Running Head: ACUSTIMULATION IN POST OP NAUSEA
Does acustimulation reduce the occurrence of post-operative nausea in adult patients undergoing
abdomino-pelvic surgical procedures?
Cristina Correa
Shelli Hunter
Seretha Kimbrough-Powell
Kathryn Lyle
Megan Naylor
Sarah Peek
Jennifer Skane
Hannah Wilhoite
NUR 600 – Research & Statistics for Advanced Practice
Professor Anne Turner-Henson
University of Alabama at Birmingham
March 29, 2013
1
ACUSTIMULATION IN POST OP NAUSEA
2
Introduction
Post-operative nausea and vomiting (PONV) is an adverse event often experienced post
anesthesia. According to the American Society of PeriAnesthesia Nurses Clinical Practice Guideline,
PONV is the most commonly occurring postoperative complication, affecting seventy-five million people
annually (2013). PONV results in unnecessary patient discomfort, prolonged post-operative stays,
increased healthcare costs, inhibition of the healing process, and an overall negative surgical experience.
In current practice, various anti-emetic medications are utilized to control PONV. Acustimulation has
recently been integrated as a non-pharmacologic approach to PONV control. This new approach is being
investigated to determine its effectiveness in the reduction of PONV. The independent variable being
researched is the use of P6 acustimulation, and the dependent variable is the effect on PONV.
Appraisal of Collective Findings
The collective findings of six randomized controlled trials examined the effects of acustimulation
on post-operative patients in the reduction of nausea and vomiting. Five articles focused on women ages
18-81 undergoing elective gynecological and abdominal laparoscopic surgery. One article focused on
males and females older than 18 years undergoing laparoscopic cholecystectomy. All six articles found a
decrease in PONV with P6 acustimulation. Two studies, Frey, Funk, Lohlein, & Peters (2009) and Frey,
Scharmann, Lohlein, & Peters (2009), found that the timing of pre- or post-induction of anesthesia had no
significant effects on PONV reduction. However, El-Deeb & Ahmady (2011) explained that acupuncture
should be performed prior to emetic stimulation by anesthesia and surgery. Four articles addressing
acustimulation prior to anesthesia found that PONV was decreased up to six hours post-operatively, with
no decrease in PONV 24 hours post-operatively, while the study of Frey and Scharmann (2009) did find
reduced effects of late PONV (24 hours). Only one study by Turgut et al. (2006) evaluated PONV in
gynecological patients receiving Morphine through PCA pumps. Frey & Scharmann (2009) and Frey &
Funk (2009) both used the ReliefBand as an instrument in their studies, applying 31Hz. The study of
Kim, Kim, Lee, Shim, & Yoon (2011) found the largest decrease in PONV through the use of a
Cleartrode instrument at 50Hz showing a success of 49% in the treatment group, which included a
ACUSTIMULATION IN POST OP NAUSEA
decrease by 48% in nausea and 59% in vomiting. While all six research studies resulted in improvement
of PONV, some also resulted in an overall improvement of satisfaction scores as well. The strength of
acustimulation is being a low-risk, non-invasive, affordable option to implement within a 6 hour postoperative period resulting in reduced PONV. The weakness of ascustimulation is that not everyone is a
candidate and evidence does not conclude that it reduces PONV after the 6 hour post-operative period.
Decision Based on Evidence in Nursing Practice
The use of acupressure stimulation would be a cost-effective, non-pharmacologic and noninvasive intervention to implement in the treatment of gynecologic patients who are at risk for PONV.
Studies have shown that this intervention has been effective specifically in gynecologic laparoscopic
surgeries. In another study that included both males and females undergoing laparoscopic
cholecystectomy, it was found that PONV within the first two hours after surgery was significantly lower
in the group who received acustimulation (Frey and Funk, 2009). Based on this evidence, there appears to
be a beneficial relationship between the use of acupressure stimulation and laparoscopic surgeries. Thus
the evidence presented in the research supports an addition of acupressure stimulation therapy to current
practice for the control of PONV.
Implications for Practice
Through the use of electrical acustimulation, patients can experience a decrease in PONV as
opposed to using anti-emetic therapy alone. Acupressure stimulation has been found to be effective
against nausea in the early post-op stages, specifically in the first 6 hours after surgery (Arnberger, et al.,
2007). Acustimulation has also been effective in decreasing nausea and vomiting in patients with
Morphine PCA pumps after surgery (Turgut, et al., 2006). Various techniques including the use of a
Seaband, electrodes, and a ReliefBand were used to apply the acupressure stimulation, which allows for
variation in applying the intervention. Studies have shown the combined use of early acustimulation and
anti-emetic drug therapy can further decrease PONV in laparoscopic patients. Further research will be
necessary to determine the effectiveness of acupressure stimulation in patient populations outside of those
undergoing laparoscopic surgeries.
ACUSTIMULATION IN POST OP NAUSEA
4
References
American Society of PeriAnesthesia Nurses. (2013). PONV/PDNV Clinical Guidelines.
Retrieved from:
http://www.aspan.org/ClinicalPractice/ClinicalGuidelines/PONVPDNV/tabid/3257/Default.aspx
Arnberger, M., Stadelmann, K., Alischer, P., Ponert, R., Melber, A., & Greif, R. (2007).
Monitoring of Neuromuscular Blockade at the P6 acupuncture point reduces the incidence of
postoperative nausea and vomiting. Anesthesiology, 107(6), 903-908.
doi: 10.1097/01.anes.0000290617.98058.d9
Level: Randomized control trial
Strength of research evidence: Strong
El-Deeb, A. M., & Ahmady, M.S. (2011). Effect of acupuncture on nausea and/or vomiting
during and after cesarean section in comparison with ondansetron. Journal of Anesthesia, 25(5),
698-703. doi: 10.1007/s00540-011-1198-0
Level: Randomized control trial
Strength of research evidence: Strong
Frey, U. H., Funk, M. M., Lohlein, C. C., & Peters, J. J. (2009). Effect of P6
acustimulation on post-operative nausea and vomiting in patients undergoing a laparoscopic
cholecystectomy. Acta Anaesthesiologica Scandinavica, 53(10), 1341-1347. doi:10.1111/j.13996576.2009.02081.x
Level: Randomized control trial
Strength of research evidence: Strong
Frey, U., Scharmann, P., Lohlein, C., & Peters, J. (2009). P6 acustimulation effectively decreases
postoperative nausea and vomiting in high-risk patients. British Journal of Anaesthesia, 102(5),
620-625. doi: 10.1093/bja/aep014
Level: Randomized control trial
Strength of research evidence: Strong
ACUSTIMULATION IN POST OP NAUSEA
Kim, Y. H., Kim, K. S., Lee, H. J., Shim, J. C., & Yoon, S. W. (2011). The efficacy of several
neuromuscular monitoring modes at the P6 acupuncture point in preventing postoperative nausea
and vomiting. Anesthesia and Analgesia, 112(4), 819-823.
doi: 10.1213/ANE.0b013e31820f819e
Level: Randomized control trial
Strength of research evidence: Strong
Turgut, S., Ozalp, G., Dikman, S., Savli, S., Tuncel, N., & Kadiogullari, N. (2007). Acupressure
for postoperative nausea and vomiting in gynaecological patients receiving patient-controlled
analgesia. European Journal of Anaesthesiology, 24(1), 87-91.
doi: 10.1017/S0265021506001190
Level: Randomized control trial
Strength of research evidence: Strong
ACUSTIMULATION IN POST OP NAUSEA
6
N600 Collective Findings Table
Category
Reference
(.91 points/ .15
each article)
This article was chosen because of the specific sample population used in the study
as well as the randomized controlled trial utilized.
Kim, Y. H., Kim, K. S., Lee, H. J., Shim, J. C., & Yoon, S. W. (2011). The efficacy
of several neuromuscular monitoring modes at the P6 acupuncture point in
preventing postoperative nausea and vomiting. Anesthesia and Analgesia,
112(4), 819-823. doi: 10.1213/ANE.0b013e31820f819e
Purpose
(.91 points)
Sample
(.91 points)
Conceptual or
Theoretical
Framework
(.91 points)
Concepts and
Variables
(.91 points)
Design
(.91 points)
This study sought to find the most effective neuromuscular monitoring mode in
post-operative nausea and vomiting (PONV) by comparing multiple neuromuscular
monitoring modes: single twitch (ST), train-of-four (TOF), double-burst stimulation
(DBS), and tetanus at the P6 acupuncture point and identify which mode can best
prevent PONV after patients receiving laparoscopic hysterectomy surgery. Multiple
neuromuscular interventions have been studied in decreasing PONV.
A power analysis of PONV from a previous study determined the sample size of 50
patients per test group. The study was given IRB approval. Informed consent was
obtained from 264 women, with ASA physical status I–II, between ages 31 and 67
scheduled for laparoscopic hysterectomy prior to being randomly assigned to one of
five groups: Control (54 members), ST (52 members), TOF (53 members), DBS (53
members), or tetanus (52 members). Exclusion criteria was receiving antiemetic
medications 24 hours or less prior to surgery, obesity, neuromuscular, hepatic, or
renal diseases; or allergies to any of the medications used during the study.
Theoretical Framework: Up to 70% of patients receiving major gynecologic surgery
report PONV, and even higher percentage when receiving opiates post operatively.
Multiple drugs as well as non-pharmacologic methods are used to help decrease
PONV with minimal side effects. Several studies report the effective use of
electrical stimulation of peripheral nerves at P6 acupoint against PONV. Four
effective neuromuscular monitoring modes were chosen for comparison in this study
in order to find the most effective intervention for PONV and accurately measuring
neuromuscular blockade.
Independent variables consisted of single twitch (ST), train-of-four (TOF), doubleburst stimulation (DBS), and tetanus neuromuscular monitoring modes at the P6
acupuncture point. Dependent variables consisted of nausea, vomiting and retching
symptoms postoperatively.
Prospective, randomized, double blind, placebo controlled study was used that
included five neuromuscular monitor test groups. PONV was assessed by an
independent observer unaware of the study groupings and neuromuscular
monitoring mode. In the control group, two electrodes were positioned over the
ulnar nerve of patient’s dominant arm prior to anesthesia and detached after
anesthesia in the operating room (OR). Each electrode was attached to a peripheral
nerve stimulator. In the 4 treatment groups the same electrodes, peripheral nerve
stimulator, square wave pulses, constant current, as the control group were used
prior to anesthesia and removed after anesthesia in the OR, but placed on the median
nerve at the P6 acupoint on the patient’s dominant arm and tested using the different
monitoring modes respectively.
ACUSTIMULATION IN POST OP NAUSEA
Instruments/How
variables
measured
(.91 points)
Interventions/or
methods
(.91 points)
Statistical Tests/
Analysis Method
(.91 points)
Results/Findings
(.91 points)
Implications
(.91 points)
An investigator uninvolved with the members of the study set up the neuromuscular
monitors. Both patients and medical staff were unaware of group assignments. A
simplified Apfel score was used to measure PONV risk on a 3 point scale: 0-no
symptoms, 1-only nausea, 2-vomiting. The highest score was documented for study
purposes. Pain scores were measured using a scale: 0=no pain to 10=unbearable
pain. The first 24 hours after surgery use of opioids and patient satisfaction scores
were documented (0=very dissatisfied to 10=most satisfied).
ST, TOF, DBS, and tetanus neuromuscular monitoring modes at the P6 acupuncture
point were used as interventions in comparison to a control group and each other.
No training was involved in preparing the subjects for the study.
Differences between the five groups were shown using a series of 1-way analysis of
variances. The post hoc Bonferroni correction test was used for comparisons if a
significant difference was found. The Kruskal-Wallis test and the Mann-Whitney
rank sum test were used to measure differences in nonparametric group variables
and intergroup differences. Analysis of variance for repeated measures was used to
assess pain. SPSS version 17.0 statistical software was used for statistical analysis.
Study groups did not reveal significantly different pain scores within the first 2
hours post op. Within 6 hours the tetanus group (P=0.003) had a significantly lesser
need for opioids than the control group, but not in the ST (P=0.506), TOF (P=0.854)
or DBS (P=0.273) groups. A 30% total reduction of PONV, = 0.05 and  = 0.2
with a power of 80%. Statistical differences were considered significant if P < 0.5.
This study revealed 70% of patients reported PONV in the control group (P=0.022),
compared to 49% in the treatment groups. The tetanus group also revealed higher
overall satisfaction scores in comparison to the control group. There were no
differences found in the ST, TOF, and DBS groups compared with the control
group. The effect of electroacupuncture on PONV is unknown at this time.
Limitations to the study include continuous use of patient controlled anesthesia, and
the use of a non-verbal pain scale. P6 tetanic acupuncture has been found to reduce
PONV mostly within the first 6 hours after laparoscopic hysterectomy surgery while
also proving to increase patient satisfaction. Because of the minimal side effects
seen after use of acupuncture, the integration of the practice is realistic with further
research.
ACUSTIMULATION IN POST OP NAUSEA
8
N600 Collective Findings Table
Category
Reference
(.91 points/ .15
each article)
This article was chosen provided the article’s study included the specific population
requirements. The study was randomized and controlled.
El-Deeb, A. M., & Ahmady, M. S. (2011). Effect of acupuncture on nausea and/or
vomiting during and after cesarean section in comparison with ondansetron.
Journal of Anesthesia, 25(5), 698-703. doi: 10.1007/s00540-011-1198-0
Purpose
(.91 points)
Sample
(.91 points)
Conceptual or
Theoretical
Framework
(.91 points)
Concepts and
Variables
(.91 points)
Design
(.91 points)
Instruments/How
variables
measured
(.91 points)
Interventions/or
methods
(.91 points)
The purpose of this study was to compare the effects of electrical acustimulation via
acupuncture therapy to the P6 acupoint (pericardium 6) with ondansetron medication
therapy for treatment and prevention of intraoperative and postoperative nausea and
vomiting (PONV). Both acupuncture and ondansetron have both been used to
decrease PONV for a number of reasons. This study compared the two interventions
in PONV.
450 women that met ASA physical status I-II were scheduled for an elective cesarean
section delivery utilizing spinal anesthesia, between the ages of 25 and 35 years of
age. A sample size of 137 was used for each group. Each group comprised 150
subjects; extra patients were included to avoid defaulters Each participant signed
informed consent and the study granted IRB approval. Exclusion criteria included
any acupuncture treatments within 6 months, nausea or vomiting within a 24hour
time window prior to operation, diabetes, hypertension, cardiovascular disease, or
other systemic disease. Participants were placed into one of three groups using
randomized sealed envelope assignments. Each group contained 150 participants. 1control group, 2- the ondansetron group, 3, the electro-acupuncture group.
Theoretical Framework: Complications of general anesthesia include PONV. No
therapy has proven effective for completely eliminating PONV. Limited availability
and side effects of available antiemetic medicines has encouraged further
interventions for PONV. Decreasing PONV is one of many studied effects of
acupuncture. Ondansetron was chosen for this study due to economic reasons and
unlikelihood of manifestation of extrapyramidal symptoms in comparison to other
antiemetic drugs.
Independent variables consisted of ondansetron and electro-acupuncture.
Dependent variables consisted of intra and postoperative nausea and vomiting, and
overall patient satisfaction.
This was a randomized, double blind study that included three separate test groups.
Nausea, vomiting, and patient satisfaction were measured throughout the study.
An independent anesthetist who was blinded to group assignment evaluated PONV
every 10 min intra-operatively and at 2, 4, 6, 12, and 24 hours after surgery. An
analogue score was used to assess nausea (0, no nausea; 10, worst nausea)
ondansetron 4 mg IV was given for a score of 4 or worse, or active vomiting. The
time to first emetic event, the duration of surgery, amount of ephedrine consumed,
and other complications were documented. Patient satisfaction scores were based
upon the entirety of the patient experience (satisfied or not satisfied).
Ondansetron and electro-acupuncture were both used as interventions in comparison
to a control group and each other. Each participant received 1liter Lactated Ringers
solution. The ondansetron group received 4mg IV ondansetron and false acupuncture
treatments. The acupuncture group received P6 acupoint stimulation and false IV
drug injection. The control group received false acupuncture and drug injection. No
ACUSTIMULATION IN POST OP NAUSEA
Statistical Tests/
Analysis Method
(.91 points)
Results/Findings
(.91 points)
Implications
(.91 points)
training was involved in preparing the subjects for the study.
This study used an appropriate type of sample by using the Epicalc program 2000
with a power of 80% and confidence interval of 95%. The Kolmogorov–Smirnov test
was used for analysis of data distribution normality. One way Analysis of Variance
and least significant difference tests were used to test the data for statistical
significant differences between groups and intergroup comparisons. Quantitative data
between groups was compared with the student’s t test. Qualitative data was tested
using the chi square test. A significant P was measured at <0.05 with a 95%
confidence interval.
Prophylactic P6 acupuncture proved a reduction of PONV by 25% in more than half
of the participants in the control group, and prophylactic ondansetron proved a
reduction of PONV by 35%. Treatments in groups 2 and 3 intra-operatively and for 6
hours post operatively proved less NV during the study time frame P = 0.001 and
0.003 respectively. Patient satisfaction scores increased in both groups 2 and 3 in
comparison to the control group 1. The study established the positive effects of
improving patient satisfaction with decreased intraoperative, and early PONV with
the use of electro-acustimulation. Members in the control group reported PONV of
34% immediately after surgery, 28% reported NV 6 hours post op which reduced to
9% in group 2, and 7% in group 3. The time period to first PONV symptoms was
considerably less in groups 2 and 3 compared to the control. Changes proved to be
statistically significant and imply a comparable effectiveness of both interventions.
There was no significant change in any of the groups PONV at 24 hours.
Comparable to ondansetron post op, Electro-acustimulation is an affordable and
relatively simple option in prevention of PONV. Further studies are necessary for
efficacy and safety of both electrical acustimulation plus Ondansetron as prophylaxis
treatment of NV during and after cesarean deliveries.
ACUSTIMULATION IN POST OP NAUSEA
10
N600 - Collective Findings Table
Category
Reference
(.91 points/
.15 each)
This article was chosen because it met requirements of assignment being a random
control trial published within the last 10 years. It also met our population of an adult
sample of women undergoing a surgical procedure.
Arnberger, M., Stadelman, K., Alischer, P., Ponert, R., Melber, A., & Greif, R. (2007).
Monitoring of neuromuscular blockade at the P6 acupuncture point reduces the
incidence of postoperative nausea and vomiting. Anesthesiology, 107(6), 903-908.
doi: 10.1097/01.anes.0000290617.98058.d9
Purpose
(.91 points)
Sample
(.91 points)
Conceptual or
Theoretical
Framework
(.91 points)
Concepts and
Variables
(.91 points)
Design
(.91 points)
Instruments/
How variables
measured
(.91 points)
“To evaluate the effects of electrical stimulation of the P6 acupuncture point at the
dominant wrist using a conventional neuromuscular stimulation device for the
evaluation of muscle relaxation during general anesthesia on the incidence of
postoperative nausea and vomiting (PONV) on women undergoing gynecological
surgery.” (Amberger, Stadelman, Alischer, Ponert, Melber, & Grief, 2007) The
hypothesis was to test that stimulation of the P6 acupuncture point with a conventional
nerve stimulator decreases the incidence of PONV.
Sample size calculation was based on the PONV incidence from a previous study by
authors where the control group of PONV was 44% and treatment group reduction by
50%. IRB approval and informed consent was obtained from 220 women ages 18-80
that met ASA physical status I-III scheduled to undergo elective gynecological and
abdominal laparoscopic surgery of more than 1 hour duration to participate in the study.
Patients were randomly selected to either a control or treatment group by computergenerated numbers resulting in 110 participants in each. Subjects and evaluators were
unaware of group assignment. Exclusion criteria: current pregnancy/breastfeeding,
eating disorders, obesity, severe renal and/or liver malfunction, CNS injury,
vertebrobasilar artery insufficiency, vestibular disease, cytostatic therapy, and
preoperative vomiting or antiemetic therapy. There were no dropouts during
observation.
Theoretical Framework: Monitoring of neuromuscular blockade is standard during
anesthesia. The idea for the study was triggered by the theory, based on review of
similar successful studies, that a constant electrical stimulus over the median nerve at
the P6 point might have an advantageous effect on PONV while monitoring
neuromuscular blockade simultaneously.
IV: intraoperative transcutaneous electrical stimulation of the P6 acupuncture point
with nerve stimulator
DV: postoperative nausea and vomiting
The study was a prospective, double-blinded, random control trial. Candidates were
randomized into two groups, control or treatment. Measurements included pain, nausea
and vomiting within certain blocks of time in a 24-hour period and need for rescue
medication as well as monitoring for side effects of treatment.
Data collected preoperatively from records and personal interviews. Preoperative and
postoperative data was averaged for each group. Ondansetron was used as an antiemetic
rescue medication and post-op analgesics were monitored and recorded for 24 hours.
Pain was evaluated with a continuous visual analog scale (1=0 pain to 10= unbearable
pain). Patients were evaluated for side effects of nerve stimulation and for nausea and
vomiting at the following intervals while awake: 0-2 hours, 2-6 hours (early PONV), 6-
ACUSTIMULATION IN POST OP NAUSEA
Interventions
or methods
(.91 points)
Statistical
Tests/
Analysis
Method
(.91 points)
Results/
Findings
(.91 points)
Implications
(.91 points)
12 hours, 12-24 hours (late PONV). Nausea was defined as the desire to vomit,
vomiting as active expulsion of gastric contents, retching as active attempt to vomit
without expulsion. To address validity, patients and PONV evaluators were uninformed
of group assignments. The attending anesthesiologist was not involved in the assessment
as he could not be blinded to group assignment.
Authors assessed dominant hand during interview process as is recommended. Both
randomly selected groups given same medications for anesthesia and reversal and the
same amount of neuromuscular stimulation.
 Control: ulnaris group-subjects had electrode placed on ulnar nerve and on radial
side of wrist to elicit thumb adduction with stimulation
 Treatment : P6 acupuncture group-electrode were used to stimulate the medial
nerve at P6 point of the forearm by placing electrodes proximal and distal to P6
point so the current would mass through.
The previous study determined a sample size of 216 would provide 95% chance of
statistical significance between groups at a two-tailed -level of 0.05 (type I error) using
a chi-square analysis. Chi-square testing used for Morphometric and parametric data as
well as intraoperative and postoperative results were compared for interval data with a
Student t test or for categorical data, analysis of number of patients with PONV in each
group for 24 hours. Statistical significance at P< 0.05, data presented as mean +/- SD or
as percentages. Statistical analysis was conducted using SAS 9.1 and Primer of
biostatistics.
No dropouts reported in either group (n=110 each). No side effects reported or detected.
Results for pain at 2-hour mark (2.1 +/- 1.7 for P6 vs. 1.9 +/- 1.5 for control, P=0.41).
Need for opioids within 6 hours. (6 +/- 6vs. 5 +/- 5mg, P=0.14) and late, up to 24 hours
(1 +/- 5 vs. 1 +/- 2mg, P=0.19). No significant difference in NSAIDS use for 24 hours
(55% vs. 68%, P=0.051). Postoperative nausea was significantly lower in P6 treatment
group (40% vs. 56%, P=0.022). Early combined PONV and nausea at 0-6 hours (33%
vs. 51%, P=0.009) where no difference found in late period. Decrease of 12% found in
need for rescue antiemetic (27% vs. 39%, P=0.086) in 24 hours with major difference
early phase (25% vs. 36%, P=0.109), and no difference in late period. Combined
unilateral stimulation of P6 acupressure point while measuring neuromuscular blockade
reduces PONV overall in the early period after surgery.
Combination acustimulation and medication for prophylactic use in surgery is promising
and most effective in early nausea (first 6 hours). The effects were similar to antiemetic
medication. It’s cost effective and easy to perform with no side effects or complications.
Limitations included female only subjects, use of single-twitch mode as opposed to
train-of-four mode of neuromuscular blockade, and lack of a formal cost-effective
analysis. More testing would be needed in the future was well as application to other
settings and subjects.
ACUSTIMULATION IN POST OP NAUSEA
12
N600 Collective Findings Table
Category
This article was chosen because it is a peer reviewed randomized controlled trial less
than 10 years old (published in 2006). It provided insight into use of P6
acustimulation in our target population, female gynecological patients.
Reference
Turgut, S., Ozalp, G., Dikmen, S., Salvi, S., Tuncel, G., & Kadiogullari, N.
(2006). Acupressure for postoperative nausea and vomiting in
gynaecological patients receiving patient-controlled analgesia. European
Journal of Anaesthesiology, 24(1), 87-91. doi:
10.1017/S0265021506001190
Purpose
Sample
“To evaluate the effectiveness of acupressure in preventing nausea and vomiting in
patients undergoing gynaecological operations and receiving a patient-controlled
analgesia device” (Turgut, Ozalp, Dikmen, Salvi, Tuncel, Kagiogullari, 2006).
Probability sampling was used in this study. 100 female patient’s ages 40-65 years
old with an ASA level I-II undergoing elective gynaecological surgery were
randomized into two groups, acupressure group and control group using closed
envelopes. Exclusion criteria included obesity (BMI > 30), diabetes mellitus, and
history of motion sickness, postoperative nausea/vomiting, or smoking. The study
was observer-blinded and the participants had no previous experience with
acupressure bands.
Conceptual or
Theoretical
Framework
Theoretical framework: Acupressure at the P6 meridian point will lead to a decrease
in experienced postoperative nausea and vomiting. Prevention of nausea increases
patient satisfaction. Stimulation of the P6 meridian point is non-pharmacological and
non-invasive.
Concepts and
Variables
Independent variable: P6 stimulation
Dependent variable: Postoperative nausea and vomiting
Design
Experimental design was used for this study. There were two groups: intervention
group (receiving P6 stimulation, n=50) and the control group (no P6 stimulation,
n=50). Five different outcomes were measured: sedation, postoperative nausea,
vomiting, pain, and patient satisfaction.
Instruments/How
variables
measured
Sedation was measured with a five-point scale (1: completely awake, 2: awake but
drowsy, 3: asleep but responds to verbal commands, 4: asleep but responds only to
physical stimulus, 5: unarousable).
Postoperative nausea was defined as none, mild, moderate, or severe
Degree of vomiting was recorded as none, mild (1-2 episodes), moderate (3-5), and
severe (>5)
Visual analog scale (VAS) was used to determine pain level
Patient satisfaction was assessed using a 4-point scale (1: poor, 2: moderate, 3: good,
ACUSTIMULATION IN POST OP NAUSEA
4: excellent)
Interventions/or
methods
The intervention used was acupressure (using a plastic bead) of the P6 point using a
SeaBand. The control group had the SeaBand placed with the plastic bead at a site
other than the P6 point. The researchers discussed the proper positioning of the
SeaBand in the study, on the anterior forearm between the tendons of the extensor
carpi radialis and the palmaris longus. In both groups, bands were covered by loose
gauze to ensure observer-blinding. The acupressure bands were applied 30 minutes
before induction of anaesthesia in both groups. The anesthesiologist who placed the
bands was not involved in the outcome assessments. In addition, the patients did not
receive any antiemetic medication before or during surgery.
Statistical Tests/
Analysis Method
Age, weight, height, operation time, HR, arterial pressure, respiratory rate and total
morphine consumption were compared using the T-test. Chi-squared test was used to
analyze nausea, vomiting, additional analgesic consumption, ASA classification and
antiemetic requirement. VAS, sedation and patient satisfaction by U-test
Results/Findings
Implications
With acupressure, the incidence of nausea and vomiting were 33% and 25%,
respectively, and in controls was 63% and 61%. The study showed acupressure of the
P6 point decreased nausea and vomiting effectively in postoperative patients
receiving Morphine PCA. "The cumulative incidence of nausea, vomiting, and
antiemetic use was significantly lower with acupressure (P< 0.05)" (Turgut et al.,
2006).
In patients with a moderate baseline risk of nausea and vomiting postoperatively P6
stimulation may be used as an alternative to antiemetics. Further research is needed
for patients at very high risk of postoperative nausea and vomiting.
ACUSTIMULATION IN POST OP NAUSEA
14
N600 Collective Findings Table
Category (points
for category
across all
studies)
Reference
(.91 points/ .15
each article)
Patient safety, cost effectiveness, and improved outcomes are high priority in the
healthcare setting today. Forward thinking is actively seeking noninvasive, safe, nonpharmacological solutions to common problems such as PONV. P6 acustimulation is
new, fresh, innovative and meets all aforementioned criteria. It is well worth the
effort and resources toward research and possible implementation into practice.
Frey, U. H., Funk, M., Lohlein, C., & Peters, J. (2009). Effect of P6 acustimulation
on post-operative nausea and vomiting (PONV) in patients undergoing a
laparoscopic cholecystectomy. Acta Anaesthesiologica Scandinavica, 53(10),
1341-1347. doi:10.1111/j.1399-6576.2009.02081.x
Purpose
(.91 points)
To investigate the effectiveness of acustimulation on mitigating PONV in patients
undergoing laparoscopic cholecystectomy (lap chole); To investigate if there are
differences in PONV reduction if applied pre- or post-anesthesia induction; To
investigate if PONV can be reduced independent of known risk factors (female
gender, non-smoker, history of PONV/motion sickness, post op morphine usage)
utilizing P6 acustimulation.
Sample
Calculation based upon PONV incidence within the first 6 hours after surgery and
previous study. Sample size includes 200 adults, male and female, >18 years with an
ASA class I-III scheduled to undergo a lap chole requiring general anesthesia.
Exclusions: Those with cardiac pacemakers, implanted cardioverter/defibrillator; risk
for malignant hyperthermia; allergy to nickel/chrome; changes in surgical technique.
Random assignment to four different groups by drawing a sealed envelope.
(.91 points)


Active ReliefBand placed at the P6 acupoint of the accustimulation group
(n=101): (A) pre-induction (n=57); (B) post-induction (n=44).
Inactive device applied to the P6 acupoint of the Sham group (n=99):
(C) pre-induction (n=55); (D) post-induction (n=44)
Conceptual or
Theoretical
Framework
(.91 points)
Theoretical - PONV is the most frequent side effect of anesthesia and effectively
treated pharmacologically with adverse effects. However, studies are underway to
discover non-pharmacological options for PONV namely P6 acustimulation proven
to reduce PONV in female patients undergoing vaginal hysterectomy with the highest
incidences of reduction in patients at high risk for PONV. Also being explored is
whether the placement of P6 acustimulation, pre- or post-operatively, has a
significant effect on PONV.
Concepts and
Variables
(.91 points)
Design
(.91 points)
IV: P6 acustimulation with ReliefBand active or inactive
DV: post-op nausea, retching, vomiting
Single centre, prospective, randomized, double blind experimental study assessing
nausea, retching, and vomiting post-op. Written informed consent obtained prior to
study. Male and female patients scheduled to undergo a lap chole under general
anesthesia randomly assigned to one of four groups:
ACUSTIMULATION IN POST OP NAUSEA
(a) Acustimulation starting before induction of anesthesia (n=57);
(b) Acustimulation starting directly after induction of anesthesia (n=44);
(c) Sham acustimulation starting before induction of anesthesia (n=55);
(d) Sham acustimulation starting directly after induction of anesthesia (n=44)
Morphometric, demographic data and risk factors collected pre-op from patient
records or via interview during consent process. Data collectors blind to treatments
administered. Acustimulation provided by ReliefBand (31 Hz, strength grade III of
V). Two flat metal electrodes provide conduction transcutaneously; inactivity
achieved by covering with silicone invisible to the patient and data collector. Active
and sham bands placed in induction room to the P6 acupoint on the dominant upper
extremity.
Instruments/How
variables
measured
(.91 points)
Patients evaluated for nausea, retching, vomiting, pain and potential side effects of
ReliefBand by an investigator blind to group assignments. Nausea, vomiting and
retching categorized by: 0=no episode; 1=at least 1 episode; interval 2h in PACU;
6hour and 24 hours after surgery. Vomiting defined as expulsion of stomach
contents; retching defined as involuntary attempt to vomit but no production of
stomach contents.
Interventions/or
methods
(.91 points)
Active ReliefBand device placed at the P6 acupoint of the acustimulation group;
Inactive device applied at the P6 acupoint of the sham group.
No intervention training was provided; fidelity not specifically addressed.
ReliefBand FDA approved, non-invasive
Statistical Tests/
Analysis Method
(.91 points)
Two-sided tests, computer software SPSS, version 15.0 used for all statistical tests.
Parametric variables compared using an unpaired student’s t-test; categorical
variables using the X2 test.
Multivariate binary logistic regression model used to calculate odds ratios (ORs);
95% confidence intervals (CI), and P-values for the risk of PONV.
Logistic regression analysis performed in a stepwise backward manner using age,
gender, body mass index, duration of anesthesia, post-op morphine usage, history of
PONV, smoking status, history of motion sickness and acustimulation as covariates.
Differences statistically significant if alpha error P of <0.05.
Results/Findings
(.91 points)
Early nausea (up to 2h postop) was significantly lower in the acustimulation group
than in the sham group (29% vs. 42%; P=0.043) but there was no significant effect on
retching/vomiting. The best effects on nausea was in patients with three or more risk
factors for PONV (relative risk reduction 40%; P=0.021; 55% for retching/vomiting;
P=0.048). There was no effect on PONV after 6 and 24 hours. PONV was
significantly lower in the acustimulation group compared with the sham group (30%
vs 43%; relative risk reduction: 31%; P=0.031). The timing, pre- or post-induction,
had no significant effect on PONV reduction.
Implications
(.91 points)
P6 acustimulation is proven effective in early pre- and post-operative period for
vaginal hysterectomy and lap chole patients with even higher success rates in the
presence of 3 or more risk factors. Implications to practice should be based upon the
results of further studies.
ACUSTIMULATION IN POST OP NAUSEA
16
N600 Collective Findings Table
Category
Reference
This article was chosen because it included information about PONV prevention in
our target population. It is randomized and controlled
Frey, U., Scharmann, P., Lohlein, C., Peters, J. (2009). P6 acustimulation
effectively decreases postoperative nausea and vomiting in high-risk
patients. British Journal of Anaesthesia, 102(5), 620-625. doi:
10.1093/bja/aep014
Purpose
(.91 points)
Sample
(.91 points)
Conceptual or
Theoretical
Framework
(.91 points)
Concepts and
Variables
(.91 points)
Design
(.91 points)
Instruments/How
variables
measured
(.91 points)
Interventions/or
methods
“The primary purpose of this study was to investigate the effectiveness of
acustimulation in relation to known risk factors for PONV. We also tested the
secondary hypothesis that pre- or post-induction application of acustimulation
results in differences in PONV reduction” (Frey, Scharmann, Lohlein, Peters, 2009).
Probability sampling was used in this study. Ethics committee approval and
informed consent were obtained from 200 women > 18 years of age with an ASA
class I-III who were scheduled for a vaginal hysterectomy under general anesthesia
were included in this study. Exclusion criteria were patients with a cardiac
pacemaker or implanted cardioverter/defibrillator, patients at risk for malignant
hyperthermia, patients with an allergy to nickel/chrome, and change in surgical
technique. Patients were randomly divided into an acustimulation group (n=101) or
a sham acustimulation group (n=99). Those two groups were then randomized
further into a preoperative (before induction of anesthesia) acustimulation group
(n=48), a postoperative (after induction of anesthesia) acustimulation group (n=53),
a preoperative sham acustimulation group (n=49) and a postoperative sham
acustimulation group (n=50). Randomization was achieved by drawing a sealed
envelope.
Theoretical framework: PONV occurs in up to 30% of unselected patients and is the
most frequent side effect after anesthesia. Several studies have shown the
effectiveness of P6 stimulation to reduce PONV. One study, however, showed
electrical stimulation at the P6 site decreased postoperative nausea but not vomiting.
Optimum timing of acustimulation is debatable. PONV reduction was measured in
patients with known risk factors (female gender, non-smoker, history of
PONV/motion sickness, and postoperative morphine usage) both with acupressure
applied before induction of anesthesia and after.
Independent variables: P6 acustimulation using the ReliefBand pre-anesthesia
induction and post-anesthesia induction.
Dependent variables: postoperative nausea and vomiting
This study was a prospective, observer-blind, randomized controlled trial. There
were four different groups: two intervention and two control groups. Nausea,
retching, vomiting, and pain were evaluated at 2h in the PACU, then at 6h and 24h.
The investigators responsible for collecting data were blind to the treatments
administered to the participants. Patients were evaluated for the occurrence of
nausea, vomiting, and retching at the following intervals: 2 hours in the PACU and
at 6 and 24 hours. Nausea, vomiting, and retching were categorized (0, no episode;
1, at least one episode).
Acustimulation was provided via a ReliefBand – a non-invasive, FDA approved,
portable, battery powered, watch-like acustimulation device capable of providing
ACUSTIMULATION IN POST OP NAUSEA
(.91 points)
Statistical Tests/
Analysis Method
(.91 points)
Results/Findings
(.91 points)
Implications
(.91 points)
current at 31 Hz up to 35 mA gradable in five strengths. The devices were applied in
the anesthesia induction room to the P6 acupoint on the dominant upper extremity.
The Sham ReliefBands were prepared by inactivating the electrodes with a silicone
cover. No training was necessary for use of the ReliefBand. Tropisetron was used as
a rescue antiemetic for any patient that experienced severe nausea or retching.
Categorical variables (nausea, vomiting, and retching) were determined using the
Chi-squared test. Parametric variables were analyzed using an unpaired Student’s ttest. A binary logistic regression model was used to calculate odds. Confidence
intervals and P values were used for the risk of PONV or the need of rescue therapy.
Differences were regarded statistically significant with an alpha error of <0.05. All
statistical analyses were two-sided and performed using SPSS, version 15.0.
PONV was significantly lower in the acustimulation group (33% at 6 h, 33% at 24
h) compared with the sham group (55% at 6 h, 63% at 24 h). Only 39% of patients
required a rescue antiemetic in the acustimulation group, compared with 61% in the
sham group. No significant difference in PONV was found between applying the
ReliefBand pre- or post-induction of anesthesia (0.31 versus 0.33).
Acustimulation by the ReliefBand decreases PONV, with greater effects on nausea
than vomiting, in patients with three or more risk factors. Acustimulation was
effective regardless of when applied (pre- or post-induction). The study was limited
by a tingling sensation felt by patients receiving P6 acustimulation pre-induction
which could have led to patient bias. Findings of the study were hard to generalize
due to the focus on a specific surgical procedure in women receiving postoperative
morphine.