86
Journal of the Royal Society of Medicine Volume 83 February 1990
Postoperative
nausea
is relieved by
acupressure
G Barsoum FRcs
E P Perry Rcs I A Fraser MD FRcs Walsgrave General Hospital, Coventry CV2 2DX
Department of Surgery,
Keywords: acupressure; postoperative nausea
Summary One hundred and sixty-two general surgical patients were prospectively randomized to one of three treatments for postoperative nausea and vomiting: (1) acupressure using elasticated bands containing a plastic button to apply sustained pressure at the P6 (Neiguan) point above the wrist, (2) control dummy bands without the pressure button and (3) antiemetic injections of prochlorperazine with each opiate given and as required. All patients received papaveretum injections as required for pain, and additional prochlorperazine injections were prescribed if nausea was not controlled in groups 1 and 2. The severity of nausea was assessed using a linear analogue scale and was significantly (P=0.002) reduced by acupressure on both days 1 and 2, in comparison to both controls and drug treated patients. The incidence of postoperative vomiting, and the need for unplanned antiemetic injections was also reduced by acupressure but this was not statistically significant. Acupressure can work and should be investigated in other clinical situations. Introduction Postoperative nausea and vomiting are common symptoms in general surgical patients and often ignored. The major causes are anaesthetic agents, paralytic ileus and the injection of opiate analgesics. Antiemetic drugs are frequently prescribed for these symptoms and there is an increasing trend towards their routine use with opiates'. The value of this approach is not established2 and may be an inefficient use of nursing time and hospital funds. Although postoperative nausea may have been reduced by improvements in anaesthetic technique, it remains a significant problem, particularly when opiates are
given3. Acupressure is a variation of acupuncture involving constant pressure on acupuncture points without puncture of the skin. A British product has been marketed (Sea Bands) which comprises bands of elasticated fabric with a small round plastic button inside each, to be born on both wrists. The buttons exert constant pressure on the Neiguan (P6) acupuncture points, located on the anterior surface ofthe wrists three fingers breadth above the distal skin crease of the wrist joint between the tendons of
palmaris longus and flexor carpi radialis. There have been anecdotal reports suggesting benefit from use ofthis device in motion sickness, nausea of pregnancy and cytotoxic chemotherapy. We have chosen to test the effectiveness of acupressure on the nausea and vomiting which commonly follows general surgical operations in a randomized prospective clinical trial, comparing acupressure
to a control group and also to the routine use of conventional antiemetic drugs.
Patients and methods A total of 162 patients aged 18 to 84 were entered into the trial. They were randomized by an envelope system into one of three treatment groups: (1) Acupressure (n=49, 53% males). Sea Bands were applied to both wrists and no antiemetic given unless clinically required later. (2) Controls (n=54, 48% males). Dummy bands (no pressure button) were applied to both wrists and antiemetics given only if clinically required. (3) Antiemetics (n=49, 47% male). Dummy bands were applied to both wrists and prochlorperazine 12.5 mg intramuscularly given with each postoperative opiate injection and when clinically required. Ten patients were later excluded because of language or age difficulty with completing the analogue score (n=4), erroneous premature removal ofbands (n=4), and incomplete follow-up data (n=2). This left 152 in the study distributed as above. All patients wore wrist bands (dummy or Sea Bands), which were applied in the theatre recovery area and patients told that they were wearing bands Table 1. Principal details of the types ofoperations performed and anaesthetic agents used with their distribution between treatment groups
Acupressure Control Antiemetics Operation type Cholecystectomy
Ingainal hernia Breast surgery Varicose veins Anal surgery Upper GI Lower GI Other
Anaesthetic details Premedication Papaveretum
14 9 4 0 1 3 9 9
15 7 7 4 6 3 4 8
18 7 5 2 4 4 3 6
Benzodiazepine None Anaesthetic Propofol Thiopentone Paralysing agent Fentanyl Isofluorane Reversing agents
75% 19% 6%
58% 30% 12%
66% 22% 12%
29% 71% 77% 29% 97% 42%
32% 61% 52% 32% 94% 48%
23% 67% 60% 40% 100% 53%
Total numbers
49
54
49
0141-0768/90/ 020086-04/$02.00/0 © 1990 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 83 February 1990
to try to prevent sickness. Several anaesthetists were involved and, consequently, several types of anaesthetic were used with agents shown in Table 1. Papaveretum was given four hourly as required for postoperative pain relief. If postoperative nausea remained a significant problem in groups 1 and 2, prochlorperazine was prescribed by the on call doctor and this event noted. All bands were worn until discharge from hospital or for seven days if that was sooner. Patients were visited and assessed every day until they were eating normally, when it was assumed that nausea was not a significant problem. Nausea was assessed using a linear analogue scale and a prescribed standard sentence used to communicate this in order to minimize any observer bias: 'Would you please mark on this line how sick you feel at present. At one end is terribly sick and at the other is not sick at all. Mark it anywhere in between, according to how you feel.' Vomiting incidents were noted on an accurate fluid balance chart and the tines to unlimited fluid and food intake recorded. Drugs administered each day were recorded in detail. Statistical analysis Students' t-test or the chi squared test were used to compare groups as appropriate.
Results One hundred and fifty-two patients completed the trial. Details of the operations performed and anaesthetic agents used, including premedications, are given in Table 1. It can be seen that the groups are comparable with regard to the range of operation and anaesthetic agents used. The results of linear analogue nausea scores are illustrated in Figure 1 and summarized in Table 2. Nausea scores were significantly lower in the first two postoperative days in those patients treated by acupressure when compared with both controls and patients having antiemetics (P=0.002). This difference was not present on the third and subsequent postoperative days. Table 3 shows the proportion of patients in each treatment group who received prochlorperazine on each postoperative day. Papaveretum usage was similar in all three groups (73-83% on day 1, 48-59% on day 2 and 30-50% on day 3). It can be seen that the acupressure group received fewer antiemetic 3
2 IL10
z
01I,1 I ,I II Ii 1
2 3 4 Pbstoperative Days * Acupressure O Controls !/9 Antiemetic Drugs
Figure 1. The effect of treatment on nausea. The mean 'Nausea Score', as assessed by linear analogue scale, is shown for patients within each treatment group on each postoperative day, as tabulated in Table 2. P=0.002 for differences between acupressure and the other two treatments on days 1 and 2
Table 2. The effect of treatment on nausea experienced by patients Acupressure Control Antiemetics Day 1 n Day 2 n Day 3 n Day 4 n Day 5 n Day 6 n
1.2 (2.1)* 46 0.9 (2.0)* 38 1.3 (2.8) 27 0.6 (1.0) 19 0.4 (0.6) 11 1.6 (1.9) 6
3.1 (3.5) 47 2.2 (2.5) 39 1.22 27 1.7 (2.6) 18 16 3.3 (3.7) 2.1 (3.1) 6 9 1.1 (1.4) 0.3 (0.2) 4 5
2.4 (2.6) 54 2.2 (2.7) 45 1.1 (1.7) 28 0.9 (1.1)
Results are given for the linear analogue nausea scores as means with standard deviation in parenthesis and numbers of patients in the group on that day (those who were not eating). *P=0.002 for difference to other groups on that day Table 3. The proportion ofpatients in each treatment group who received prochlorperazine injections on each of the first 3 postoperative days
Acupressure Control Antiemetics Day 1 Day 2 Day 3
32% 14% 15%
45% 27% 21%
76% 44% 20%
Table 4. Details of the proportion ofpatients in each treatment group who vomited on each of the first 3 postoperative days, and the mean times to free oral fluids and food Acupressure Controls Antiemetics
Patients vomiting: Day 1 Day 2 Day 3 Days to free oral fluids Days to food
16% 14% 4%
21% 19% 8%
20% 18% 20%
1.2 2.2
1.1 2.0
0.9 1.6
injections, on each postoperative day, than the drug or control group but this difference did not achieve statistical significance. Furthermore, vomiting was recorded in less patients amongst the acupressure group than the control or drug groups, but this difference did not achieve statistical significance. The overall incidence of vomiting on the first 2 postoperative days was 18% (Table 4). All groups required a similar number of days to be able to take both free fluids and food orally. The bands were well tolerated by patients, except for four who reported some local tightness and discomfort. One ofthese experienced carpal tunnel like symptoms and removed the bands. The data from these patients is included in the results.
Discussion We have found that acupressure is effective in reducing the severity and incidence of postoperative nausea, by comparison to controls wearing identical wrist bands without pressure buttons and to patients
87
88
Journal of the Royal Society of Medicine Volume 83 February 1990
having antiemetic injections. Nausea, measured by linear analogue scale, was significantly reduced in the acupressure group (P=0.002) for the first two postoperative days. All three groups were comparable and we believe that the reason for this improvement is the effect of acupressure. It is not surprising that nausea was not completely abolished by acupressure and that vomiting was not significantly reduced, since some postoperative patients suffer paralytic ileus or other complications likely to have marked visceral effects. However, it is clear that acupressure had more than a placebo effect. It is interesting to note no benefit from the routine use of injected antiemetics. Our third patient group received antiemetics with each opiate injection and at other times by request, but suffered no less nausea or vomiting than controls who were given no routine antiemetic drugs. These results do not support the routine prophylactic use of antiemetics with opiates. We would like to stress that a number of different factors can contribute to nausea in the postoperative period - types of anaesthesia, type and duration of surgery, analgesics administered and individual patients' susceptibilities. Although nausea can be a problem after any operation, it is by no means simply related to these factors. They have been mixed in this study, but to similar degrees leaving each group comparable. This is not only inevitable from the nature of work seen in a busy surgical unit, involving many individual surgeons and anaesthetists, but we feel that it is desirable since our study is intended to represent routine clinical practice. Its conclusions are then more relevant to the practice of other surgeons, and may more easily stimulate them to test our findings. Most Western scientific studies on the effects of acupuncture have concerned anaesthesia. Vincent4 and Dundee5 have reported the prevention of postanaesthetic nausea and vomiting by acupuncture. Dundee et al. compared preoperative acupuncture at the Neiguan point with controls not receiving acupuncture, in groups of 25 patients undergoing minor gynaecological surgery5. They reported that nausea and vomiting in the first few hours after surgery occurred less commonly in the acupuncture group. However, Weightman et aL6 in a smaller study where acupuncture was given during anaesthesia failed to demonstrate any therapeutic effect on postoperative nausea and vomiting. Dundee has also reported that electroacupuncture at the Neiguan point is effective in reducing nausea and vomiting after cancer chemotherapy7-9. Part of this study included a randomized comparison within 10 patients of the use of a 'dummy' ineffective acupuncture point, which supported the beneficial effects of acupuncture. We have found a minimal amount of Western literature about acupressure. Fry'0 has reported the use of manual acupressure for 30 seconds before and after general anaesthesia for a wide variety of procedures, and stated that nausea and vomiting were observed less frequently in the immediate postoperative period in the treated group. Dundee compared daily acupressure by manual pressure 4 hourly at the Neiguan and a dummy point in the treatment of morning sickness"" 2. Unfortunately, this was studied by postal questionnaire with almost half of some groups not replying, but there was a lower incidence of nausea and vomiting during acupressure treatment. He has recently reported a study of 31 women
undergoing minor gynaecological surgery'3. Acupressure with Sea Bands was as effective as manual acupuncture in reducing nausea and vomiting but this effect was only marked during the first hour. In our patients, where the stimulus to nausea must be greater, the beneficial effect of acupressure lasted for several days. This difference is difficult to explain. In Dundee's study the incidence of nausea and vomiting was high in the control group and in our study acupressure was applied to both, not one wrist. This study has described a technique which permits continuous acupressure to be extended into the full postoperative period, and used a large number of patients and a quantitative scale of measurement for nausea. There has been a clear effect from acupressure in the reduction of nausea. The Sea Bands allow continuous pressure to be safely and easily applied for a number of days, which is sometimes necessary for this common problem. We have used them placed on each wrist (in contrast to Dundee's studies'2) with the button over the Neiguan point. This applies a constant pressure which obviates the need for repeated stimulation of this point by either the medical practitioner or the patient, which can be a very time consuming and limiting feature of acupuncture. There is little understanding of traditional Chinese medical techniques in the West and a striking paucity of properly constructed investigations into acupuncture9"10. We have shown in a controlled clinical trial that the Sea Bands acupressure reduces postoperative nausea. This technique should be studied more thoroughly in the variety of clinical conditions where nausea is a problem, and considered for routine use on patients undergoing general surgical procedures. Acknowledgment: We would like to acknowledge the cooperation of our surgical colleagues in the incorporation of patients, the help of Mr DAK Woodward in the preparation and Mrs Lynne Rowley in the typing of this manuscript. References 1 Adriani J, Summers FW, Anthony SO. Is the Prophylactic use of antiemetics in surgical patients justified. JAMA
1961;175:666-71 2 Dundee JW, Assaf RAE, Loan WB, Morrison JD. A comparison of the efficacy of cyclizine and perphenazine in reducing the emetic effects of morphine and pethidine. Br J Clin Pharmacol 1975;2:81-5 3 Dundee JW, Moore J, Clarke RSJ. Studies of drugs given before anaesthetic. V. Pethidine 100 mgs alone and with atropine or hyoscine. Br J Anaesth 1964;36:703-10 4 Vincent CA, Richardwn PH. The evaluation of therapeutic acupuncture: concepts and methods. Pain 1986;24:1-13 5 Dundee JW, Chestnutt WN, Ghaly RG, Lynas AGA. Traditional Chinese acupuncture, a potential useful antiemetic? Br Med J 1986;293:583-4 6 Weightman Wm, Zacharias M, Herbison P. Traditional chinese acupuncture as an antiemetic. Br Med J
1987;295:1379-80 7 Dundee JW, Ghaly RG, Fitzpatrick KTJ, Lynch GA, Abram WP. Acupuncture to prevent cisplatin-associated vomiting. Lancet 1987;i:1083 8 Dundee JW, Ghaly RG, Fitzpatrick KTJ, Lynch GA, Abram WP. Optimising antiemesis in cancer chemotherapy. Lancet 1987;i:179 9 Dundee JW, Ghaly RG, Fitzpatrick KTJ. Randomised comparison of the antiemetic effects of metoclopramide and electroacupuncture in cancer chemotherapy. Br J Clin Pharmacol 1988;26:678-9P
Journal of the Royal Society of Medicine Volume 83 February 1990 10 Fry ENS. Acupressure and postoperative vomiting. Anaesthesia 1986:661-2 11 Dundee JW, Sourial FBR, Ghaly RG, Bell PF. P6 acupressure reduces morning sickness. J R Soc Med 1988;81:456-7 12 Dundee JW. Studies with acupuncture/acupressure as an antiemetic. Acupunct Med 1988;5:22-4 13 Bill KM, Dundee JW. Acupressure for postoperative nausea and vomiting. Br J Clin Pharmacol 1988; 26:225P
14 Bernard S, Millman MD. Acupuncture: context and critique. Ann Rev Med 1977;28:223-34 15 Prance SE, Dresser A, Wood C, Fleming J, Aldridge J, Pietroni PC. Research on traditional Chinese acupuncture - science or myth: a review. J R Soc Med 1988;81:588-590
(Accepted 29 March 1989. Correspondence to Mr I A Fraser)
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89
Journal of the Royal Society of Medicine Volume 83 February 1990
Postoperative
nausea
is relieved by
acupressure
G Barsoum FRcs
E P Perry Rcs I A Fraser MD FRcs Walsgrave General Hospital, Coventry CV2 2DX
Department of Surgery,
Keywords: acupressure; postoperative nausea
Summary One hundred and sixty-two general surgical patients were prospectively randomized to one of three treatments for postoperative nausea and vomiting: (1) acupressure using elasticated bands containing a plastic button to apply sustained pressure at the P6 (Neiguan) point above the wrist, (2) control dummy bands without the pressure button and (3) antiemetic injections of prochlorperazine with each opiate given and as required. All patients received papaveretum injections as required for pain, and additional prochlorperazine injections were prescribed if nausea was not controlled in groups 1 and 2. The severity of nausea was assessed using a linear analogue scale and was significantly (P=0.002) reduced by acupressure on both days 1 and 2, in comparison to both controls and drug treated patients. The incidence of postoperative vomiting, and the need for unplanned antiemetic injections was also reduced by acupressure but this was not statistically significant. Acupressure can work and should be investigated in other clinical situations. Introduction Postoperative nausea and vomiting are common symptoms in general surgical patients and often ignored. The major causes are anaesthetic agents, paralytic ileus and the injection of opiate analgesics. Antiemetic drugs are frequently prescribed for these symptoms and there is an increasing trend towards their routine use with opiates'. The value of this approach is not established2 and may be an inefficient use of nursing time and hospital funds. Although postoperative nausea may have been reduced by improvements in anaesthetic technique, it remains a significant problem, particularly when opiates are
given3. Acupressure is a variation of acupuncture involving constant pressure on acupuncture points without puncture of the skin. A British product has been marketed (Sea Bands) which comprises bands of elasticated fabric with a small round plastic button inside each, to be born on both wrists. The buttons exert constant pressure on the Neiguan (P6) acupuncture points, located on the anterior surface ofthe wrists three fingers breadth above the distal skin crease of the wrist joint between the tendons of
palmaris longus and flexor carpi radialis. There have been anecdotal reports suggesting benefit from use ofthis device in motion sickness, nausea of pregnancy and cytotoxic chemotherapy. We have chosen to test the effectiveness of acupressure on the nausea and vomiting which commonly follows general surgical operations in a randomized prospective clinical trial, comparing acupressure
to a control group and also to the routine use of conventional antiemetic drugs.
Patients and methods A total of 162 patients aged 18 to 84 were entered into the trial. They were randomized by an envelope system into one of three treatment groups: (1) Acupressure (n=49, 53% males). Sea Bands were applied to both wrists and no antiemetic given unless clinically required later. (2) Controls (n=54, 48% males). Dummy bands (no pressure button) were applied to both wrists and antiemetics given only if clinically required. (3) Antiemetics (n=49, 47% male). Dummy bands were applied to both wrists and prochlorperazine 12.5 mg intramuscularly given with each postoperative opiate injection and when clinically required. Ten patients were later excluded because of language or age difficulty with completing the analogue score (n=4), erroneous premature removal ofbands (n=4), and incomplete follow-up data (n=2). This left 152 in the study distributed as above. All patients wore wrist bands (dummy or Sea Bands), which were applied in the theatre recovery area and patients told that they were wearing bands Table 1. Principal details of the types ofoperations performed and anaesthetic agents used with their distribution between treatment groups
Acupressure Control Antiemetics Operation type Cholecystectomy
Ingainal hernia Breast surgery Varicose veins Anal surgery Upper GI Lower GI Other
Anaesthetic details Premedication Papaveretum
14 9 4 0 1 3 9 9
15 7 7 4 6 3 4 8
18 7 5 2 4 4 3 6
Benzodiazepine None Anaesthetic Propofol Thiopentone Paralysing agent Fentanyl Isofluorane Reversing agents
75% 19% 6%
58% 30% 12%
66% 22% 12%
29% 71% 77% 29% 97% 42%
32% 61% 52% 32% 94% 48%
23% 67% 60% 40% 100% 53%
Total numbers
49
54
49
0141-0768/90/ 020086-04/$02.00/0 © 1990 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 83 February 1990
to try to prevent sickness. Several anaesthetists were involved and, consequently, several types of anaesthetic were used with agents shown in Table 1. Papaveretum was given four hourly as required for postoperative pain relief. If postoperative nausea remained a significant problem in groups 1 and 2, prochlorperazine was prescribed by the on call doctor and this event noted. All bands were worn until discharge from hospital or for seven days if that was sooner. Patients were visited and assessed every day until they were eating normally, when it was assumed that nausea was not a significant problem. Nausea was assessed using a linear analogue scale and a prescribed standard sentence used to communicate this in order to minimize any observer bias: 'Would you please mark on this line how sick you feel at present. At one end is terribly sick and at the other is not sick at all. Mark it anywhere in between, according to how you feel.' Vomiting incidents were noted on an accurate fluid balance chart and the tines to unlimited fluid and food intake recorded. Drugs administered each day were recorded in detail. Statistical analysis Students' t-test or the chi squared test were used to compare groups as appropriate.
Results One hundred and fifty-two patients completed the trial. Details of the operations performed and anaesthetic agents used, including premedications, are given in Table 1. It can be seen that the groups are comparable with regard to the range of operation and anaesthetic agents used. The results of linear analogue nausea scores are illustrated in Figure 1 and summarized in Table 2. Nausea scores were significantly lower in the first two postoperative days in those patients treated by acupressure when compared with both controls and patients having antiemetics (P=0.002). This difference was not present on the third and subsequent postoperative days. Table 3 shows the proportion of patients in each treatment group who received prochlorperazine on each postoperative day. Papaveretum usage was similar in all three groups (73-83% on day 1, 48-59% on day 2 and 30-50% on day 3). It can be seen that the acupressure group received fewer antiemetic 3
2 IL10
z
01I,1 I ,I II Ii 1
2 3 4 Pbstoperative Days * Acupressure O Controls !/9 Antiemetic Drugs
Figure 1. The effect of treatment on nausea. The mean 'Nausea Score', as assessed by linear analogue scale, is shown for patients within each treatment group on each postoperative day, as tabulated in Table 2. P=0.002 for differences between acupressure and the other two treatments on days 1 and 2
Table 2. The effect of treatment on nausea experienced by patients Acupressure Control Antiemetics Day 1 n Day 2 n Day 3 n Day 4 n Day 5 n Day 6 n
1.2 (2.1)* 46 0.9 (2.0)* 38 1.3 (2.8) 27 0.6 (1.0) 19 0.4 (0.6) 11 1.6 (1.9) 6
3.1 (3.5) 47 2.2 (2.5) 39 1.22 27 1.7 (2.6) 18 16 3.3 (3.7) 2.1 (3.1) 6 9 1.1 (1.4) 0.3 (0.2) 4 5
2.4 (2.6) 54 2.2 (2.7) 45 1.1 (1.7) 28 0.9 (1.1)
Results are given for the linear analogue nausea scores as means with standard deviation in parenthesis and numbers of patients in the group on that day (those who were not eating). *P=0.002 for difference to other groups on that day Table 3. The proportion ofpatients in each treatment group who received prochlorperazine injections on each of the first 3 postoperative days
Acupressure Control Antiemetics Day 1 Day 2 Day 3
32% 14% 15%
45% 27% 21%
76% 44% 20%
Table 4. Details of the proportion ofpatients in each treatment group who vomited on each of the first 3 postoperative days, and the mean times to free oral fluids and food Acupressure Controls Antiemetics
Patients vomiting: Day 1 Day 2 Day 3 Days to free oral fluids Days to food
16% 14% 4%
21% 19% 8%
20% 18% 20%
1.2 2.2
1.1 2.0
0.9 1.6
injections, on each postoperative day, than the drug or control group but this difference did not achieve statistical significance. Furthermore, vomiting was recorded in less patients amongst the acupressure group than the control or drug groups, but this difference did not achieve statistical significance. The overall incidence of vomiting on the first 2 postoperative days was 18% (Table 4). All groups required a similar number of days to be able to take both free fluids and food orally. The bands were well tolerated by patients, except for four who reported some local tightness and discomfort. One ofthese experienced carpal tunnel like symptoms and removed the bands. The data from these patients is included in the results.
Discussion We have found that acupressure is effective in reducing the severity and incidence of postoperative nausea, by comparison to controls wearing identical wrist bands without pressure buttons and to patients
87
88
Journal of the Royal Society of Medicine Volume 83 February 1990
having antiemetic injections. Nausea, measured by linear analogue scale, was significantly reduced in the acupressure group (P=0.002) for the first two postoperative days. All three groups were comparable and we believe that the reason for this improvement is the effect of acupressure. It is not surprising that nausea was not completely abolished by acupressure and that vomiting was not significantly reduced, since some postoperative patients suffer paralytic ileus or other complications likely to have marked visceral effects. However, it is clear that acupressure had more than a placebo effect. It is interesting to note no benefit from the routine use of injected antiemetics. Our third patient group received antiemetics with each opiate injection and at other times by request, but suffered no less nausea or vomiting than controls who were given no routine antiemetic drugs. These results do not support the routine prophylactic use of antiemetics with opiates. We would like to stress that a number of different factors can contribute to nausea in the postoperative period - types of anaesthesia, type and duration of surgery, analgesics administered and individual patients' susceptibilities. Although nausea can be a problem after any operation, it is by no means simply related to these factors. They have been mixed in this study, but to similar degrees leaving each group comparable. This is not only inevitable from the nature of work seen in a busy surgical unit, involving many individual surgeons and anaesthetists, but we feel that it is desirable since our study is intended to represent routine clinical practice. Its conclusions are then more relevant to the practice of other surgeons, and may more easily stimulate them to test our findings. Most Western scientific studies on the effects of acupuncture have concerned anaesthesia. Vincent4 and Dundee5 have reported the prevention of postanaesthetic nausea and vomiting by acupuncture. Dundee et al. compared preoperative acupuncture at the Neiguan point with controls not receiving acupuncture, in groups of 25 patients undergoing minor gynaecological surgery5. They reported that nausea and vomiting in the first few hours after surgery occurred less commonly in the acupuncture group. However, Weightman et aL6 in a smaller study where acupuncture was given during anaesthesia failed to demonstrate any therapeutic effect on postoperative nausea and vomiting. Dundee has also reported that electroacupuncture at the Neiguan point is effective in reducing nausea and vomiting after cancer chemotherapy7-9. Part of this study included a randomized comparison within 10 patients of the use of a 'dummy' ineffective acupuncture point, which supported the beneficial effects of acupuncture. We have found a minimal amount of Western literature about acupressure. Fry'0 has reported the use of manual acupressure for 30 seconds before and after general anaesthesia for a wide variety of procedures, and stated that nausea and vomiting were observed less frequently in the immediate postoperative period in the treated group. Dundee compared daily acupressure by manual pressure 4 hourly at the Neiguan and a dummy point in the treatment of morning sickness"" 2. Unfortunately, this was studied by postal questionnaire with almost half of some groups not replying, but there was a lower incidence of nausea and vomiting during acupressure treatment. He has recently reported a study of 31 women
undergoing minor gynaecological surgery'3. Acupressure with Sea Bands was as effective as manual acupuncture in reducing nausea and vomiting but this effect was only marked during the first hour. In our patients, where the stimulus to nausea must be greater, the beneficial effect of acupressure lasted for several days. This difference is difficult to explain. In Dundee's study the incidence of nausea and vomiting was high in the control group and in our study acupressure was applied to both, not one wrist. This study has described a technique which permits continuous acupressure to be extended into the full postoperative period, and used a large number of patients and a quantitative scale of measurement for nausea. There has been a clear effect from acupressure in the reduction of nausea. The Sea Bands allow continuous pressure to be safely and easily applied for a number of days, which is sometimes necessary for this common problem. We have used them placed on each wrist (in contrast to Dundee's studies'2) with the button over the Neiguan point. This applies a constant pressure which obviates the need for repeated stimulation of this point by either the medical practitioner or the patient, which can be a very time consuming and limiting feature of acupuncture. There is little understanding of traditional Chinese medical techniques in the West and a striking paucity of properly constructed investigations into acupuncture9"10. We have shown in a controlled clinical trial that the Sea Bands acupressure reduces postoperative nausea. This technique should be studied more thoroughly in the variety of clinical conditions where nausea is a problem, and considered for routine use on patients undergoing general surgical procedures. Acknowledgment: We would like to acknowledge the cooperation of our surgical colleagues in the incorporation of patients, the help of Mr DAK Woodward in the preparation and Mrs Lynne Rowley in the typing of this manuscript. References 1 Adriani J, Summers FW, Anthony SO. Is the Prophylactic use of antiemetics in surgical patients justified. JAMA
1961;175:666-71 2 Dundee JW, Assaf RAE, Loan WB, Morrison JD. A comparison of the efficacy of cyclizine and perphenazine in reducing the emetic effects of morphine and pethidine. Br J Clin Pharmacol 1975;2:81-5 3 Dundee JW, Moore J, Clarke RSJ. Studies of drugs given before anaesthetic. V. Pethidine 100 mgs alone and with atropine or hyoscine. Br J Anaesth 1964;36:703-10 4 Vincent CA, Richardwn PH. The evaluation of therapeutic acupuncture: concepts and methods. Pain 1986;24:1-13 5 Dundee JW, Chestnutt WN, Ghaly RG, Lynas AGA. Traditional Chinese acupuncture, a potential useful antiemetic? Br Med J 1986;293:583-4 6 Weightman Wm, Zacharias M, Herbison P. Traditional chinese acupuncture as an antiemetic. Br Med J
1987;295:1379-80 7 Dundee JW, Ghaly RG, Fitzpatrick KTJ, Lynch GA, Abram WP. Acupuncture to prevent cisplatin-associated vomiting. Lancet 1987;i:1083 8 Dundee JW, Ghaly RG, Fitzpatrick KTJ, Lynch GA, Abram WP. Optimising antiemesis in cancer chemotherapy. Lancet 1987;i:179 9 Dundee JW, Ghaly RG, Fitzpatrick KTJ. Randomised comparison of the antiemetic effects of metoclopramide and electroacupuncture in cancer chemotherapy. Br J Clin Pharmacol 1988;26:678-9P
Journal of the Royal Society of Medicine Volume 83 February 1990 10 Fry ENS. Acupressure and postoperative vomiting. Anaesthesia 1986:661-2 11 Dundee JW, Sourial FBR, Ghaly RG, Bell PF. P6 acupressure reduces morning sickness. J R Soc Med 1988;81:456-7 12 Dundee JW. Studies with acupuncture/acupressure as an antiemetic. Acupunct Med 1988;5:22-4 13 Bill KM, Dundee JW. Acupressure for postoperative nausea and vomiting. Br J Clin Pharmacol 1988; 26:225P
14 Bernard S, Millman MD. Acupuncture: context and critique. Ann Rev Med 1977;28:223-34 15 Prance SE, Dresser A, Wood C, Fleming J, Aldridge J, Pietroni PC. Research on traditional Chinese acupuncture - science or myth: a review. J R Soc Med 1988;81:588-590
(Accepted 29 March 1989. Correspondence to Mr I A Fraser)
Forthcoming events
Second Greek/Australian International Medical & Legal Conference 25 May to 1 June 1990, Rhodes, Greece Further details from: Secretariat, ICMS, PO Box 29, Parkville, Victoria, Australia 3052
First Breton Workshop of Autoimmunity 9-10 March 1990, Medical School, Brest, France Call for abstracts: deadline 31 January 1990 Further details from: Professor P Youinou, Immunologie, CHU, BP 824, F 29285 Brest Cedex, France
7th Annual Meeting of the American Society for Bariatric Surgery 7-9 June 1990, Toronto, Ontario, Canada Further details firom: Dr D Deitel, 2238 Dundas Street West, Toronto M6R 3A9 Canada
1990 International Association for the Study of Pain Congress 1-6 April 1990, Adelaide, South Australia Further details from: Loisa E Jones, BS, Executive Officer, ISAP, 909 NE 43rd St., Suite 306, Seattle, WA 98105-6020, USA
XX Congress of the International Society of Internal Medicine 17-21 June 1990, Stockholm, Sweden Further details from: ISIM 90, Congrex, PO Box 5619. S-11486 Stockholm, Sweden, Phone +46-08 32 69 00
First World Symposium on Myalgic Encephalomyelitis (ME) 10-12 April 1990, Cambridge University Further details from: Hazel Moodie, The Nightingale Research Foundation, NCM Ltd, New England House, Ridley Place, Newcastle upon Tyne NEI 8JW (Tel: 091 2221777)
35th General Assembly of the International Union against Venereal Diseases and the Treponematoses: Sexually Transmitted Diseases in the Age of AIDS 11 May 1990, Royal Society of Medicine, London Further details from: Dr R D Mann, The Royal Society of Medicine, 1 Wimpole Street, London WlM 8AE
Advanced Training Program in Biomedical Research Management 17-28 June 1990, Elsinore, Denmark Further details from: Professor Torben Agersnap, Institute of Organization, Copenhagen School of Economics, Blagardsgade 23 B, DK-2200 Copenhagen N, Denmark (Tel: 45 31 37 05 55) Medical Informatics Europe 90: Health Added Value 20-23 August 1990, Scottish Exhibition and Conference Centre, Glasgow Call for papers: deadline 1 December 1989 Further details firom: Congress Secrtarial, Meeting Makers. 50 Richmond Street, Glasgow Gl 1XP
Techniques & Applications of Molecular Biology: a Course for Medical Practitioners 9-12 April 1990, University of Warwick Further details from: Dr Rachel Strachan, Department of Biological Sciences, University of Warwick, Coventry CV4 7AL
East-Coast Conference on Biomechanics 26-28 August 1990 Call for papers: please send one page abstract by 1 February 1990 Further details from: Professor H S Ranu, Department of Biomechanics, Nycom, New York Institute of Technology, Old Westbury, New York 11568, USA
Tenth Instructional Course on Tinnitus and its Management 11 April 1990, Nottingham University Further details from: Mrs J P Willoughby, Course Secretary, MRC Institute of Hearing Research, University of Nottingham, University Park, Nottingham NG7 2RD
10th Congress of the European Association of CranioMaxillo-Facial Surgery 10-14 September 1990, Brussels, Belgium Further details from: Mrs H van Leemputten, 10th Congress EACMFS, rue Joseph Stallaert 28, B-1180 Brussels, Belgium
World Conference on Lung Health 20-24 May 1990, Boston, Massachusetts, USA Deadline for abstracts: 1 November 1989 Further details from: American Lung Association, 1740 Broadway, New York, NY 100194374, USA
4th International Conference on Human Papillomaviruses and Squamous Carcinoma 16-19 September 1990, Chicago, Illinois Further details fiom: Deene Alongi, 111 East Wacker Drive, Suite 600, Chicago, Illinois 60601, USA (Tel: 312 644-6610. Fax: 312 5654658)
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