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GENERAL ARTICLES

Acupressure Treatment for Prevention of PostoperativeNausea and VomitingChin-Fu Fan, MD, Eduardo Tanhui, MD, Sanjoy Joshi, MD, Shivang Trivedi, MD,Yiyan Hong, MD, and Ketan Shevde, MDDepartment of Anesthesiology, Maimonides Medical Center, Brooklyn, New York

Postoperative nausea and vomiting are still commonproblems after general anesthesia, especially in am-bulatory surgery. Drug therapy is often complicatedwith central nervous system symptoms. We studied anonpharmacological method of therapy-acupres-sure-at the Pericardium 6 (P.6) (Nei-Guan) merid-ian point. Two hundred consecutive healthy patientsundergoing a variety of short surgical procedureswere included in a randomized, double-blind study :108 patients were in the acupressure group (Group 1)and 92 patients were in the control group (Group 2).Spherical beads of acupressure bands were placed atthe P.6 points in the anterior surface of both forearmsin Group 1 patients, while in Group 2 they wereplaced inappropriately on the posterior surface. Theacupressure bands were placed before induction ofanesthesia and were removed 6 h postoperatively.

They were covered with a sof t cotton wrapping toconceal them from the blinded observer who evalu-ated the patients for presence of nausea and vomitingand checked the order sheet for any antiemetics pre-scribed. In both groups, the age, gender, height,weight, and type and duration of surgical procedureswere all comparable without significant statisticaldifference. In Group 1, only 25 of 108 patients (23%)had nausea and vomiting as compared to Group 2, inwhich 38 of 92 patients (41%) had nausea and vomit-ing (P = 0.0058). We concluded that acupressure atthe P.6 (Nei-Guan) point is an eff ect ive prophylaxisfor postsurgical nausea and vomiting and thereforea good alternative to conventional antiemetictreatment.

(Anesth Analg 1997;84:821-5)

P stoperative nausea and vomiting are distress-ing symptoms associated with general anesthe-sia. In several studies the incidence has beenshown to be between 60% and 70% in patients under-going gynecologic procedures (l-3), laparoscopy (4),and strabismus surgery (5,6). Various medicationshave been used to alleviate these symptoms, but nonehas been devoid of side effects. Antiemetic drugs cancause symptoms varying from lethargy to extrapyra-midal effects which could lead to delayed dischargeand unintended hospital admission. Treatment withacupuncture at the Pericardium 6 (P.6) (Nei-Guan)point has shown good results in the treatment ofmorning sickness (7,8) and nausea/vomiting after che-motherapy (7,9). However, this mode of therapy isinvasive and the risk of infection is a concern.The purpose of this study was to test the hypothesisthat less postoperative nausea and vomiting would beexperienced by patients wearing an acupressure band

Accepted for publication December 17, 1996.Address correspondence and reprint requests to Chin-Fu Fan,MD, Department of Anesthesiology, Maimonides Medical Center,Brooklyn, NY 11219.01997 by the International Anesthesia Research Society0003-2999/97/$5.00

at the P.6 meridian point compared to those wearing aplacebo band at a different location. We selected op-erative caseswhich were prone to these complicationsto emphasize the value of this treatment.

MethodsThe protocol for this study was approved by ourinstitutional research committee, and informed con-sent was obtained from all patients. Two hundredconsecutive healthy (ASA physical status I or II) pa-tients of both genders, aged between 19 and 59 yr, andhaving surgery associated with a high incidence ofpostoperative nausea and vomiting such as laparo-scopic and gynecologic procedures, tonsillectomy, andopen cholecystectomy, were included in a random-ized, double-blind study. Patients receiving antiemeticmedications, a histamine HZ-receptor antagonistwithin 72 h of surgery, or tranquilizers, or those withhypertension were excluded to prevent interferencesecondary to drug interactions.Three individuals were specifically trained in theproper application of the acupressure band and they,

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Figure 1. The location of Pericardium 6 (P.6) meridian point an d the proper application of acupressure band to the wrist.

were the only ones who applied them. Patients in-cluded al l ethnic groups, however there were no Ori-enta l patients in the study group. AcuBandTM wriststraps (AcuBand Inc., PO Box 355, Litt le Silver, NJ)were placed on both wrists in al l patients. The acu-pressure band has an adjustable strap, 3! inch inwidth, with a spherical plastic bead attached to it andVelcro fasteners to prevent the bead from slippingfrom its position. Both bands were concealed from theblinded observer with the use of a soft cotton roll.The treatment point P.6 (Nei-Guan), is the number 6meridian point in the Pericardium Channel of Hand-Jueyin, and is located on the anterior surface of theforearm, 2 inches proximal to the distal wrist creasebetween the tendons of musculus flexor carpi radialisand musculus palmaris longus (10). The forearm of thepat ient from the transverse crease of the wrist to thecubi tal crease is measured as 12 inches. Thus, 2 inchesare one sixth of the forearm (Fig. 1). The I.6 is themeridian point specifically designated in Chinesemedicine for the treatment of nausea and vomiting(10). In the study group (Group l), spherical beads ofthe acupressure band were placed at the P.6 point onboth wrists of patients. In the control group (Group 2),the acupressure bands were tied loosely and thespherical beads were placed on the dorsum of bothwrists. There is no known acupressure point or me-ridian pathway located at that anatomic site. Acupres-sure bands were al l placed preoperatively in the hold-ing area and the spherical beads were compressedintermittent ly for a few minutes to activate the P.6merid ian point. Patients wore them continuously for

6 h postoperatively when the study was completed.No patients in either group received any premedica-tion. No antiemetic medication was given pre- or in-traoperatively. Anesthesia was administered by differ-ent anesthesiologists under a standardized plan. Theanesthetic technique included induction with midazo-lam l-2 mg intravenously (IV), fentanyl2-3 pg/ kg IV,thiopenta14 mg/ kg IV, and a muscle relaxant selectedby the anesthesiologist. Anesthesia was then main-tained with oxygen, nitrous oxide, isoflurane, and anondepolarizing muscle relaxant. The electrodes ofthe neuromuscular monitor were placed on the ulnarside of either forearm near cubital crease in al l pa-tients. A nasogastric tube was inserted orally in al lpatients after induction of anesthesia and the stomachwas then emptied. Drugs with antiemetic properties,such as propofol (5,ll) and droperidol (6), wereavoided.

At the end of the surgical procedure, patients weretracheally extubated in the operating room after rever-sal with appropriate doses of neostigmine or edropho-nium and atropine or glycopyrrolate. The nasogastrictube was removed and patients transferred to thepostanesthesia care unit (PACU). A blinded observerevaluated patients for the presence of nausea and/orvomiting, and dose and frequency of antiemetics ad-ministered. The study was concluded 6 h after pa-tients arrival in the PACU. Nursing staff in the PACUwere unaware of which patients were in the studygroup and which were in the placebo group.For the postoperative pain management, our stan-dard practice was to administer meperidine 25 mg IV

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Table 1. Demographic Data Table 2. Number of Procedures in Each GroupAcupressure group Control group(Group 1) (Group 2)

Age 64 37 ? 9 36 + 9Gender (M/F) 51103 6186Weight (kg.) 67 2 13 72 f 18Height (cm) 161 ? 7 164 + 8Values are mean ? SD.

ProceduresAcupressure Control group

group (Group2;(Group 1; n = 108) n = 92)LaparoscopiccholecystectomyLaparoscopic tubal ligationHysteroscopy, & CDiagnostic laparoscopyD&COpen cholecystectomyTonsillectomyLaparoscopic lysis ofadhesionsGynecologic tubalreanastomosis

38 43

and repeat once if necessary. Most patients felt com-fortable after such pain medication. However, if thepatient still had severe pain, more meperidine wasadministered.

23 1210 929 175 21 32 10 40If the patients vomited, they received an antiemeticmedication, i.e., metoclopramide, percloperazine or

ondansetron, and the study was concluded. If thepatient merely felt nausea which was tolerable, thenno antiemetic medication was given. However, if thepatient felt nausea which was intolerable, even thoughno vomiting occurred, the patient received antiemetictreatment and the study ended at that point.

D & C = dilation and cure ttage.

Table 3. The Duration of Surgical Procedures in MinutesAcupressure group(Group 1) Control group(Group 2)

No N/V N/V No N/V N/V84 2 41 89 + 31 85 + 49 96 2 51Results

Two hundred consenting patients were enrolled in thestudy. One hundred eight patients were in the acu-pressure group (Group 1) and 92 patients were in thecontrol group (Group 2). No patients were excludedsubsequent to their admission to the study. The age,gender, and height were comparable in both groups.The mean weight of patients in the control group wasmore than the acupressure group, but this was notstatistically significant (Table 1).

Values are mean 2 SD; t-Te st = two samples assuming equal variance.N/V = nausea/vom iting.Acupressure group versus Control group: No N/V, P = 0.15; N/V, P =

0.56.No N/V versus N/V in the same group: Acupressure group, P = 0.55;Control group, P = 0.87.

Table 4. Ef fect of Meperidine on Postoperative Nauseaand Vomiting

The procedures in both groups were comparable(Table 2). The duration of procedures (Table 3) andpostoperative nausea and vomiting secondary to theuse of meperidine for postoperative pain control inboth groups were not statistically significant (Table 4).The acupressure group had a significantly lower inci-dence of nausea and vomiting as compared to thecontrol group, using 2 test, P = 0.0058 (Fig. 2). Therewere no observed side effects or complications due tothe placement of the acupressure band in either groupand all patients felt comfortable while wearing them.

Meperidine

Control groupAcupressure group (Group 2;(Group 1; II = 108) n = 92)N/V No N/V N/V NON/V

Yes 15 48 22 28No 10 35 16 262 test: Group 1, P = 0.853; Group 2, P = 0.580.N/V = nausea/vom iting.

reduce postoperative nausea and vomiting (P =0.0058).

DiscussionThe P.6 (Nei-Guan) meridian point in acupuncture hasbeen used to treat vomiting and other stomach ail-ments in traditional Chinese medical practice (10). In1990, Dundee (8) revealed that acupuncture or acu-pressure at the P.6 meridian point was as effective asthe standard antiemetic in treating nausea and vom-iting. Our present study of 200 patients demonstratedthat acupressure at the P.6 can indeed significantly

No treatment is effective in all casesof nausea andvomiting. Pharmacologic therapy, using drugs such asdroperidol, metoclopramide, and ondansetron, is of-ten associated with side effects. Droperidol at the doseof 0.1 mg/kg may be associated with drowsiness andextrapyramidal symptoms (12). Metoclopramide hasthe same type of side effects in addition to headacheand diarrhea. Ondansetron is associated with head-ache, diarrhea, and transient increase in hepatictransaminase levels. Drowsiness is of particular con-cern in ambulatory surgical patients because it cancause extended stay in the PACU or possible hospitaladmission for overnight stay which can inconvenience

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ICUPRESSURE GROUP CONTROL GROUPFigure 2. Statistica l analysis of acupressure treatment for postop-erative nausea and vomiting. Open bars denote patients who had nonausea and vomitinsea and vomitmg. 9 and solid bars denote patients who had nau-test, P = 0.0058.the patient and also increase the hospital cost. In con-trast, acupressure has no side effects or drug interac-tions. I t is noninvasive, simple to apply, has a highdegree of patient acceptance, and is economical (ap-proximately $8.00 for a reusable pair of acupressurebands). Thus, acupressure is a good alternative to theroutine ly prescribed antiemetics for the treatment ofpostoperative nausea and vomiting.

Acupuncture or acupressure at the P.6 merid ianpoint is inconsistent in its efficacy. Dundee et al.(8,13,14), Hyde (15), and our preliminary study in 41patients proved that the stimulation by acupunctureor acupressure at the P.6 point is high ly effective inreducing postoperative nausea and vomiting. Lewis etal. (16) and Yentis and Bissonnette (17) did not dem-onstrate good efficacy with this treatment. The possi-ble reasons for the poor results could be the inaccuratelocalization of the P.6 meridian point or the wrongtiming of the P.6 activation. As Mann (18) has ex-plained, The only thing of importance in acupunc-ture is to stimulate the right place. What the stimulusis, is of secondary importance. Dundee and Ghaly(19) failed to demonstrate an antiemetic effect of theP.6 when acupressure was applied immediately beforeinduction of anesthesia or during its maintenance. Wewould surmise that in order to be effective, the acu-pressure bands must be applied prior to the emeticstimulus which occurs during anesthesia and surgery(14). This is also supported by studies in oncologywhich showed that the P.6 acupressure was as effec-tive as an antiemetic only when it was given beforechemotherapy was started (9). Thus, to achieve good

antiemetic effect, the timing of the P.6 meridian pointactivation is important.The psychological aspect, or placebo effect, of acu-pressure at the P.6 merid ian point in our study can be

ruled out, since both the acupressure group and thecontrol group wore the same type of acupressurebands.The mechanism of acupressure (or acupuncture) atthe P.6 meridian point to prevent postoperative nau-sea and vomiting is not yet fully understood. Addi-tional research (20-23) has shown that acupuncturefor pain therapy is mediated by a neurochemical sub-stance, possibly endorphin, and its analgesic effect canbe blocked by naloxone. The P.6 (Nei-Guan) meridianpoint is located near the median nerve (10). It is pos-sible that a variety of stimuli to the P.6 point, e.g.,either with a needle (with manual twisting or electricalstimulat ion) or with acupressure (8) may release aneurochemical substance which in turn desensitizesthe chemoreceptor trigger zone in the brain and pre-vents postoperative nausea and vomiting caused byintravenous or inhalat ion anesthetics or chemothera-peutic drugs. However, once the chemoreceptor trig-ger zone is sensitized, it is diff icul t to overcome ordesensitize it by the neurochemical substance. Thismay explain why acupressure, to be effective in treat-ing nausea and vomiting, must be applied before theemetic stimulus has been initiated (14). The nature ofthe neurochemical substance has not yet beenelucidated.In conclusion, the traditional Chinese method ofacupuncture or acupressure at the P.6 (Nei-Guan) me-ridian point, although looked upon in the past withskepticism, has a demonstrated effectiveness in pre-venting postoperative nausea and vomiting and is avalid nonpharmacological alternative to the standarddrug therapy.The authors wish to express their gratitude for the cooperation of allthe anes thesiolo gists and registered nurses in the postane sthesiacare unit at Maimonides Medical Center. The authors also wish tothank Ms. Marie Botti and Ms. Linda ONeill for their tireless effortin preparation of the manus cript, Mr. Willie Wood for his photog-raphy, Ms. Lydia Friedman and Mr. Chang a Tyaga raj for the liter-ature search, and AcuBan d Inc. for providing all the AcuBa ndsT forthe project.

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