Non-Pharmacologic Interventions for Post-operative Nausea and Vomiting (PONV)

Post-operative nausea and vomiting (PONV) is a common problem affecting about 30% of patients. It is a significant cause of patient dissatisfaction and discomfort and has been the subject of extensive outcomes research. Existing pharmaceutical interventions to minimize these outcomes can be associated with clinically relevant side effects, including sedation and potentially life-threatening arrhythmias. Considering these complications, it is worth exploring non-pharmacologic interventions for PONV.

One widely researched alternative to antiemetic drugs for PONV is PC6 stimulation. The PC6 acupuncture point is located on the anterior forearm between the tendons of the palmaris longus and flexor carpi radialis and is targeted in acupuncture therapy to relieve anxiety, stress, and nausea. A Cochrane review synthesizing existing data on PC6 therapy for relieving nausea found moderate evidence to support similar anti-nausea effects compared to commonly used anti-nausea medications like metoclopramide, ondansetron, and cyclizine (Hofman et al., 2015).

However, evidence demonstrating superiority over placebo has been less consistent (Vickers, 1996). This approach is further complicated by the specificity required to target the PC6 point, as it lies in an area of the body often used for IV access or placement of a patient identification bracelet. It is worth considering that the studies included in the Cochrane review were fairly heterogeneous and compared PC6 therapy to several different antiemetics across separate trials, which may limit the overall strength of pooled conclusions (Hofman et al., 2015). In addition, physician adherence to an intervention without a clearly established physiological mechanism may be limited, especially given the aforementioned heterogeneity of data.

Inhaled isopropyl alcohol rescue is another non-pharmacologic strategy for preventing PONV that has received some research interest. In a randomized controlled trial comparing inhaled isopropyl alcohol to saline placebo among emergency department patients, inhaled isopropyl alcohol was associated with a clinically significant decrease in median self-reported nausea levels from 6 out of 10 to 3 out of 10 (Beadle et al., 2016). Furthermore, this effect was achieved within 10 minutes, which suggests potential utility as a rapid adjunctive intervention in acute settings. Isopropyl alcohol is merely one available option within the broader category of aromatherapeutic interventions for treating nausea; other popular alternatives include lavender, citrus, and peppermint.

Nevertheless, the existing research on isopropyl alcohol and other aromatherapy in treating nausea and vomiting is methodologically limited and inconsistent. While the aforementioned study seemed promising, the emergency department setting limits the ability to extrapolate findings directly to PONV (Beadle et al., 2016). Furthermore, studies that document self-reported patient responses can be subjective and vulnerable to bias, particularly in small cohorts. Although other small randomized controlled trials report similar improvements in nausea or vomiting with inhaled isopropyl alcohol over placebo (Anderson & Gross, 2004), the current literature does not consistently support its use as a replacement for established antiemetic therapies.

Overall, reported reductions in nausea vary across studies. Nevertheless, non-pharmacologic therapy may provide a promising adjunct for patients experiencing PONV in the aftermath of surgery, particularly for those who prefer not to add another medication to their postoperative regimen or for patients who do not experience complete relief with standard antiemetics (Lee & Done, 1999). Furthermore, several of the aforementioned studies cited high patient satisfaction with care regardless of achieved clinical effect, highlighting the importance of autonomy in improving patient satisfaction. For these reasons, it is worth considering non-pharmacologic alternatives to antiemetic therapies as complementary options rather than solitary treatments.

References

1. Anderson, L. A., & Gross, J. B. (2004). Aromatherapy with Peppermint, Isopropyl Alcohol, or Placebo is Equally Effective in Relieving Postoperative Nausea. Journal of PeriAnesthesia Nursing, 19(1), 29-35. DOI: 10.1016/j.jopan.2003.11.001
2. Beadle, K. L., et al. (2016). Isopropyl Alcohol Nasal Inhalation for Nausea in the Emergency Department: A Randomized Controlled Trial. Annals of Emergency Medicine, 68(1), 1-9. DOI: 10.1016/j.annemergmed.2015.09.031
3. Hofman, D., et al. (2015). P6 acupoint stimulation for preventing postoperative nausea and vomiting. Cochrane Database of Systematic Reviews, (7). DOI: 10.1002/14651858.CD003281.pub4
4. Lee, A., & Done, M. L. (1999). The use of nonpharmacological techniques to prevent postoperative nausea and vomiting: A meta-analysis. Anesthesia & Analgesia, 88(6), 1362-1369. DOI: 10.1016/s0952-8180(99)00035-5
5. Vickers, A. J. (1996). Can acupuncture have specific effects on health? A systematic review of acupuncture antiemesis trials. Journal of Royal Society of Medicine. DOI: 10.1046/j.1365-2648.1997.t01-15-00999.x