomiting postulated that opioids may also have an antiemetic effect mediated by the action of beta-endorphin on mu receptors.62. Variable Odds ratio 95% CI P Difficulties in acupuncture and acupressure research have Nausea/vomiting 0. the point estimates suggested cerebrospinal fluid after acupuncture stimulation. side effects or complications caused by placement of the The 43% incidence of nausea and vomiting after lapar- acupressure band in either group. compared with the control group (P50. with an The mechanism of action of acupressure remains specul.31 In most cases. Acupressure may result in the release of beta-endorphin with increased antiemetic tone. This stresses model. For vomiting.01 have a counter-irritation effect which may have an effect Nausea 0.

Increased β-endorphin but not met-enkephalin levels in human cerebrospinal fluid after acupuncture stimulation for References recurrent pain. 87: 52–9 35 McKenzie R. Wadhwa RK. Anaesthesia 1997. A vomiting after gynaecological surgery. Beecher HK. Pandit UA. Spinal epidural hematoma with following ambulatory surgery: are all procedures created equal? subarachnoid hemorrhage caused by acupuncture. 77: of postoperative nausea and vomiting. Thomson W. Laparoscopic findings in 375 women vomiting after gynaecological laparoscopy depends upon the phase attending the Rotunda Hospital infertility clinic. 20 Tigerstedt I. Ghaly RG. 63: 630P 4 Knapp MR. et al. Fitzpatrick KTJ. Tomlin S. Its 11 Al-Sadi M. Patterson CC. 7: 62–3 laparoscopy is influenced by the day of the menstrual cycle. Gruen P. 1984. Effect of stimulation of the P6 antiemetic point on and vomiting of pregnancy: a randomised. Postanesthetic nausea. 69 (Suppl. Besser GM. J Am Podiatr Med 1): 40–5S Assoc 1997. 63: 612–18 Gynecol 1994. 22 Clement-Jones V. 2: 946–9 1 Snow J. Amersham: J Anaesth 1991. 38: 876–9 390 . Subacute bacterial endocarditis following of post-operative nausea and vomiting in women undergoing ear acupuncture. BMJ 1987. Lim NT. Can Assoc Radiol J 1991. Stuber FE. acupuncture injury and intragluteal injection. Rees LH. White PF. 38: 298–302 Churchill Livingstone. Bissonnette B. Korttila K.) are needed. Fox EJ. Br J Anaesth 1991. 67: 73–8 32 Watcha MF. Litt RC. 1): 24–32S 26 Dundee JW. Antiemetic effectiveness 14 Gray R. BMJ 1997.g. Ghaly RG. 7: 115–17 8 Dundee JW. On Narcotism by the Inhalation of Vapours. 42: 139–40 droperidol. Lancet 1980. vomiting and 25 Fitzpatrick KTJ. 92: 1527–30 and vomiting. 23 Lin X. Bill KM. Am J Chin Med 1997. Ghaly RG. JAMA 1956. Harmon et al. Dundee JW. The pitfalls of clinical acupuncture research: can east Anesth Analg 1997. combination of acupressure and prophylactic antiemetic 22: 691–3 drugs should also be investigated. Kitching AJ. nausea and vomiting after laparoscopy. White A. McIlwain JC. Anesth Analg 1981. the non-pharmacological technique of transdermal scopolamine.v. The Foundations of Chinese Medicine. Does the timing of P6 acupuncture 3 Korttila K. Wen HL. Beard MC. Anaesthetic factors contributing to 13 Sobel E. Pneumothorax resulting from of intramuscular hydroxyzine compared with intramuscular acupuncture. Eisenberg L.v. Nausea and vomiting 12 Keane JR. Stillwell DM. McLoughlin L. The incidence 16 Lee RJE. Studies in Fertility and Sterility. Drop foot as a complication of postoperative nausea and vomiting. 1848 stimulation of acupuncture points enhances gastric myoelectrical 2 Rowbotham DJ. Current management of postoperative nausea activity in humans. In: Harrison RF. Br J Anaesth 1992. Postoperative nausea and vomiting. 25: 3–11 treatment for prevention of postoperative nausea and vomiting. Mu F. Huang EY. eds. droperidol 19 Allen DL. Chen JDZ. 435–6 37 Honkavaara P. 14: 365–6 34 Rabey PG. Is it retching. of the menstrual cycle. Double-blind comparison of In summary.65 mg i. Acupuncture: safety first. Buckley DN. 69 (Suppl. Effect of 31 Orkin FK. Tanhui E. Anaesth Intensive Care 1994. 84: 821–5 satisfy west? Arthritis Care Res 1994. Ahmadi J. The study of postoperative nausea and vomiting. Wilton NCT. Lindblad T. Anesth Analg 1992: 74: S225 outpatient strabismus correction. and ondansetron 4 mg i. Ghaly G. Br J influence its efficacy as a postoperative anti-emetic? Br J Anaesth Anaesth 1992. Maharajh GS. 67: S163 1993. Shevde K. Nagle C. Can 17 Giovanni M. treatment and prevention. Diagnosis studies comparing acupressure with standard doses of com. Clin Pharmacol Ther 1991. is easy to apply and action of P6 acupuncture. Lehtinen AM. 160: 376–85 necessary always to use the right forearm for acupuncture 5 Lerman J. Pain 1977. Surgical and patient factors involved in postoperative antiemesis? Br J Anaesth 1988. 1): 46–59S 24 Dundee JW. Local anesthesia blocks the antiemetic devoid of possible side effects. Joshi S. 314: 1362 36 Beattie WS. A review of problems in clinical acupuncture 7 Fan CF. Br J Anaesth 1991. Julious SA. Obstet postoperative nausea and vomiting. White AR. Salmela L. London: Royal Society of Medicine Services Ltd. Lee KA. What do patients want? Preferences for immediate P6 acupressure on postoperative vomiting in children undergoing postoperative recovery. Electrical 1991. Katz M. Ren J. Can J Anaesth 1991. Liang J. 61: 117–18P nausea and vomiting. Fitzpatrick KTJ. Ghaly RG. Hovorka J. 294: 179 points for pain: correlations and implications. Zhang M. Pryn SJ. Controlled Bonnar J. Chestnutt WN. 1): 20–23S 1989. facsimile Edn. Newman B. Wieting CB. Br J Anaesth 1992. 1989. Hyland R. 779–80 Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1979. 177–80 monly used prophylactic antiemetic drugs (e. Am J Neuroradiol Anesth Analg 1988. 50: 78–80 economical. Acupressure is 32: 454–7 21 Dundee JW. Trivedi S. interval reflected the small number of events. 84: 245–8 27 Ernst E. Acta Anaesthesiol Scand 1988. 67: for operative dentistry: a comparison of acupuncture and placebo. 69 (Suppl. Reynolds PI. Forrest JB. Acupressure for nausea Lynas AGA. Aromaa U. Hong Y. Lancaster: MTP Press. Acupuncture in the prevention etiology. Int J Cardiol 1985. Optimising antiemesis in 29 Melzack R. Lecky JH. Analgesia vomiting after tonsillectomy in children. 3: 3–23 9 Yentis SM. Nausea and 18 McKenna P. Smith G. Kitz DS. Trigger points and acupuncture cancer chemotherapy. 6 Belluomini J. Mitchell JN. Acupressure research. droperidol and placebo against acupressure at the P6 point was effective in preventing postoperative nausea and vomiting. P6 acupuncture and postoperative 30 Taub HA. 48: 205–10 10 Lewis IH. 52: 162–84 658–61 33 Pataky AO. 69 (Suppl. Br J Anaesth 1989. 60: 783–8 15 Ernest E. Harrison RF. 28 Harden RN. Andrews RW. P6 acupressure and nausea and 0. Am J Gastroenterol 1997. blinded study. Br J Anaesth 1992. and Management of Tubo-Uterine Factors in Infertility. Anesthesiology 1992.