Kimberly Moriarty
Inhalation of Isopropyl Alcohol as an Intervention
To Prevent Post-operative Nausea and Vomiting
Kimberly Moriarty
December 11, 2008
University of Wisconsin Milwaukee
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Kimberly Moriarty
Section 1:
PICO Question
Does inhalation of isopropyl alcohol reduce post operative nausea and vomiting in gynecological post
surgical patients as compared with an intravenous antiemetic?
Problem: Nausea and Vomiting that occurs after surgery in the gynecologic population
Intervention: Inhalation of Isopropyl Alcohol
Comparison: Intravenous antiemetic
Outcomes: Decrease in amount of post operative nausea and vomiting
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Kimberly Moriarty
Section2:
Theoretical Foundation
Physiological Theory of Nausea and Vomiting:
The vomiting center is located in the medulla. This area is full of neuronal pathways that
transmit impulses to and from this center. There are 5 areas that influence and trigger the vomiting
reflex. These pathways are: vagal sensory pathways from the gastro-intestinal tract, neuronal pathways
from the labyrinths, higher centers of the cortex in the brain, intracranial pressure receptors and the
chemoreceptor trigger zone. The exact mechanism is unknown and may include one or more of these
areas. Four neurotransmitters are also involved, including, histamine, dopamine, serotonin and
acetylcholine. When released, these neurotransmitters stimulate the chemoreceptor trigger zone,
which then causes nausea and vomiting. It is hypothesized that inhaled anesthetics affects ion
conduction, making the pathways more sensitive to stimulation (Spencer 2004). Post operative nausea
could also be a result of the anesthesia, pain, or motion while in transport. Numerous factors have been
named in adding to the risk of developing post operative nausea including: anesthesia, duration of
surgery, age, gender, motion sickness, obesity, or delayed gastric emptying (Spencer 2004). Nausea and
vomiting after surgery is uncomfortable and hinders timely recovery.
This theory of physiological methods provides the essential foundation for studying isopropyl
alcohol inhalation as a treatment for post operative nausea and vomiting. By interfering with the
pathways that stimulate nausea and vomiting, isopropyl alcohol may prove to be a safer, more effective
and less costly means of treating this side effect of surgery.
Spencer, K (2004) Isopropyl Alcohol Inhalation as Treatment for Nausea and Vomiting. Plastic
Surgical Nursing. 24(4).
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Kimberly Moriarty
Section 3:
Articles
1. Merrit, B., Okyere, C., Jasinski, D. (2002). Isopropyl Alcohol Inhalation: Alternative Treatment of
Postoperative Nausea and Vomiting. Nursing Research, 51(2).
2. Teran, L., Hawkins, J. (2007). The Effectiveness of Inhalation Isopropyl Alcohol VS Granisetron for
the Prevention of Postoperative Nausea and Vomiting. American Association of Nurse
Anesthetists,75(6).
3. Smiler, B. (1998). Isopropyl Alcohol for Transport-Related Nausea. Anesthesia and Analgesia,
87(5).
4. Winston, A., Rinehart, R., Riley, G., Vacchiano, C., Pellegrini, J. (2003). Comparison of Inhaled
Isopropyl Alcohol and Intravenous Ondansetron for Treatment of Postoperative Nausea.
American Association of Nurse Anesthetists, 71(2).
5. Cotton, J., Rowell, L., Hood, R., Pellegrini, J. (2007). A Comparative Analysis of Isopropyl Alcohol in
the Treatment of Postoperative Nausea and Vomiting from the Hospital Setting to the Home.
American Association of Nurse Anesthetists, 75(1).
6. Spencer, K. (2004). Isopropyl Alcohol as Treatment for Nausea and Vomiting. Plastic Surgical
Nursing 24(4).
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Kimberly Moriarty
Section 4:
Critique of Research Articles
One:
Title of Study
Isopropyl Alcohol Inhalation Treatment: Alternative Treatment of Postoperative Nausea and Vomiting
Year of Publication
2002
Authors (list first two)
Merrit, B. Okeye, C. Jasinski
__X___ Clinical experience
_____ Research expertise
_____ Prior publications
__X__ Funding
_____ Non-federal funding
_____ Federal funding
_____ Non US governmental funding
Purpose
Evaluate the effect of IPA inhalation for rescue treatment of POVN in adult same day surgery patients
who underwent general anesthesia.
Review of Literature
__X___ Logical
__X___ Clarity
__X___ Current and comprehensive references
__X___ Pros/Cons presented
__X___ Gaps in knowledge identified
__X___ Importance of study
Comments:
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Kimberly Moriarty
Starts with overview of the vomiting reflex. States lack of actual known pathways. Mentions
previous studies on what influences nausea and vomiting. Then proceeds into current
drug therapies, alternative therapies. Background of use of isopropyl alcohol, lack of
risks, unknown mechanism, short acting. References from 1976-1999. Articles vary in
topic: children, post operative nausea, isopropyl alcohol in rats, antiemetic intravenous
medication use and risk factors. No studies were used that previously looked at the use
of isopropyl alcohol.
Research Question/Hypothesis
Patients treated with inhalation of IPA would have decreased nausea and vomiting in the immediate
postoperative period; Inhalation treatment would be more effective in decreasing nausea and vomiting
than standard rescue treatment; IPA inhalation would decrease post anesthesia care.
Study Design
___
Experimental/Randomized Clinical Trial
___X__ Quasi-Experimental
_____ Correlation
_____ Descriptive
_____ Program Evaluation
____
Other
Sample and Setting
General description of participants (age, gender, etc.)
111 participants. Only 40 studied. 19-80 years old, average of 43. Surgery types included intraabdominal, orthopedic, perineal, and neuro-skeletal. 36% had post operative nausea, 84.6% got
prophylactic anti-emetics.
Important Inclusion and Exclusion Criteria:
Patients admitted from same day surgery. Must have had general anesthesia, ability to breathe
through the nose, 18 years of age or greater, ASA physical status of 1, 2, or 3. Also had to be able to read
and write in English.
Could not have allergy to IPA, alcohol abuse, recent history of nausea/vomiting in last 8 hours,
no recent intake of cefoperazone, antabuse, metrondazole, must have ability to communicate in
recovery room, regional anesthesia, and monitored anesthesia care.
Groups
_____ True control group
_____ Usual care group
__X___ Intervention group(s)
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Name or brief description of group:
Experimental: received inhalation treatment; three deep sniffs with the pad once inch
from the nose. Repeated every five minutes for three doses. If not relieved in three doses, intravenous
drug was given.
Name or brief description of group:
Control: Did not receive inhalation treatment. Just received intravenous anti-emetic.
Type of Sample
Probability
Non-Probability
_____ Simple Random Sampling
__X___
Convenience
_____ Stratified Random Sampling
_____
Quota
_____ Cluster
_____
Purposive
_____ Systematic
_____
Snowball
Instruments
Measurement Tool
What did it measure?
Information about the measure:
# or type questions; reliability
or validity; inter-rater reliability;
other
DOS score
Perception of nausea and
vomiting, scale 0-10.
Reliability/validity not measured.
Similar to VAS scores. Self
reported data from patient.
Detailed Description of the Intervention
Specific Steps of the intervention
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Kimberly Moriarty
The patient reported score of nausea/vomiting, either the inhalation treatment or intravenous
treatment was given.
Knowledge and skills needed to deliver intervention (education, licensure, etc)
Assume intervention was given by RNs.
Time to deliver/use the intervention
Time spent was in recovery room. Three five minute interventions or usual intervention. Time
spent in recovery room was basic.
How frequently does it need to be delivered and what is the time interval in between delivery?
Three, five minute interventions
IRB Approval
__X___ Yes
_____ Does not mention
Threats to Validity
Threats to Internal Validity
_____
History
Threats to External Validity
__X___
Novelty effects
_____ Maturation
_____
__X___
__X___ Experimenter effect
Testing
_____ Instrumentation
Interaction of history and treatment
_____ Measurement effect
_____ Mortality
_____ Selection Bias
Results
Of the 21 given the intervention: 11 had relief after first dose, and 10 needed at least one intervention
of standard medication.
Of the 18 in the control group: 13 had relief after the first dose of standard anti-emetic. Five had no
relief.
Results not significant regarding differences in IPA being superior to standard medications.
IPA group had average cost of 9.75. Control had average cost of 17.08. This is significant.
Major Findings
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Kimberly Moriarty
Few actually had PONV due to aggressive premedication. PONV could be related to pain. This study does
suggest IPA is clinically important. However, does not prove to be more effective. This study points to
other explanations for PONV and the associated risk factors.
Strengths and Weaknesses of Study
Strength
Looked at the direct use of IPA for PONV
treatment.
Appropriate area to have intervention
Uses self report for nausea scale
Leaves door open for future research, supports
previous research.
Weakness
Small sample size.
Uses self report in patients coming out of
anesthesia
Didn’t break down by surgical type (more
significant in abdominal surgeries?)
Didn’t address dose, times of intervention.
Ranking of Scientific Merit
Agency for Health Care and Research
Evaluate each study – Assign a quality number to the study
Evaluate all articles within the collection of studies reviewed – Assign a Letter
•Types of Evidence
____
Level 1 = meta-analysis
____ Level II = experimental studies
__X__ Level III = well-designed, quasi-experimental studies
____ Level IV = well designed, non-experimental studies
____ Level V = case reports and clinical examples
Two:
Title of Study
The Effectiveness of Inhalation Isopropyl Alcohol VS Granisetron for the Prevention of Postoperative
Nausea and Vomiting
Year of Publication
2007
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Kimberly Moriarty
Authors (list first two)
Teran, M and Hawkins, J.
__X___ Clinical experience
_____ Research expertise
_____ Prior publications
__X___ Funding
_____ Non-federal funding
__X___ Federal funding
_____ Non US governmental funding
Purpose
To compare the effectiveness of granisteron, the use of inhalation of isopropyl alcohol as prophylactic
treatments for PONV with a control group.
Review of Literature
___X__ Logical
_X____ Clarity
__X___ Current and comprehensive references
_____ Pros/Cons presented
__X___ Gaps in knowledge identified
_____ Importance of study
Comments:
Literature review involved 20 previous studies which focused on numerous topics: prediction,
alternative methods, various medications, sex differences, menstrual cycle influence
and children. The review itself started with explaining risk factors and went into what
causes PONV. The article also explained the pathways that trigger this. They explain
medications and that have been studied and that may help prevent PONV. They finish
the review by describing the work done on IPA.
Research Question/Hypothesis
Evaluate treatment for post operative nausea and vomiting using IPA inhalation, granisteron and no
treatment preoperatively, on arrival to PACU, at discharge from PACU, 6 hours after estuation, and 24
hours post intubation.
Study Design
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___
Experimental/Randomized Clinical Trial
__X___ Quasi-Experimental
_____ Correlation
_____ Descriptive
_____ Program Evaluation
____
Other
Sample and Setting
General description of participants (age, gender, etc.)
57 women, 18-50 years old
Important Inclusion and Exclusion Criteria:
Inclusion: ASA status of 1 or 2, scheduled for elective laparoscopic surgery.
Exclusion: nausea within 24 hours before surgery, allergy to IPA, laparoscopic which went to an
open procedure, neuraxial block, decreased ability to breathe through the nose, history of alcohol abuse
or disulfiram, pregnancy, menopause, emergency procedures.
Groups
_____ True control group
_____ Usual care group
___X__ Intervention group(s)
Name or brief description of group:
Prophylactic inhalation of IPA
Name or brief description of group:
Prophylactic 0.1mg of granisetron
Name or brief description of group:
No prophylactic treatment
Type of Sample
Probability
Non-Probability
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___X__ Simple Random Sampling
_____
Convenience
_____ Stratified Random Sampling
_____
Quota
_____ Cluster
_____
Purposive
_____ Systematic
_____
Snowball
Instruments
Measurement Tool
What did it measure?
Information about the measure:
# or type questions; reliability
or validity; inter-rater reliability;
other
Demographic data
Age, LMP, height, weight,
procedure type, physical status,
history of smoking, motion
sickness, and PONV
Factual data. Patient reported
data.
Numeric rating scale
Nausea on a 0-10 scale
Self reported data. Similar to
VAS scale.
Detailed Description of the Intervention
Specific Steps of the intervention
Patients are randomly assigned to one of three groups.
Given medication. Either 3 deep breaths of alcohol, .1 mg of grainistron 15-30 mins pre extubation, or
nothing.
Knowledge and skills needed to deliver intervention (education, licensure, etc)
PACU RNs were trained, and blinded to the study. Investigators called the participants at home
for follow up information.
Time to deliver/use the intervention
Depending on the intervention. Inhalation of alcohol, giving IV medication.
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How frequently does it need to be delivered and what is the time interval in between delivery?
Not mentioned in the study. Only one inhalation of 3 deep breaths was given.
IRB Approval
___X__ Yes
_____ Does not mention
Threats to Validity
Threats to Internal Validity
_____
History
Threats to External Validity
___X__
Novelty effects
_____ Maturation
_____
___X__
__X___ Experimenter effect
Testing
_____ Instrumentation
Interaction of history and treatment
_____ Measurement effect
_____ Mortality
_____ Selection Bias
Results
57 participants. Group one: 22, group 2:16, group 3:19. No differences in groups regarding
demographics. 47 complained of nausea. No significance in regards to minutes to first episode, NRS at
rescue treatment, number of episodes of PONV from 0-6 hours postoperatively, total number of
episodes in 24 hour period. Was a difference in group one reporting more PONV episodes than the
others. From the 6 to 24 hour period. NO correlation with smoking, motion sickness, or menstrual cycle.
Major Findings
Inhalation of alcohol is associated with increase number of episodes of PONV in 6 to 24 hour period. No
correlation between menstrual period, smoking, history of motion sickness
Strengths and Weaknesses of Study
Strength
Weakness
Small focused group.
Small sample size
Randomized, PACU RNs were blinded.
Self reported data
Ranking of Scientific Merit
Agency for Health Care and Research
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Kimberly Moriarty
Evaluate each study – Assign a quality number to the study
Evaluate all articles within the collection of studies reviewed – Assign a Letter
•Types of Evidence
____
Level 1 = meta-analysis
____ Level II = experimental studies
___X_ Level III = well-designed, quasi-experimental studies
____ Level IV = well designed, non-experimental studies
____ Level V = case reports and clinical examples
Three:
Title of Study
Isopropyl Alcohol for Transport Related Nausea
Year of Publication
1998
Authors (list first two)
Smiler, B. Srock, M.
__X___ Clinical experience
_____ Research expertise
_____ Prior publications
_____ Funding
_____ Non-federal funding
_____ Federal funding
_____ Non US governmental funding
Purpose
To determine of inhalation of isopropyl alcohol decreases nausea in patients being transported in the
hospital.
Review of Literature
_____ Logical
_____ Clarity
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Kimberly Moriarty
_____ Current and comprehensive references
_____ Pros/Cons presented
_____ Gaps in knowledge identified
_____ Importance of study
Comments:
No review of literature given
Research Question/Hypothesis
Does inhalation of isopropyl alcohol while in transport decrease nausea in post operative patients.
Study Design
___
Experimental/Randomized Clinical Trial
_____ Quasi-Experimental
_____ Correlation
_____ Descriptive
_____ Program Evaluation
__X__ Other
Intervention done on patients who complained of nausea during transport
Sample and Setting
General description of participants (age, gender, etc.)
Post operative patients. No information given on gender, age etc.
Important Inclusion and Exclusion Criteria:
None reported.
Groups
_____ True control group
_____ Usual care group
___X__ Intervention group
Name or brief description of group:
77 patients given alcohol to inhale.
Type of Sample
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Probability
Instru
ments
Non-Probability
_____ Simple Random Sampling
__X___
_____ Stratified Random Sampling
_____
Quota
_____ Cluster
_____
Purposive
_____ Systematic
_____
Snowball
Measurement Tool
What did it measure?
Convenience
Information about the measure:
# or type questions; reliability
or validity; inter-rater reliability;
other
Not given
Detailed Description of the Intervention
Specific Steps of the intervention
The transport staff wet the upper lip of patients complaining of nausea during transport and
told them to inhale.
Knowledge and skills needed to deliver intervention (education, licensure, etc)
None
Time to deliver/use the intervention
Time taken to apply alcohol and have patient inhale.
How frequently does it need to be delivered and what is the time interval in between delivery?
No mentioned
IRB Approval
_____ Yes
___X__ Does not mention
Threats to Validity
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Threats to Internal Validity
_____
History
Threats to External Validity
___X__
Novelty effects
_____ Maturation
_____
___X__
__X___ Experimenter effect
Testing
_____ Instrumentation
Interaction of history and treatment
_____ Measurement effect
_____ Mortality
_____ Selection Bias
Results
65 of 77 patients reported relief of their symptoms.
Major Findings
See above
Strengths and Weaknesses of Study
Strength
Weakness
Using the intervention directly on post operative
patients.
No mention of how these patients were selected.
Done by a person in the department of anesthesia
No details of how, when, how much etc.
No formal “study” done. It was just an
observation.
Ranking of Scientific Merit
Agency for Health Care and Research
Evaluate each study – Assign a quality number to the study
Evaluate all articles within the collection of studies reviewed – Assign a Letter
•Types of Evidence
____
Level 1 = meta-analysis
____ Level II = experimental studies
____ Level III = well-designed, quasi-experimental studies
____ Level IV = well designed, non-experimental studies
___X_ Level V = case reports and clinical examples
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Kimberly Moriarty
Four:
Title of Study
Comparison of Inhaled Isopropyl Alcohol and Intravenous Ondansetron for Treatment of Postoperative
Nausea
Year of Publication
2003
Authors (list first two)
Winston, A. Rinehart, R. Riley, G.
__X___ Clinical experience
_____ Research expertise
_____ Prior publications
__X___ Funding
_____ Non-federal funding
__X___ Federal funding
_____ Non US governmental funding
Purpose
Compare the efficacy of inhaled isopropyl alcohol and IV ondansetron for the treatment and control of
PON in groups of women undergoing outpatient gynecological laparoscopic procedures.
Review of Literature
__X___ Logical
_X____ Clarity
__X___ Current and comprehensive references
_____ Pros/Cons presented
_____ Gaps in knowledge identified
_____ Importance of study
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Kimberly Moriarty
Comments:
The review of literature focused on why PONV happens, the physiological mechanisms. The
authors barely touched on previous research done. Overviewed the IV antiemetic
chosen. Did mention cost of POSN, time spent in the PACU. How it could be beneficial to
investigate this but it was brief and non specific. References were from 1987 to 2002. All
references looked specifically at nausea and vomiting. Very brief introduction before
the study was introduced.
Research Question/Hypothesis
Is the use of inhaled isopropyl alcohol more beneficial in reducing PONV than IV ondansetron.
Study Design
__X_
Experimental/Randomized Clinical Trial
_____ Quasi-Experimental
_____ Correlation
_____ Descriptive
_____ Program Evaluation
____
Other
Sample and Setting
General description of participants (age, gender, etc.)
100 women older than 18, ASA status I or II, undergoing a diagnostic laparoscopic, operative
laparoscopy, or laparoscopic bilateral tubal occlusion.
Important Inclusion and Exclusion Criteria:
Exclusion: sensitivity to IPA or ondansetron, inability to breathe through nose, pregnant, using
disulfiram, preexisting nausea, alcoholism.
Groups
_____ True control group
_____ Usual care group
___X__ Intervention group(s)
Name or brief description of group:
Control: received 4mg IV ondansetron, maybe be repeated times one.
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Name or brief description of group:
Intervention: use of an alcohol prep pad, 3 consecutive deep breaths through the nose.
May be repeated times one.
Type of Sample
Probability
Non-Probability
___X_ Simple Random Sampling
_____
Convenience
_____ Stratified Random Sampling
_____
Quota
_____ Cluster
_____
Purposive
_____ Systematic
_____
Snowball
Instruments
Measurement Tool
What did it measure?
Information about the measure:
# or type questions; reliability
or validity; inter-rater reliability;
other
Numeric rating scale
Degree of nausea experienced
on a 1 to 10 scale
Not mentioned. Most commonly
used scale for self report. Relies
on self report.
Detailed Description of the Intervention
Specific Steps of the intervention
Either put in ondansetron group or alcohol group when first reporting nausea in the PACU.
Intervention was standardized in both groups.
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Kimberly Moriarty
Knowledge and skills needed to deliver intervention (education, licensure, etc)
Giving IV medications require a MD, RN. Inhalation treatment does not require any specific
skills.
Time to deliver/use the intervention
Time was that spent in the PACU.
How frequently does it need to be delivered and what is the time interval in between delivery?
Alcohol: 3 consecutive deep breaths, up to two treatments
Ondansetron: 4mg IV every 15 minutes for up to two doses.
IRB Approval
__X___ Yes
_____ Does not mention
Threats to Validity
Threats to Internal Validity
_____
History
Threats to External Validity
__X___
Novelty effects
_____ Maturation
_____
___X__
_____ Experimenter effect
Testing
_____ Instrumentation
_____ Mortality
_____ Selection Bias
Results
Interaction of history and treatment
_____ Measurement effect
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Demographic characteristics were similar in both groups, equal number of surgical procedures between
groups. 41 of 100 experienced nausea. 29 in alcohol, 12 in control. No statistically significant differences
in mean verbal NRS scores except at 5, 10 and 15 min mark. Time of reduced nausea of 6.3(alcohol) vs.
27.7(ondansetron). Did not influence total time spent in PACU. Alcohol group did report more episodes
of nausea at home during first 24 hours. 8 of inhalation and 2 of ondansetron did not receive any relief
from their intervention, other means were used.
Major Findings
Decrease in nausea faster in inhalation group. Not better long term effects. No impact on PACU stay.
Strengths and Weaknesses of Study
Strength
Weakness
Specific surgical population
Small sample size
Randomized
No blinded study intervention
Consistent and regular interventions
Self reported data
Practical day to day setting
Ranking of Scientific Merit
Agency for Health Care and Research
Evaluate each study – Assign a quality number to the study
Evaluate all articles within the collection of studies reviewed – Assign a Letter
•Types of Evidence
____
Level 1 = meta-analysis
__X__ Level II = experimental studies
____ Level III = well-designed, quasi-experimental studies
____ Level IV = well designed, non-experimental studies
____ Level V = case reports and clinical examples
Five:
Title of Study
A Comparative Analysis of Isopropyl Alcohol and Ondansetron in the Treatment of Postoperative Nausea
and Vomiting from the Hospital Setting to the Home
Year of Publication
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Kimberly Moriarty
2007
Authors (list first two)
Cotton, J. Rowell, L. Hood, R, Pellegrini, J.
___X__ Clinical experience
_____ Research expertise
_____ Prior publications
___X__ Funding
_____ Non-federal funding
___X__ Federal funding
_____ Non US governmental funding
Purpose
Validate the results reported from Winston et al and determine whether IPA was just as effective
through a patient’s entire hospitalization and in the home setting.
Review of Literature
___X__ Logical
__X___ Clarity
__X___ Current and comprehensive references
_____ Pros/Cons presented
_____ Gaps in knowledge identified
___X__ Importance of study
Comments:
The review of literature set the background for the issue. Discussed at risk populations,
explained mechanism of PONV, and reviewed a few past studies. This study piggybacked
off a previous study done by colleges. The review of literature was very short. It did set a
good background for the proposed study to help further knowledge about this specific
population. The authors also further delved into prior studies done in the discussion
section.
Research Question/Hypothesis
Will women undergoing surgery experience less PONV using inhaled IPA, report quicker relief of these
symptoms and have less episodes of PONV at home.
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Kimberly Moriarty
Study Design
___X
Experimental/Randomized Clinical Trial
_____ Quasi-Experimental
_____ Correlation
_____ Descriptive
_____ Program Evaluation
____
Other
Sample and Setting
General description of participants (age, gender, etc.)
100 women, ages 18-65 scheduled for laparoscopic same day surgery.
Important Inclusion and Exclusion Criteria:
Exclusion: recent upper respiratory infection, impaired ability to breathe through nose,
hypersensitivity to IPA, 5-HT antagonists, promethezine, or anesthesia medication. Also excluded if;
using an antiemetic in last 24 hours, pregnant or breast feeding, inner ear pathology, motion sickness,
migraine headaches, or using disulfiram, cefoperazone, or metronidazole.
Groups
_____ True control group
_____ Usual care group
___X__Intervention group(s)
Name or brief description of group:
Control: treated with IV ondansetron
Name or brief description of group:
Intervention: treated with IPA
Type of Sample
Probability
Non-Probability
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Kimberly Moriarty
__X___ Simple Random Sampling
_____
Convenience
_____ Stratified Random Sampling
_____
Quota
_____ Cluster
_____
Purposive
_____ Systematic
_____
Snowball
Instruments
Measurement Tool
What did it measure?
Information about the measure:
# or type questions; reliability
or validity; inter-rater reliability;
other
VNRS (verbal numeric rating
scale)
Self reported nausea on 0-10
scale. 0=none 10=worst
imaginable
Most commonly used and
trusted scale in self report
Data collection tool
Records nausea and vomiting
events, treatment used and
effectiveness
No information or sample
provided within the study
Detailed Description of the Intervention
Specific Steps of the intervention
Obtain score for nausea post anesthesia, every 5 minutes upon complaint and 30 minutes post
treatment and then every 15 until discharged from PACU. Ondansetron group given 4mg IV every 15
min. times two doses. IPA given by 3 deep breaths every five minutes up to 3 administrations. Home
collection of data for 24 hours after discharge.
Knowledge and skills needed to deliver intervention (education, licensure, etc)
None needed. PACU nurses gave the intervention.
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Time to deliver/use the intervention
3 deep breaths every five minutes
How frequently does it need to be delivered and what is the time interval in between delivery?
See above, total of 3 administrations
IRB Approval
___X__ Yes
_____ Does not mention
Threats to Validity
Threats to Internal Validity
_____
History
Threats to External Validity
___X__
Novelty effects
_____ Maturation
_____
__X___
___X__ Experimenter effect
Testing
_____ Instrumentation
Interaction of history and treatment
__X___ Measurement effect
_____ Mortality
_____ Selection Bias
Results
72 subjects in the study (34 control 38 experiment). 5 in control required treatment, 8 in experiment in
PACU stay. 15 in control and 21 in experimental required treatment in SDSU. Control group reported
33.88 min to achieve 50% reduction in nausea, while 15 min in experimental group during first
treatments. Second treatments control reported 26.25 min to relief while experimental reported 15min.
13 of the control group needed rescue treatment while 10 in the experimental needed rescue. 21
reported nausea at home, only one subject in experimental group used the rescue treatment while 5 in
the control needed it. No significant scores reported for satisfaction of overall anesthesia experience.
Major Findings
IPA works significantly faster and is as effective as ondansetron in reducing PONV.
Strengths and Weaknesses of Study
Strength
Weakness
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Kimberly Moriarty
Supports previous study done on inhaled IPA.
Was not a blinded study
Specific group targeted.
Information collected by numerous providers (not
consistent)
Sample size appropriate to get significant results
Regimented intervention
Self reported data
Ranking of Scientific Merit
Agency for Health Care and Research
Evaluate each study – Assign a quality number to the study
Evaluate all articles within the collection of studies reviewed – Assign a Letter
•Types of Evidence
____
Level 1 = meta-analysis
__X__ Level II = experimental studies
____ Level III = well-designed, quasi-experimental studies
____ Level IV = well designed, non-experimental studies
____ Level V = case reports and clinical examples
Six:
The article begins with a purpose, rather a question that IPA is used in practice and no one really
knows why or how it works. She then reviews the importance of investigating this problem of post
operative nausea and vomiting. She touches on how PONV affects healthcare costs. Then the article
delves into the actual physiology of why and how nausea and vomiting occur in the body. The author
does a good job setting the stage for the article reviews. She goes on to touch on drug therapy and
some non-pharmaceutical therapies. She mentions 7 studies involving IPA. These studies all support
that inhalation of IPA decrease post operative nausea and vomiting. She mentions the weaknesses of
these studies, accounting some of the relief to controlled breathing patterns. She mentions one study
involving children. Then transitions onto the necessary nursing assessment during the period of nausea,
and provides a framework for inhalation therapy. She finishes with advantages of inhalation therapy.
27
Kimberly Moriarty
28
Section 5:
Evidence table
#3
Smiler,
B. 1998
#1
Merritt,
B
2002
#4
Winston,
A.
2003
IPA for
transport
related
nausea
Other:
Intervention.
Evaluate the
effect of IPA
inhalation for
rescue
treatment of
POVN in adult
same day
surgery
patients who
underwent
general
anesthesia
Quasiexperimental
Compare the
efficacy of
inhaled
isopropyl
alcohol and IV
ondansetron
for the
treatment and
control of
PON in
groups of
women
undergoing
outpatient
gynecological
Experimental
N=77
One
group
N=40
Two
groups
N=100
Two
groups
Patients
being
transported
within a
hospital
setting
Patients
inhale IPA
from a
wetted
upper lip
84% had relief
of symptoms,
15%did not
Level
5, B
Patients
undergoing
various
surgeries
3 sniffs
one inch
from the
nose.
Repeated
every five
minutes
for three
doses.
Intervention: 21
of 11 had relief
after first dose,
and 10 needed
at least one
intervention of
standard
medication.
Control group:
18 of 13 had
relief after the
first dose of
standard antiemetic. Five
had no relief.
Results not
significant
regarding
differences in
IPA being
superior to
standard
medications.
IPA group had
average cost of
9.75.
Control:17.08.
This is
significant.
Level
3B
Women,
laparoscopic
surgery
3 deep
breaths of
IPA, up to
3
treatments
41 of 100
experienced
nausea. 29 in
alcohol, 12 in
control. Time of
reduced nausea
of 6.3(alcohol)
vs 27.7(control).
Experimental
reported more
episodes of
PONV at home.
Level
2B
Kimberly Moriarty
29
laparoscopic
procedures
#6
Spencer,
K.
2004
#5
Cotton,
J.
2007
Review of
studies using
inhaled IPA
Literature
review
7 studies
reviewed
briefly
variable
Inhalation
of IPA
Varies. See
attached
summary
Level
5B
Validate the
results
reported from
Winston et al
and
determine
whether IPA
was just as
effective
through a
patient’s
entire
hospitalization
and in the
home setting.
Experimental
N=72
Women,
laparoscopic
surgery
3 deeps
breaths
every five
minutes,
up to 3
treatments
Level
2B
#2
Teran, L.
2007
To compare
IPA to IV
Granisetron in
Postoperative
nausea and
vomiting/
Quasiexperimental
Women,
Laparoscopic
surgery
3 deep
breaths of
IPA
Control group
reported 33.88
min to achieve
50% reduction
in nausea.
Experimental:15
min. Second
treatments:
control=26.25
min.
experimental=
15min. 13 of the
control group
needed rescue
treatment while
10 in the
experimental
needed rescue.
21 reported
nausea at
home, one
subject in
experimental
group used the
rescue
treatment while
5 in the control
needed it.
IPA group
reported more
episodes of
PONV in 6 to 24
hour
postsurgical
timeframe. No
significant
values between
groups
regarding
number of
PONV
episodes.
Two
groups
N=57
Three
groups
Level
3B
Kimberly Moriarty
Section Six:
Research Based Intervention Protocol:
-Person receiving the intervention: Any woman undergoing a surgical procedure with no allergies to
isopropyl alcohol, or an impaired ability to breathe through the nose. (2, 4, 5)
-Person delivering the intervention: To be given in a post anesthesia area, can be administered persons
authorized to care for patients (1, 2, 4, 5, 6).
To be administered as follows:
-Assess patient’s nausea upon arrival to post anesthesia care unit on a scale of 0-10 (1, 2, 4, 5)
-Administer three sniffs of isopropyl alcohol under the patient’s nose with inhalation (1, 2, 4, 5)
-Reassess nausea in 5 minutes on same scale (1, 2, 4, 5)
-If present, administer inhalation again, up to three doses, five minutes apart, reassess every
five minutes (1, 2, 4, 5)
-If no relief, may administer Doctor prescribed intravenous antiemetic (1, 2, 4, 5)
-Give one dose intravenous antiemetic before discharge (2,5)
30
Kimberly Moriarty
Section 7:
Evaluation Plan
The outcome to be measured is that of the patient’s experience of nausea and vomiting after
the surgical procedure. The effectiveness of the intervention may be evaluated by looking at the
patient’s self reported nausea and vomiting scores. The scale, measured from 0-10, is easily identifiable
as successful if the reported number decreases to a tolerable level. In the scale, 0 is reported as no
nausea or vomiting, and 10 is reported as the worst possible nausea and vomiting imaginable. In the
previous studies listed, all of the studies used the same scale. Because nausea is subjective, it is almost
impossible to measure this without self report.
To actually conduct an evaluation of this intervention, the patient’s self reported data should be
tracked, along with a follow up survey or phone call 24 hours after the intervention. This data should
show less nausea and vomiting episodes during the immediate post operative period through 24 post
surgery. A practitioner could follow up with the patient and attain this information. This intervention is
quick and easy to use. It saves the hospital and patient’s money, as isopropyl alcohol is considerably less
expensive than commonly used intravenous antiemetic.
31