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Cost effectiveness of non-pharmacological management of postoperative nausea and vomitingin low risk
- Anwar K Rashid (29 June 2005)
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Anwar K Rashid, Senior House Officer (Anaesthetics) East Surrey Hospital ,Redhill
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Dear editor, I congratulate Dr Rowbotham for drawing our attention towards the necessity of a multi-modal approach including non-pharmacological techniques for the prophylaxis and treatment of the “ big little problem” of postoperative nausea and vomiting (PONV). Although routine administration of prophylactic anti-emetics [1] to low risk patients is of questionable benefit, higher risk patient populations clearly benefit from the use of prophylactic approaches to minimize the uncomfortable symptoms of nausea and vomiting. In a systematic review of postoperative vomiting after day-case surgery, McQuay and Moore [2] concluded that none of the currently available antiemetic drugs is sufficiently effective to be used for routine prophylaxis. Combination therapy appears to be efficacious, but the side effects also increase with that. That brings us to the use of non-pharmacological techniques for both prevention and treatment of nausea and vomiting. Although there is no proven mechanism to explain the efficacy of acupressure stimulation at P6 point, in reducing nausea and vomiting, it has been previously demonstrated that acupoint stimulation using a transcutaneous electrical nerve stimulation device can increase levels of endogenous opioids within the central nervous system. Elaborating on the increased levels of endogenous opioids, I would like to point out that the pain relief associated with endogenous opioids might contribute to the relief of PONV. Anderson and Krohg [3] demonstrated that the relief of pain led to the resolution of emetic symptoms in over 80% of patients experiencing both pain and nausea in the early postoperative period. This needs further investigation in future studies. It is not clear from the studies quoted in the review whether it will be of any benefit to administer P6 Acupuncture point stimulation to patients with low risk of developing PONV. Acupuncture injections and electro-acupuncture appears to have a less favorable side-effect profile and might be time consuming and requiring specially trained personnel when compared to acupressure or acustimulation due to the invasive nature of both the procedures. Future studies will have to look into cost effectiveness of these non- pharmacological techniques when compared to combination antiemetic therapy and prophylaxis and their efficacy in patients with lower risk to develop PONV. Yours truly, Anwar Dr Anwar K Rashid Senior House Officer (Anaesthetics) East Surrey Hospital, Redhill. RH1 5RH. E-mail: anwarkrashid@hotmail.com References: 1. Fisher DM. Surrogate outcomes: meaningful not! Anesthesiology 1999; 90:355-356 2. McQuay HJ, Moore RA. Postoperative analgesia and vomiting, with special reference to day-case surgery: a systematic review. Health Technol Assess 1998; 2:1-236 3. Anderson R, Krohg K. Pain as a major cause of postoperative nausea. Can Anaesth Soc J 1976; 23:366-369 Conflict of Interest:None declared |
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