Integrating Acupressure to Alleviate Postoperative Nausea and Vomiting

Nausea, an unpleasant subjective experience, is a feeling that vomiting is imminent, although it may not ensue.1 Postoperative nausea and vomiting (PONV) add to morbidity through dehydration, electrolyte disturbance, aspiration, and wound pain, causing unnecessary delay in recovery, increased costs, and poor satisfaction among patients.2,3 The incidence of PONV varies depending on multiple risk factors. Associated patient factors include increasing age, female sex, obesity, emotions/stress, history of motion sickness, and previous PONV. Treatment factors include operative procedure, inhalation anesthetic agents, and opioids.4–6Typically, PONV is treated with antiemetics. But pharmacological interventions may be only partially effective. Some patients may not tolerate antiemetics because of adverse effects such as headache, agitation, or tachycardia, whereas PONV develops in others despite use of antiemetics.6 Nonpharmacological methods such as acupressure have shown promise in lessening PONV and chemotherapy-induced nausea and vomiting. Acupressure, a variation of acupuncture based on more than 3000 years of Chinese medicine, involves applying pressure on acupressure points without puncturing the skin. These acupoints correspond to an invisible circuitry of channels known as meridians that conduct energy (qi) to specific anatomic regions. If channels are disturbed, meaning energy flow is too slow, fast, turbulent, or static, there is said to be a qi imbalance, which can cause symptoms such as nausea and vomiting. From the Eastern perspective, acupressure is believed to stimulate or interrupt energy, thereby altering responses to negative stimuli, whereas the mechanism of action proposed in Western medicine involves triggered release of endogenous endorphins.6,7 In this clinical review, we discuss available evidence of the effect of acupressure techniques in reducing PONV.The strategy included searching MEDLINE, CINAHL, Cochrane Library, Joanna Briggs Institute, and the TRIP database. Key words included nausea/vomiting, PONV, acupressure, and SeaBands. Only evidence from 1999 to 2010 on pericardial median acupoint (P6) interventions was included. Other exclusions included patients undergoing cesarean section.Two meta-analyses and 13 randomized controlled trials were retrieved (Table 1). Acupressure interventions included bands (SeaBands), electro-acustimulation via ReliefBands, or finger-pressing the P6 acupoint. P6 is located on the dorsal surface of the forearm 2 inches (5 cm) proximal to the wrist crease between the palmaris longus and flexor carpi radialis tendons.6 Five trials evaluated bilateral treatment, 4 unilateral, 1 unilateral vs bilateral, and 3 a combination of treatments. Bands were usually applied 30 to 60 minutes before induction, and duration of treatment ranged from 6 to 72 hours. Primary outcomes included PONV and need for rescue antiemetics.Although available studies reveal mixed findings, evidence from the meta-analyses and larger trials generally favors acupressure in reducing PONV and antiemetic rescue. Populations that benefited included outpatient plastic surgery patients; patients undergoing endoscopic sinus procedures, gynecological procedures, and laparoscopic procedures such as cholecystectomy; and cardiac surgery patients. Overall, adults responded positively, whereas findings for children varied. Bilateral and unilateral bands had mixed effects, although bilateral application had more consistent complete response (PONV incidence and antiemetic use). Results of another trial19 indicated no difference between bilateral and unilateral bands.One meta-analysis8 and 1 randomized controlled trial15 showed comparable efficacy between acupressure bands and antiemetics, suggesting that acupressure was at least as effective as antiemetics for preventing nausea. Time was another important variable, with significant effects of acupressure in the first 6 hours.9,15 Other investigators found that bands significantly affected PONV at 24 hours.16,20 These differences may reflect time intervals of outcome evaluation. Despite the lack of efficacy in other populations,13,17–19 Klein16 demonstrated positive effects of SeaBands on outcomes in female cardiac surgical patients. Alkaissi et al14 also found vaginal surgery patients had significant effects compared with other laparoscopic gynecological procedures.Mixed findings were revealed in trials investigating combination versus antiemetic therapy. Although researchers in 1 study22 found that droperidol was associated with less nausea than acupressure, most evidence favored a combination of acupressure and antiemetic use for PONV outcomes. In 2 large trials,20,21 ReliefBand/Zofran therapy demonstrated efficacy equal to that for antiemetics for complete response (PONV/antiemetic rescue), suggesting that Zofran enhanced the overall efficacy of ReliefBands.Overall, “class 1” evidence exists for the efficacy of acupressure on PONV in surgical populations (Table 2). Acupressure offers a noninvasive approach to preventing PONV that has comparable antiemetic efficacy to more invasive treatments such as acupuncture or medications, with fewer side effects and lower cost. Acupressure is easy to administer and carries no infection risk. Reported side effects are minor: some patients reported that acupressure bands were uncomfortable, causing red indentations and itching, blistering, or swollen wrists; drowsiness; and headache/dizziness.8,9,14,22 Mild cutaneous irritations were reported with acustimulation devices.12 Consequently, clinicians must carefully monitor for local side effects and discontinue use of the bands if needed. No long-term adverse events were documented.9 Thus, these interventions offer potential benefit that outweighs the minimal to no harm they cause.During the preoperative phase, patients should be assessed for PONV risk factors. Such assessment can be accomplished with a screening tool of evidence-based risk factors such as increasing age, sex, obesity, history of motion sickness, and prior PONV history. Noninvasive treatments such as use of SeaBands or ReliefBands may be offered to patients as an adjunct to their care. Bands should be applied before emetic stimulus at the correct P6 location. Either bilateral or unilateral bands may offer PONV protection, although bilateral application appears to be associated with more complete response. Older evidence suggests best results may be achieved through the use of the dominant hand.24 Further considerations in critically ill patients focus on the use of hemodynamic catheters. In patients with catheters in the radial artery, correct placement of acupressure bands in the P6 position on the wrists may not be possible. Therefore, reliance on unilateral application on the nonused extremity may offer potential for using this technique for PONV prevention.Beyond integrative approaches to perioperative care, nurses have an opportunity to collaborate with pharmacists and physicians in modifying postoperative pain protocols to reduce reliance on narcotic analgesics that are emetigenic. Nonpharmacological interventions such as music therapy, guided imagery, healing touch, or massage can be integrated to achieve effective pain control and thereby reduce offenders that contribute to PONV morbidity. Because pain and anxiety often go hand-in-hand, integrative therapies that target both symptoms may be especially effective in promoting postoperative comfort for patients. An added benefit is that therapies such as acupressure may reduce the amount of analgesics and antiemetics that patients may need, further limiting more potential drug-related side effects.