|Year : 2020 | Volume
| Issue : 2 | Page : 87-90
P6 point acupressure versus ondansteron in prevention of carboprost-induced nausea and vomiting
G Rajaram1, K Raghu2, Shishir Kumar3, N Nikhil4
1 Graded Specialist (Anaesthesiology) 5 Air Force Hospital, Jorhat, Assam, India
2 Graded Specialist (Anaesthesiology) 4 Air Force Hospital, Kalaikunda, West Bengal, India
3 Graded Specialist (Anaesthesiology), Military Hospital, Pithoragarh, Uttarakhand, India
4 Anaesthesiologist, Axon Hospital, Bangalore, Karnataka, India
|Date of Submission||02-Sep-2019|
|Date of Acceptance||22-Apr-2020|
|Date of Web Publication||20-Aug-2020|
Dr. K Raghu
Graded Specialist (Anaesthesiology), Department of Anesthesiology, 4 Air Force Hospital, Kalaikunda, West Midnapore (D), West Bengal
Source of Support: None, Conflict of Interest: None
Context: Perioperative nausea and vomiting is an important clinical problem that occurs in a group of patients requiring carboprost during cesarean section. Apart from pharmacological measures, other modalities have also been introduced to decrease the incidence. Aims: Our study aimed at comparing the effectiveness of acupressure and ondansetron in the prevention of nausea and vomiting following the use of carboprost. Settings and Design: This was a prospective randomized controlled study. Methods and Materials: One hundred patients scheduled for elective caesarean section under spinal anesthesia were divided into two groups of 50 each to receive either acupressure (Group A) or injection ondansetron (Group O) 0.1 mg/kg intravenous (i.v.) immediately after spinal anesthesia. Injection carboprost 250 μg was given intramuscularly in both groups after delivery of the anterior shoulder. Incidences of nausea and vomiting were observed intraoperatively and postoperatively for 2 h. Statistical Analysis Used: Standard qualitative and quantitative tests were used to compare data. A value of P = 0.05 was considered significant. Results: A total of 11 patients had nausea, of whom 7 were in Group O and 4 patients were in Group A (P = 0.350). In total, six patients had nausea and vomiting, of whom four were in Group O and two were in Group A (P = 0.424). No statistical difference was observed between two groups in the incidences of nausea and vomiting. However, the incidence rates were low in Group A as compared to Group O. Conclusion: P6 point acupressure is as effective and comparable as ondansetron in the prevention of carboprost-induced nausea and vomiting.
Keywords: Acupressure, carboprost, nausea, ondansetron, vomiting
|How to cite this article:|
Rajaram G, Raghu K, Kumar S, Nikhil N. P6 point acupressure versus ondansteron in prevention of carboprost-induced nausea and vomiting. J Obstet Anaesth Crit Care 2020;10:87-90
|How to cite this URL:|
Rajaram G, Raghu K, Kumar S, Nikhil N. P6 point acupressure versus ondansteron in prevention of carboprost-induced nausea and vomiting. J Obstet Anaesth Crit Care [serial online] 2020 [cited 2021 Jan 18];10:87-90. Available from: https://www.joacc.com/text.asp?2020/10/2/87/292737
| Introduction|| |
Cesarean section is the commonly performed operative procedure in the field of obstetrics. One of the complications that occur following cesarean section which pose a significant risk to mother's life is postpartum hemorrhage (PPH). Studies have shown that administration of uterotonic agents following cesarean section may reduce the incidence of PPH. Commonly used uterotonic drugs include oxytocin, ergotamines, and prostaglandin analog such as carboprost.
Carboprost is synthetic 15 methyl analog of prostaglandin F2α. It is reported to be highly effective in the management of PPH. The most common and distressful complication of the use of carboprost is the occurrence of nausea and vomiting. Incidence of nausea and vomiting following cesarean section is 50%–80% and it is even more following the use of carboprost. Many methods are available to decrease the incidence of nausea and vomiting; these include use of antiemetics such as ondansetron and metoclopramide.
An alternative for modern anti-vomiting medications is traditional Chinese medicine, acupressure. Acupressure has been used for thousands of years for treating nausea and vomiting. Now it is gaining importance due to its simplicity, easy to apply, and devoid of side effects.
Not many studies have been done to assess the effectiveness of acupressure and conventional antiemetics. This study aimed at comparing the effectiveness of acupressure and ondansetron in the prevention of nausea and vomiting following the use of carboprost.
| Subjects and Methods|| |
This was a prospective study undertaken after taking approval from the Institution Ethical Committee between November 2018 and July 2019. One hundred patients with American Society of Anesthesiologists (ASA) grade I or II scheduled for elective cesarean section under spinal anesthesia were included in the study. The exclusion criteria of the study were emergency cesarean section, significant cardiovascular, renal, hepatic diseases, thyroid disease, previous history of postoperative nausea and vomiting (PONV), motion sickness, migraine, known asthma, and the refusal for consent. All patients were explained in detail about the anesthetic procedure and written informed consent was obtained.
Subjects were divided into two groups based on computer-generated random numbers into Groups A and O. All the patients were preloaded with 500 mL of lactated Ringer's solution 15 min prior to spinal anesthesia. Standard monitors including electrocardiogram, noninvasive blood pressure, and pulse oximetry were placed. Basal values were recorded.
The patients were placed in the sitting position and dural puncture was performed at L3–L4 interspace. Hyperbaric bupivacaine (0.5%) 2.5 mL was injected intrathecally and patient made to lie down with wedge under the right buttock. Blood pressure measurement was recorded immediately after subarachnoid block and repeated every 3 min in the first 30 min and cycled to 5 min till the end of surgery. Mean arterial pressure (MAP) was maintained within 20% of the baseline. A decline in pulse rates (<50 beats per min) were treated with 0.5 mg intravenous (i.v.) atropine. In the both groups, carboprost 250 μg was administered intramuscularly after delivery of anterior shoulder of the baby along with oxytocin 10 units in an infusion. In Group A, a commercially available acupressure band was applied immediately after subarachnoid block and the band kept at P6 point, which is located on the volar side of forearm 2 cm proximal to the wrist crease, between the tendons of palmaris longus and flexor carpi radialis [Figure 1]. The pressure of the elastic band was adjusted not to impair patient's radial or ulnar pulses, nor to impair venous return from distal. In Group O, injection ondansetron 0.1 mg/kg was given intravenously immediately after subarachnoid block. Incidence of nausea and vomiting were recorded in both groups for the 2 h after end of surgery. Patients having more than one episode of vomiting were given rescue antiemetic 10 mg i.v. metoclopramide.
With a hypothesized difference of incidence of nausea and vomiting of 10% between two groups and a β of 80% and α of 0.05, the sample size came to 42 in each group. We included 100 patients to increase statistical strength. Mean and standard deviation were used for age, height, and weight, and independent t test was used to compare if the difference between the two groups was significant. Incidence of nausea and vomiting was expressed in percentage, and compared using the Fischer exact test. A value of P < 0.05 was taken as significant.
| Results|| |
One hundred patients of ASA grade I or II scheduled for elective cesarean section under spinal anesthesia were included for this study [Table 1]. Patients were divided into two groups of 50 each [Figure 2]. In Group A, a commercially available acupressure band was applied and Group O received injection ondansetron 0.1 mg/kg i.v. immediately after spinal anesthesia. Both groups were comparable in terms of age, weight, height, and ASA grades. Incidences of nausea and vomiting were noted. Total 11 patients had nausea (11%), of whom 7 were in Group O and 4 patients were in Group A (P = 0.350) [Table 2]. Total six patients had nausea and vomiting (6%), of whom four were in Group O and two were in Group A (P = 0.424) [Table 2]. No statistical difference was observed between two groups in the incidence of nausea and vomiting, but rates were less in Group A as compared to Group O.
| Discussion|| |
Nausea with or without vomiting is one of the most common complications that is faced by anesthesiologist during or after surgery. Although it is self-limiting, it may cause significant morbidity, ranging from dehydration, electrolyte imbalances, and suture dehiscence to serious airway compromise. They are also associated with increased duration of hospital stay and increased hospital costs.
The etiology of perioperative nausea and vomiting in patients undergoing cesarean section is multifactorial. These include hypotension, visceral stimulation during surgery, the effect of neuraxial opioid administration, and the use of uterotonic agents.
Management of nausea and vomiting includes pharmacological and non-pharmacological measures. Pharmacological measures even though effective but have significant side effects; this has led to the search for alternative treatment. One such alternative method is acupressure. Acupressure is a part of the Chinese system of medicine, which works on the hypothesis that there is a flow of vital energy inside the body through different pathways which is required for an organism to live and function. This vital energy is called chi or qi and pathways are called meridians. Stimulating the specific points on the meridian performs a particular action. Point PC6 (also named Nei-guan) is one such point located on the Meridian Pericardium Jueyin. Stimulation of this P6 point hypothesized to increase hypophyseal secretion of β-endorphins and adrenocorticotropic hormone, with subsequent inhibition of the chemoreceptor trigger zone and vomiting center.
In this study, we compared the effectiveness of commonly used antiemetic ondansetron and alternative method acupressure in the prevention of nausea and vomiting following the use of carboprost in patients undergoing cesarean section under spinal anesthesia. We found out that the overall incidence of nausea was 11% and nausea with vomiting was 6%. The incidences were a little bit higher in the ondansetron group as compared to the acupressure group but there was no statistical difference (P = 0.350 for nausea and P = 0.424 for vomiting).
In a study conducted by Levin et al. to find out the effectiveness of P6 point acupressure and conventional antiemetics in prevention of nausea and vomiting during cesarean section, the rate of intraoperative vomiting experienced in the P6 and IV antiemetic groups was found to be comparable (OR 0.77; 95% CI 0.28–2.11, P = 0.61) and P6 point acupressure was as effective as antiemetics. In another study conducted by Wani et al., the overall incidence of nausea and vomiting after the use of carboprost was significantly less in acupressure group than in ondansetron group and there was no significant difference in the incidence of nausea and vomiting among the two groups when considered individually.
In a systemic analysis of six clinical trials, the effectiveness of intraoperative P6 stimulation was found to be inconclusive. In five of these six trials, the P6 acupoint was stimulated via an elastic acupressure band with a plastic button. The researchers believe that inconclusive results may be due to the inadvertent displacement of the device by the patients and the band was not being applied to the actual P6 point. In our study, due care was taken to avoid displacement of the device; this may be a reason for the difference in the results.
| Conclusion|| |
Our study showed that P6 stimulation is as effective as conventional i.v. antiemetic ondansetron in the prevention of carboprost-induced nausea and vomiting.
We sincerely thank Dr. Vidya Shree Kalapura Mathada for helping in preparing manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hema KR, Johnson R. Techniques for performing caesarean section. Best Pract Res Clin Obstet Gynaecol 2001;15:17-47.
Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, et al
. Global causes of maternal death: A WHO systematic analysis. Lancet Glob Health 2014;2:323-33.
Begley CM, Gyte GM, Devane D, McGuire W, Weeks A. Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev 2011:CD007412. doi: 10.1002/14651858.CD007412.pub3.
Buttino L Jr, Garite TJ. The use of 15 methyl F2 alpha prostaglandin (Prostin 15M) for the control of postpartum hemorrhage. Am J Perinatol 1986;3:241-3.
Abouleish EI, Rashid S, Haque S, Giezentanner A, Joynton P, Chuang AZ. Ondansetron versus placebo for the control of nausea and vomiting during Caesarean section under spinal anaesthesia. Anaesthesia 1999;54:479-82.
Wieland GB, von der Laage D, Tolksdorf W. Acupressure in the prevention of postoperative nausea and vomiting. Anaesthesist 1993;44:221-6.
Balki M, Carvalho JC. Intraoperative nausea and vomiting during cesarean section under regional anesthesia. Int J Obstet Anesth 2005;14:230-41.
Hooper VD. SAMBA consensus guidelines for the management of postoperative nausea and vomiting: An executive summary for perianesthesia nurses. J Perianesth Nurs 2015;30:377-82.
Allen TK, Habib AS. P6 stimulation for the prevention of nausea and vomiting associated with cesarean delivery under neuraxial anesthesia: A systematic review of randomized controlled trials. Anesth Analg 2008;107:1308-12.
Gliedt JA, Daniels CJ, Wuollet A. Narrative review of perioperative acupuncture for clinicians. JAMS 2015;8:264-9.
Samuels N. Acupuncture for nausea: How does it work? Harefuah 2003;142:297-300.
Levin D, Cohen S, Mellender S, Shah U, Kang P, Mohiuddin A, et al
. Effectiveness of P6 stimulation for reduction of nausea and vomiting during caesarean section under combined spinal-epidural anaesthesia: A randomised controlled trial. Turk J Anaesthesiol Reanim 2019;47:120-7.
Wani SA, Chadha M, Prakash A, Aggarwal S. A comparison of ondansetron and P6 point acupuncture stimulation in prevention of carboprost induced nausea and vomiting in patients undergoing cesarean section under subarachnoid block. Anaesth Pain Intensive Care 2015;19:24-17.
[Figure 1], [Figure 2]
[Table 1], [Table 2]