Intervention Review

Stimulation of the wrist acupuncture point PC6 for preventing postoperative nausea and vomiting

  1. Anna Lee*,
  2. Simon KC Chan,
  3. Lawrence TY Fan

Editorial Group: Cochrane Anaesthesia, Critical and Emergency Care Group

Published Online: 2 NOV 2015

Assessed as up-to-date: 31 DEC 2014

DOI: 10.1002/14651858.CD003281.pub4


How to Cite

Lee A, Chan SKC, Fan LTY. Stimulation of the wrist acupuncture point PC6 for preventing postoperative nausea and vomiting. Cochrane Database of Systematic Reviews 2015, Issue 11. Art. No.: CD003281. DOI: 10.1002/14651858.CD003281.pub4.

Author Information

  1. The Chinese University of Hong Kong, Department of Anaesthesia and Intensive Care, Shatin, New Territories, Hong Kong

*Anna Lee, Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong. annalee@cuhk.edu.hk.

Publication History

  1. Publication Status: New search for studies and content updated (conclusions changed)
  2. Published Online: 2 NOV 2015

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. Laienverständliche Zusammenfassung

Background

Postoperative nausea and vomiting (PONV) are common complications following surgery and anaesthesia. Antiemetic drugs are only partially effective in preventing PONV. An alternative approach is to stimulate the PC6 acupoint on the wrist. This is an update of a Cochrane review first published in 2004, updated in 2009 and now in 2015.

Objectives

To determine the effectiveness and safety of PC6 acupoint stimulation with or without antiemetic drug versus sham or antiemetic drug for the prevention of PONV in people undergoing surgery.

Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library, Issue 12, 2014), MEDLINE (January 2008 to December 2014), EMBASE (January 2008 to December 2014), ISI Web of Science (January 2008 to December 2014), World Health Organization Clinical Trials Registry, ClinicalTrials.gov, and reference lists of articles to identify additional studies. We applied no language restrictions.

Selection criteria

All randomized trials of techniques that stimulated the PC6 acupoint compared with sham treatment or drug therapy, or combined PC6 acupoint and drug therapy compared to drug therapy, for the prevention of PONV. Interventions used in these trials included acupuncture, electro-acupuncture, transcutaneous electrical acupoint stimulation, transcutaneous nerve stimulation, laser stimulation, capsicum plaster, acu-stimulation device, and acupressure in people undergoing surgery. Primary outcomes were the incidences of nausea and vomiting after surgery. Secondary outcomes were the need for rescue antiemetic therapy and adverse effects.

Data collection and analysis

Two review authors independently extracted the data and assessed the risk of bias domains for each trial. We used a random-effects model and reported risk ratio (RR) with associated 95% confidence interval (95% CI). We used trial sequential analyses to help provide information on when we had reached firm evidence in cumulative meta-analyses of the primary outcomes, based on a 30% risk ratio reduction in PONV.

Main results

We included 59 trials involving 7667 participants. We rated two trials at low risk of bias in all domains (selection, attrition, reporting, blinding and other). We rated 25 trials at high risk in one or more risk-of-bias domains. Compared with sham treatment, PC6 acupoint stimulation significantly reduced the incidence of nausea (RR 0.68, 95% CI 0.60 to 0.77; 40 trials, 4742 participants), vomiting (RR 0.60, 95% CI 0.51 to 0.71; 45 trials, 5147 participants) and the need for rescue antiemetics (RR 0.64, 95% CI 0.55 to 0.73; 39 trials, 4622 participants). As heterogeneity among trials was substantial and there were study limitations, we rated the quality of evidence as low. Using trial sequential analysis, the required information size and boundary for benefit were reached for both primary outcomes.

PC6 acupoint stimulation was compared with six different types of antiemetic drugs (metoclopramide, cyclizine, prochlorperazine, droperidol. ondansetron and dexamethasone). There was no difference between PC6 acupoint stimulation and antiemetic drugs in the incidence of nausea (RR 0.91, 95% CI 0.75 to 1.10; 14 trials, 1332 participants), vomiting (RR 0.93, 95% CI 0.74 to 1.17; 19 trials, 1708 participants), or the need for rescue antiemetics (RR 0.87, 95% CI 0.65 to 1.16; 9 trials, 895 participants). We rated the quality of evidence as moderate, due to the study limitations. Using trial sequential analyses, the futility boundary was crossed before the required information size was surpassed for both primary outcomes.

Compared to antiemetic drugs, the combination of PC6 acupoint stimulation and antiemetic therapy reduced the incidence of vomiting (RR 0.56, 95% CI 0.35 to 0.91; 9 trials, 687 participants) but not nausea (RR 0.79, 95% CI 0.55 to 1.13; 8 trials, 642 participants). We rated the quality of evidence as very low, due to substantial heterogeneity among trials, study limitations and imprecision. Using trial sequential analysis, none of the boundaries for benefit, harm or futility were crossed for PONV. The need for rescue antiemetic was lower in the combination PC6 acupoint stimulation and antiemetic group than the antiemetic group (RR 0.61, 95% CI 0.44 to 0.86; 5 trials, 419 participants).

The side effects associated with PC6 acupoint stimulation were minor, transient and self-limiting (e.g. skin irritation, blistering, redness and pain) in 14 trials. Publication bias was not apparent in the contour-enhanced funnel plots.

Authors' conclusions

There is low-quality evidence supporting the use of PC6 acupoint stimulation over sham. Compared to the last update in 2009, no further sham comparison trials are needed. We found that there is moderate-quality evidence showing no difference between PC6 acupoint stimulation and antiemetic drugs to prevent PONV. Further PC6 acupoint stimulation versus antiemetic trials are futile in showing a significant difference, which is a new finding in this update. There is inconclusive evidence supporting the use of a combined strategy of PC6 acupoint stimulation and antiemetic drug over drug prophylaxis, and further high-quality trials are needed.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. Laienverständliche Zusammenfassung

Wrist PC6 acupuncture point stimulation to prevent nausea and vomiting after surgery

Review question

Does a review of the evidence support the use of wrist PC6 acupuncture point stimulation (PC6 acupoint) as effective in reducing nausea and vomiting after surgery (PONV), compared to sham (dummy acupoint stimulation) or antiemetics (drugs that relieve nausea and vomiting) in people undergoing surgery? This review updates the evidence published in 2009, and is current to December 2014.

Background

Nausea and vomiting are two of the most common complications (up to 80%) after anaesthesia and surgery. Antiemetics are only partially effective and may cause adverse effects, like sedation and headache. Stimulating a PC6 acupoint, an alternative method, has been reported to reduce PONV with few serious side effects.

Study characteristics

We found 59 relevant studies, conducted between 1986 and 2015, involving 7667 participants undergoing elective surgery. Seven of the trials were conducted in 727 children. The PC6 acupoint stimulation varied from invasive techniques, such as traditional acupuncture needles, to noninvasive techniques, such as acupressure wristbands. PC6 acupoint stimulation was compared with six different types of antiemetic drugs (metoclopramide, cyclizine, prochlorperazine, droperidol. ondansetron and dexamethasone).

Key findings and quality of evidence

Effects of PC6 acupoint stimulation versus sham on PONV

We found a moderate-size effect in children and adults, although there were concerns about study limitations and unexplained variation in the effects. Further studies with sham comparisons are not necessary to confirm this beneficial effect.

Effects of PC6 acupoint stimulation versus antiemetic on PONV

We found no difference in the incidence of PONV. We rated the quality of this evidence as moderate, due to study limitations. Further studies are unlikely to show a difference.

Effects of combining PC6 acupoint stimulation and antiemetic versus antiemetic on PONV

We found a moderate-size effect on postoperative vomiting but not on postoperative nausea. However, there were concerns about study limitations, unexplained variation in effects between studies, and an insufficient number of studies. Further high-quality research on combinations of PC6 acupoint stimulation and antiemetics are needed to reduce uncertainties about this effect on PONV.

Overall, the side effects related to PC6 acupoint stimulation were minor, transient and self-limiting (e.g. skin irritation, blistering, redness and pain) in 14 studies.

Conclusion

To prevent PONV, the effect of PC6 acupoint stimulation is comparable to antiemetics.

 

Laienverständliche Zusammenfassung

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. Laienverständliche Zusammenfassung

Stimulation des Akupunkturpunkts PC6 am Handgelenk, um Übelkeit und Erbrechen nach Operationen vorzubeugen

Fragestellung

Unterstützt ein Review der Evidenz die Wirksamkeit der Stimulation des Akupunkturpunkts PC6 am Handgelenk, um postoperativer Übelkeit und Erbrechen (PONV, Englisch: postoperative nausea and vomiting) entgegenzuwirken, im Vergleich zur Scheinakupunktur (Stimulation falscher Akupunkturpunkte) oder zur Verabreichung von Antiemetika (Medikamente zur Unterdrückung von Übelkeit und Erbrechen) bei Menschen, die sich einer Operation unterziehen müssen? In diesem Review wird die Evidenz aus dem Jahr 2009 aktualisiert und auf den Stand von Dezember 2014 gebracht.

Hintergrund

Übelkeit und Erbrechen sind zwei der häufigsten Komplikationen (bis zu 80 %) nach einer Narkose im Zuge einer Operation. Antiemetika wirken nur teilweise und können unerwünschte Wirkungen verursachen, wie Sedierung (Dämpfung des zentralen Nervensystems) und Kopfschmerz. Berichten zufolge ist die Stimulierung des Akupunkturpunkts PC6 eine alternative Methode zur Reduzierung von PONV mit nur wenigen schweren Nebenwirkungen.

Studienmerkmale

Wir fanden 56 relevante Studien, die zwischen 1986 und 2015 durchgeführt wurden, mit 7667 Teilnehmern, die sich einer elektiven (geplanten) Operation unterzogen. In 7 der Studien wurden 727 Kinder untersucht. Die Stimulation des Akupunkturpunkts PC6 wurde auf unterschiedliche Weise durchgeführt, auf invasive Weise, beispielsweise mit traditionellen Akupunkturnadeln, oder auf nicht-invasive Weise, beispielsweise mit Akupressurbändern. Die Stimulation des Akupunkturpunkts PC6 wurde mit sechs verschiedenen Antiemetika verglichen (Metoclopramid, Cyclizin, Prochlorperazin, Droperidol, Ondansetron und Dexamethason).

Hauptergebnisse und Qualität der Evidenz

Wirkung der Stimulation des Akupunkturpunkts PC6 im Vergleich zur Scheinakupunktur auf PONV

Wir stellten eine moderate Wirkung bei Kindern und Erwachsenen fest, obwohl wir Einschränkungen bei den Studien sahen sowie nicht erklärte Abweichungen bei der Wirkung. Weitere Studien mit Vergleichen zur Scheinakupunktur sind nicht notwendig, um diese positive Wirkung zu bestätigen.

Wirkung der Stimulation des Akupunkturpunkts PC6 im Vergleich zu Antiemetika auf PONV

Wir konnten keinen Unterschied in Bezug auf das Auftreten von PONV feststellen. Wir erachteten die Qualität dieser Evidenz als moderat, da wir Einschränkungen bei den Studien erkannten. Von weiteren Studien ist kein anderes Ergebnis zu erwarten.

Wirkung einer Kombination aus der Stimulation des Akupunkturpunkts PC6 mit einer Verabreichung von Antiemetika im Vergleich zu Antiemetika auf PONV

Wir stellten eine moderate Wirkung auf postoperatives Erbrechen fest, jedoch nicht auf postoperative Übelkeit. Wir sahen jedoch Einschränkungen der Studien sowie nicht erklärte Abweichungen in der Wirkung unter den Studien und erachteten die Zahl der Studien als nicht ausreichend. Weitere hochwertige Forschung zur Kombination der Stimulation des Akupunkturpunkts PC6 mit der Verabreichung von Antiemetika ist notwendig, um Zweifel bezüglich dieser Wirkung auf PONV zu mindern.

Insgesamt waren die in 14 Studien angegebenen Nebenwirkungen, die auf die Stimulation des Akupunkturpunkts PC6 zurückzuführen waren, leicht, vorübergehend und selbstbegrenzend (z. B. Hautreizung, Bläschenbildung, Rötung und Schmerz).

Schlussfolgerung

Die Wirkung der Stimulation des Akupunkturpunkts PC6 zur Vorbeugung von PONV ist vergleichbar mit der Wirkung von Antiemetika.

Anmerkungen zur Übersetzung

I. Noack, freigegeben durch Cochrane Schweiz.