Does acupressure delivered by nurses and anaesthetists improve the management of postoperative nausea and vomiting?

Background<br><br> Postoperative nausea and vomiting (PONV) is a common clinical presentation of surgery and anaesthesia. PONV affects approximately 50% of cases, and up to 80% of high-risk patients. PONV is distressing and unpleasant, and interferes with return to activities of daily living, and hence lowers the quality of life. Vomiting can lead to complications that threaten or delay recovery. Pharmacological antiemetic prophylaxis alleviates but does not adequately control PONV. Level-one clinical evidence has shown that stimulation of specific acupuncture points reduces PONV. Consensus Guidelines for PONV management recommend that acupuncture be considered as part of multi-modal PONV prophylaxis. However, such clinical evidence has not been translated into routine clinical practice, and the feasibility of acupressure when delivered by hospital clinicians as part of standard PONV management to a broad surgical population is yet to be demonstrated. <br><br> The present study The present study was embedded within a National Health and Medical Research Council funded Implementation study. This study evaluated the feasibility and clinical outcomes of acupressure as part of standard PONV management protocol through two reviews, one clinical survey, one feasibility study and one clinical audit. <br><br> The two reviews: <br><br> The first review and meta-analysis included 33 acupressure studies involving 4,591 participants and demonstrated that acupressure at PC6 acupoint effectively decreases the incidence of postoperative nausea, postoperative vomiting, and the requirement for rescue antiemetics when compared with that of the control groups. There were no subgroup differences between bilateral and unilateral stimulations of PC6. In addition, while acupressure was reported to be simple and safe to use, most included studies did not report outcomes pertaining to patient experience, cost effectiveness or data related to PONV recovery. <br><br> The second systematic review (13 studies 799 participants) of the potential mechanisms underlying the antiemetic effect of acupoint stimulation indicated that acupuncture might complement the actions of pharmacological antiemetics through down regulating the concentrations of target neurotransmitters, in particular 5-HT. <br><br> The clinical survey (Stage 1) <br><br> A clinical survey of recruited surgical patients (n=71) prior to implementation of the acupressure protocol revealed that despite 85% of the patients receiving antiemetic prophylaxis, 65% of those at moderate to high PONV risk still experienced PONV, and 62% required postoperative ‘rescue’ antiemetic treatment. These findings are consistent with outcomes of a concurrent audit of postoperative antiemetic use in 184 surgical patients. However, there was no data available with respect to PONV incidence and PONV risk for the audited patients as the hospital neither charted PONV incidence nor documented patient PONV risk level. <br><br> A survey of these recruited patients’ preferences (n=71) towards acupuncture or acupressure found that over 50% would be willing to use these to manage their PONV. Seven times more patients preferred acupressure to acupuncture, however the largest cohort preferred the most effective intervention. <br><br> The pilot study (Stage 2) <br><br> Based on these findings, a pilot study (n=55) of combined PC6 and auricular acupressure delivered by researchers was undertaken. The outcomes measures were determined according to the FAME criteria: feasibility, appropriateness, meaningfulness and effectiveness. This pilot study demonstrated the feasibility of incorporating acupressure into perisurgical medicine practice. <br><br> Technically, we showed that it is possible to apply and retain acupressure before, during and after surgery. Most patients (142/160, 89%) did not have any contraindications for acupressure, and the majority of eligible patients (63/98, 64%) were willing to use acupressure as part of their PONV management. Patient satisfaction with overall PONV management including acupressure was high (96%). Adverse events associated with acupressure were mild and self-limiting. Around one quarter of participants reported tightness or discomfort, with 6% reporting that acupressure caused pain. Swelling of the hand was observed in 18.5% of participants. Swelling resolved on removal of the wristband. <br><br> The combined therapeutic pilot study approach reduced the use of rescue antiemetics in moderate to high risk patients from 62% prior to acupressure to 50% indicating the potential benefit of adding acupressure for PONV management. However, a further simplified protocol is needed to increase feasibility for broader implementation as auricular acupressure was found to be too time-consuming for nurses in the Day Procedure Unit to apply to patients preoperatively. <br><br> A clinical audit of wristband acupressure (Stage 3) <br><br> Unilateral PC6 acupressure through the use of an elasticized wristband was implemented as a nurseinitiated intervention within standard PONV management. An audit of 1,306 surgeries over five months was conducted, assessing the uptake of acupressure and clinical outcomes. All data was derived from medical records, which meant that PONV incidence could not be extracted directly from the Case Records, and outcomes were based on the requirement for rescue antiemetics. <br><br> Approximately half (51%) of the surgical patients during the observation period were assessed as moderate to high PONV risk, and therefore eligible to receive acupressure. Acupressure was administered to approximately half (49%) of these eligible patients. Those who had indicated a preference to use it, and patients at higher PONV risk, or with previous PONV history, were more likely to receive it. <br><br> Preliminary data on effectiveness was collected. One hundred and fifty-four (154) patients were matched for number of PONV risk factors, age, and surgery type, with 77 documented as using acupressure and 77 without using it. The requirement for rescue antiemetics to 24 hours after surgery was not different between groups. The acupressure group required 40% less postoperative opioid analgesia in the first 24 hours, and had a shorter duration of stay in Recovery (14 minutes) and in hospital (0.4 days). While these outcomes may not be statistically and/or clinically significant due to sample size, a positive trend of potential cost savings has been shown. <br><br> Conclusions<br><br> Acupressure appeared to be a safe and feasible option for contributing to the management of PONV. Patients with high PONV risk are more willing to use it, and hospital clinicians are more likely to administer it to these patients, supporting its potential role as an adjunct to pharmacological prophylaxis for those at high PONV risk. The findings included in this thesis are promising for the potential integration of acupressure into PONV management, but cautions need to be given to the limitations such as duration, scope and sample size of this research. Future studies will need to address these limitations and may compare the benefits of acupressure alone or an adjunct therapy with pharmacological antiemetics, using a Comparative Effectiveness Research design to determine the role of acupressure for PONV.