Effect of acupressure application to the P6 acupoint before laparoscopic cholecystectomy on postoperative nausea-vomiting: A randomized controlled clinical study

Accepted Manuscript Title: Effect of acupressure application to the P6 acupoint before laparoscopic cholecystectomy on postoperative nausea-vomiting: A randomized controlled clinical study Authors: Sibel Yilmaz Sahin, Emine ˙Iyigun, ¨ Mehmet Fatih Can PII: DOI: Reference:

S0020-7489(18)30175-5 https://doi.org/10.1016/j.ijnurstu.2018.07.011 NS 3189

To appear in: Received date: Revised date: Accepted date:

22-1-2018 12-7-2018 16-7-2018

Please cite this article as: Yilmaz Sahin S, ˙Iyigun ¨ E, Can MF, Effect of acupressure application to the P6 acupoint before laparoscopic cholecystectomy on postoperative nausea-vomiting: A randomized controlled clinical study, International Journal of Nursing Studies (2018), https://doi.org/10.1016/j.ijnurstu.2018.07.011 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

EFFECT OF ACUPRESSURE APPLICATION TO THE P6 ACUPOINT BEFORE LAPAROSCOPIC CHOLECYSTECTOMY

ON

POSTOPERATIVE

NAUSEA-VOMITING:

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RANDOMIZED

CONTROLLED CLINICAL STUDY

Sibel YILMAZ SAHİN, RN, PhD, Aisst. Prof. - Corresponding author University of Health Sciences, Gulhane Faculty of Nursing,

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Department of Surgical Nursing, TURKEY e-mail: [email protected] Emine İYİGÜN, RN, PhD, Prof.

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University of Health Sciences, Gulhane Faculty of Nursing, Department of Surgical Nursing, TURKEY e-mail: [email protected]

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Mehmet Fatih CAN MD, Assoc. Prof.

Department of General Surgery, ANKARA/ TURKEY

Corresponding author:

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e-mail: [email protected]

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University of Health Sciences, Gulhane Training and Research Hospital,

Address;

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Sibel YILMAZ ŞAHİN, RN, PhD, Aisst. Prof.

General Tevfik Saglam Caddesi

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University of Health Sciences, Gulhane Faculty of Nursing Department of Surgical Nursing, 06010 Ankara /TURKEY e-mail: [email protected]

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Phone : +903123043918

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Abstract Background: Nausea and vomiting are common postoperative complications that occur within the first 24 hours in adults. Clinical practice guidelines and a Cochrane review recommend stimulating the P6 acupoint to prevent or reduce postoperative nausea and vomiting. However, there are currently no standards and optimal timing is not known.

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Objectives: The purpose of this study was to evaluate the effect of acupressure application on the P6 acupoint, using acupressure wristbands, in the prevention of postoperative nausea and vomiting and the antiemetic drug requirement in patients who had high postoperative nausea and vomiting risk related

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to laparoscopic cholecystectomy. Design: This was a longitudinal, randomized controlled clinical study.

Settings: The study was conducted in the general surgery department of a training and research

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hospital (105 beds), from March 2015 to March 2016.

groups of 37, using a block randomization method.

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Participants: A total of 111 female patients who underwent laparoscopic surgery were divided into three

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Methods: Training on acupressure wristband use was provided to the intervention group and an

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acupressure wristband with a plastic cap was placed at the P6 acupoint. A wristband with the same appearance as the acupressure wristband, but without a cap, was used in the placebo group. No intervention was used in the control group. The wristband was placed approximately one hour before

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the surgery and removed six hours after the surgery in both the intervention and placebo groups. The data were collected at the 2nd, 6th, and 24th postoperative hours.

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Results: The application of the acupressure wristband to the P6 acupoint in patients who underwent laparoscopic cholecystectomy was found to be more effective in decreasing the severity of nausea at the 2nd postoperative hour and the nausea incidence at 2-6 hours, postoperatively, when compared to

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the placebo group (p <0.05). However, there was no statistically significant difference between the intervention group and the control group. Therefore, acupressure application to the P6 acupoint was not found to be clinically effective in decreasing postoperative vomiting, antiemetic drug requirement, and in decreasing pain, anxiety, or the need for analgesic drugs (p> 0.05).

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Conclusions: We did not find the stimulation of the P6 acupoint with an acupressure wristband to be clinically effective in reducing postoperative nausea and vomiting or antiemetic drug requirement in patients who underwent laparoscopic cholecystectomy. Keywords: acupressure; cholecystectomy, laparoscopic; perioperative care; perioperative nursing; postoperative nausea and vomiting.

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Contribution of the Paper What is already known about the topic? 

One of the most common complications in adults who undergo a surgical intervention with the use of various general anaesthesia methods is nausea and vomiting. Patients undergoing laparoscopic cholecystectomy have a high risk of developing postoperative nausea and



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vomiting. Clinical practice guidelines recommend prophylaxis with two or more interventions in patients at high risk for postoperative nausea and vomiting. The stimulation of the P6 (Neiguan) acupoint



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is one of the interventions used for postoperative nausea and vomiting prophylaxis.

Nurses are recommended to use acupressure at the P6 acupoint as one of the complementary methods used for postoperative nausea and vomiting prophylaxis. However, the transfer of this

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method to clinical practice has not been widely achieved.

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What this paper adds

Placing an acupressure wristband on the P6 acupoint of female patients who have undergone

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laparoscopic cholecystectomy from approximately one hour before surgery until the 6th

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postoperative hour was not found to be effective in preventing postoperative nausea and vomiting or decreasing the need for antiemetic drugs. In patients at high risk for postoperative nausea and vomiting, such as after laparoscopic

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cholecystectomy, application of acupressure along with routine antiemetic prophylaxis did not show an effect in preventing postoperative nausea and vomiting when compared to the standard

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1. Introduction

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clinical practice used in the control group.

Surgical intervention, whether large or small, always carries a risk of postoperative

complications. One of the most common complications, after pain, in the first 24 postoperative hours in adults is nausea and vomiting (Izveren and Dal, 2011). In general, 30% of patients experience postoperative nausea and vomiting, and the rate can increase to 70% after laparoscopic procedures

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(Ko-iam et al., 2017; Odom-Forren and Wesmiller, 2017). Postoperative nausea and vomiting is a stressful and uncomfortable condition for patients. It can cause respiratory tract obstruction, dehydration and electrolyte imbalance, haemorrhage, hematoma formation, pain at the wound site, and delayed recovery and healing (Cheong et al., 2013; Le and Gan, 2010; Holmér Pettersson and Wengström, 2012; Naik et al., 2017; Odom-Forren and Wesmiller, 2017). It also increases the need for nursing care and negatively affects patient satisfaction by causing decreased life quality and delayed discharge (Le and Gan, 2010; Lewthwaite, 2009).

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Laparoscopic cholecystectomy, one of the most common procedures performed in general surgery, is preferred to laparotomy due to the lower risk of infection and postoperative pain, shorter surgery time and recovery duration, and better aesthetic results (Brenner and Kautz, 2015; Ece et al., 2017; Graham, 2008). However, the risk for postoperative nausea and vomiting is high in laparoscopic cholecystectomy patients due to many factors related to the surgical procedure, patient, and the type of anaesthesia used. Biliary diseases are more common in women, and the risk of postoperative nausea and vomiting is two to three times greater in women than in men (Collins, 2011; Meffert et al., 2016). Stimulation of the vagal nerve during laparoscopic abdominal surgery can cause postoperative nausea

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and vomiting. Additionally, the procedure is typically performed under general anaesthesia using inhaled anaesthetics, which is associated with an increased need for nursing care due to postoperative nausea and vomiting (Collins, 2011; Gun et al., 2014).

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Many guidelines have been published for postoperative nausea and vomiting management

(ASPAN, 2006; Gun et al., 2014; Gun et al., 2007; Gun et al., 2003; Lewthwaite, 2009; Hooper, 2015; McCracken et al., 2008). The Society for Ambulatory Anesthesia guidelines, which present the strongest and most reliable evidence, (Gun et al., 2014; Smith and Ruth-Sahd, 2016), recommend that

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postoperative nausea and vomiting risk factors of the patients be determined before surgery; they also recommend that prophylaxis be provided to high-risk patients using two or more interventions. One

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recommended intervention is the stimulation of the P6 acupoint (Gun et al. 2014). There is also a

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Cochrane review that indicates stimulating P6 acupoint is an effective method in preventing postoperative nausea and vomiting (Lee et al., 2015). Since modern antiemetics and optimized

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anaesthetic techniques and drugs are not sufficient in preventing postoperative nausea and vomiting, the use of complementary methods for prophylaxis has become widespread and accepted (Nilsson et

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al., 2015). Acupressure is a non-invasive, complementary method that can be used to stimulate the P6 acupoint. The Nursing Intervention Classification describes acupressure as the application of stable, constant pressure to certain points of the body in order to decrease pain, provide relaxation, and prevent

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nausea. (Butcher et al., 2013). The application of pressure to certain points on the body has been practiced for hundreds of years and is generally accepted as a safe, low cost, and non-invasive

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treatment method with little or no side effects (Noll et al., 2017; Song et al., 2015). The American Society of PeriAnesthesia Nurses recommends that patients with a high

postoperative nausea and vomiting risk, or those who are concerned about these complications, be instructed to get an over-the-counter acupressure stimulation device and learn to use it before the operation (ASPAN, 2006). However, there is little evidence to support this recommendation, there are

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no established standards regarding the methods to apply acupressure and there are still ongoing questions about when acupressure should be applied and how long it should be continued. The relevant studies conducted by nurses are limited, and further studies with high evidence value are required for acupressure to be transferred into the nursing practice. We believe new studies in this field will help decrease postoperative complications, increase patient satisfaction, and improve the development of nursing knowledge by enabling the use of evidence-based practices.

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1.1. Study Aim The primary objective of this study was to evaluate the effect of acupressure application on the P6 acupoint (using acupressure wristbands) in preventing postoperative nausea and vomiting and antiemetic drug requirement in female patients who underwent laparoscopic cholecystectomy and were at high risk for these complications.

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The secondary objective of the study was to evaluate the effect of acupressure application (using acupressure wristbands on the P6 acupoint) on reducing postoperative pain severity, analgesic

drug requirement, and anxiety. We also wanted to collect patient feedback regarding this P6 stimulation

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method. 2. Materials and Methods 2.1. Study Design

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The study was conducted as a longitudinal, randomized controlled clinical study. A noninterventional control group was used to reveal the difference between acupressure application to the

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P6 acupoint and routine clinical practice. Given that acupressure application has been reported to have

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placebo effects (Zhang et al., 2014), we used a placebo group to investigate the actual effect of acupressure use and we designed a three-armed study. This study was registered at the

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ClinicalTrials.gov Protocol Registration and Result System (Protocol ID Number NCT02510183.)

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2.2. Study Setting

The study was conducted at the general surgery department of a training and research hospital from March 2015 to March 2016. This department had 105 beds and a postoperative care unit with 15

2.3. Participants

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beds.

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The study was conducted on women scheduled to undergo laparoscopic cholecystectomy at

this hospital from March 2015 to March 2016. This study only included patients who were admitted the day before the surgery, given that same-day admission patients have very limited time to receive

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preoperative surgical information and prepare for the surgery. 2.3.1. Inclusion Criteria This study included female patients aged 18-70 years, with an American Society of Anesthesiologists score of 1 or 2, who were scheduled to undergo elective laparoscopic cholecystectomy with a diagnosis of cholelithiasis or chronic cholecystitis; additionally, these patients were admitted to the hospital the day before the surgery and volunteered to participate in the study.

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2.3.2. Exclusion Criteria This study excluded patients who underwent emergency surgery for acute cholecystitis, underwent a surgical procedure (e.g., Nissen fundoplication or herniorrhaphy) in addition to cholecystectomy at the same session, were admitted to the hospital in the morning of the surgery, did not volunteer to participate in the study, and had an American Society of Anesthesiologists score other than 1 or 2, had upper extremity loss; those who had previous experience with acupressure wristbands or had an open wound, scar tissue, or infection at the acupressure application area were also excluded.

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2.3.3. Randomization

The patients were divided into three groups. The first group was the intervention group, and an

acupressure wristband was placed one hour before the surgery. The second group was the placebo

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group, and a wristband with the same appearance as the acupressure wristband, but without an acupressure application cap, was placed one hour before the surgery. The third group was the control group and no study intervention took place. In the clinic where the study was conducted, laparoscopic cholecystectomy could be performed on more than one patient during the same day. Therefore, we

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decided that the randomization should be performed on the day of the surgery to prevent the different

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groups of patients from influencing each other in the post-anaesthesia and postoperative care units. A block randomization list for three groups was obtained by using a web-based randomization system.

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Using this method, each patient was randomly assign to a group based on the day of admission.

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2.4. Intervention

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2.4.1. Day Before Surgery

All patients who presented to the hospital were evaluated in terms of their compliance with the study criteria, and the appropriate patients were invited to participate. We determined the American

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Society of Anesthesiologists classification and the Apfel risk score of each patient who agreed to participate in the study. The State Anxiety Inventory was administered, and the answers recorded on the data collection form. Prior to surgery, all patients received education about the preoperative,

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intraoperative, and postoperative process. This included information about preoperative fasting, wearing antithrombotic socks on the morning of surgery, premedication procedures, anaesthesia type, fluid restriction after the operation, and the importance of early mobilization according to routine clinical practice etc. The patients were also informed that they would be visited by the investigator before the

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surgery and at the 2nd, 6th, and 24th postoperative hours and asked questions regarding their nausea and vomiting. 2.4.2. Day of Surgery 2.4.2.1. One Hour Before Surgery

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The patients in the intervention group were visited one hour before the surgery and given training on how to use the acupressure wristband. The acupressure wristband was then placed on the P6 acupoint at each wrist. The acupressure wristband is an elastic band with a plastic cap and it applies continuous pressure when placed on the P6 acupoint on the wrist. The P6 acupoint is anatomically located between the flexor carpi radialis and the palmaris longus tendons, at a distance of three transversely placed fingers (the index, middle, and ring fingers) to the wrist inner fold. The P6 acupoint in the general acupressure region was found by a push-pull motion at the end of the index finger. The verbal and non-verbal messages of the patient were also used in determining the point (Butcher et al.,

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2013; Hofmann et al., 2016). The identified point was marked with a pen (with the permission of the patient) to ensure that wristband placement remained at the correct location. The patients were

instructed to reposition the band with the plastic cap on the premarked P6 acupoint if the wristband

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became dislodged. The acupressure wristband was then placed so that the plastic cap would stay on the P6 acupoint; the same procedure was repeated for the other wrist. The patients were asked to wear

the wristbands continuously on both wrists after surgery until they were removed at the end of the 6th postoperative hour. The patients were given a training brochure prepared according to the literature.

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The patients in the placebo group were visited one hour before the surgery, and a placebo wristband with the same appearance as the acupressure wristband, but with no acupressure application

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cap, was placed on both wrists. The placebo wristband location was determined using the same method

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applied in the interventional group at the level of P6 acupoint. The patients were asked to wear their wristbands on both wrists continuously from about one hour before the surgery to the end of the 6th

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postoperative hour when they were removed.

The investigator observed the patients for slippage of wristbands. Additionally, intraoperative

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and postoperative staff were informed about the study and asked not to move acupressure or placebo wristbands during the surgical procedure.

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Patients in the control group were only visited one hour before the surgery and no intervention was used in this group other than routine clinical care.

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2.4.2.2. Second and Sixth Postoperative Hour: The nausea and pain severity of the patients in all three groups were evaluated at the 2nd and 6th postoperative hours. The patients were asked whether they experienced nausea and/or vomiting at 0-2 and 2-6 hours after surgery. The amount antiemetic and analgesic drugs administered during these times were recorded from the nurse observation form.

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2.4.3. First Postoperative Day All patients were visited at the 24th postoperative hour and the nausea and pain severity was

evaluated. The patients were asked whether they experienced nausea and/or vomiting at 6-24 hours and the amount of antiemetic and analgesic drugs administered during this period were recorded from the nurse observation form. All patients were asked to re-answer the State Anxiety Inventory.

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Additionally, the patients in the intervention and placebo groups were asked to evaluate their satisfaction with the therapy. 2.4.4. Surgical Technique A standard 4-port technique was used in all patients. Ten-millimetre trocars were placed in the umbilicus and epigastrium, and two 5-mm trocars were placed in the right hypochondrium. A pneumoperitoneum was then created with carbon dioxide and the surgery was started. The dissection was performed with the help of a monopolar dissector, scissors, and an L hook. The cystic canal and

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the cystic artery were clipped and cut; the specimen was placed into the endobag at the end of the dissection and removed through the epigastrium port. The fascia gap in the epigastrium was closed

using prolene suture, while no fascia closure was performed in the other ports. No local or topical

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anaesthetic agent was administered to the peritoneal surfaces, sac bed, or incision areas. 2.4.5. Anaesthesia Protocol

All patients were premedicated with midazolam 2 mg intravenously, 5 minutes before the

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surgery. Anaesthesia induction was performed with propofol 2-2.5 mg/kg, rocuronium bromide 0.6 mg/kg, and fentanyl 2 mcg/kg, intravenously, with simultaneous use of 100% O2 at 4 l/min, followed by

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tracheal intubation. All patients were administered 0.2 mg/kg rocuronium bromide intravenously every

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30 minutes, and IV remifentanyl was adjusted to 0.25 mcg/kg/min. After endotracheal intubation, the inhalation agent desflurane was set at 6% concentration. All patients were administered intraoperative

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ranitidine HCl 20 mg and metoclopramide 10 mg. After the last skin suture was placed, the inhalation agent and remifentanyl infusion were terminated. Once spontaneous respiration started, the muscle relaxant agent was antagonized (using neostigmine 0.05 mg/kg and atropine 0.015 mg/kg), and the

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patient was extubated when spontaneous respiration and adequate muscle strength were present. Four milligrams of ondansetron was administered intravenously as a rescue treatment for patients with

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nausea and vomiting after surgery. 2.5. Measurement instruments

The data were collected from a face-to-face interview technique using the data collection form

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prepared by the investigator. Information on age, body mass index, presence of migraine, smoking status, history of nausea and vomiting, American Society of Anesthesiologists classification, and Apfel risk score were included in the data collection form. Patients were asked whether they had experienced nausea and vomiting, and a 10-point numeric rating scale was used to determine the severity of nausea

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and pain. The times the investigator placed and removed the wristband in the intervention and placebo groups was recorded. Information regarding the anaesthesia start and end times and the administration of antiemetic and analgesic drugs after surgery was recorded from the patient charts. Data were also retrieved from the State Anxiety Inventory and a form containing patient feedback regarding acupressure wristband therapy. 2.5.1. American Society of Anesthesiologists Classification

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The American Society of Anesthesiologists Classification is an evaluation system developed to determine the risks of anaesthesia by classifying the preoperative physical condition of each patient using a number between 1 and 6. The letter “E” is added after the classification number when emergency surgical intervention is required. A classification of 1 represents a healthy person who does not have a disease or systemic problem other than a surgical pathology that does not cause a systemic disorder. A classification of 2 represents a person with a mild systemic disorder due to a cause requiring surgical intervention or another disease. A classification of 6 is used to represent patients who have developed brain death and are considered suitable candidates for organ donation. This classification system is

postoperative monitoring required (Daabiss, 2011; Fitz-Henry, 2011).

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2.5.2. Apfel Risk Score

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used to help determine the anaesthesia technique to be used during surgery and the level of

The Apfel Risk Score was used to identify patients with a postoperative nausea and vomiting risk. It consists of four factors: female sex, not smoking, a history of postoperative nausea or vomiting/motion sickness, and postoperative opioid use. Each factor is assigned 1 point, with the Apfel

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Risk Score ranging from 0 and 4; an Apfel risk score of 0-1 is low risk, 2 moderate risk, and 3-4 high risk. The postoperative nausea and vomiting risk, based on each score, was determined to be: 0 = 10%,

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1 = 20%, 2 = 40%, 3 = 60%, and 4 = 80% (ASPAN, 2006; Gun et al., 2014).

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2.5.3. State Anxiety Inventory

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The State Anxiety Inventory is a Likert-type scale consisting of 20 questions. It identifies how an individual feels at a particular time and under certain conditions. It is widely used to measure preoperative anxiety. When administering the State Anxiety Inventory, the patient is asked to choose

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from the options of never, sometimes, frequently, and completely in response to the feelings, thoughts or behaviours expressed to each item. The total score ranges between 20 and 80, with a score of 0-19 indicating no anxiety, 20-39 indicating mild anxiety, 40-59 indicating moderate anxiety, and 60 or more

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indicating a high anxiety (Bilgin et al., 2012).

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2.5.4. Numeric Rating Scale

Patients were asked to use a numeric rating scale to assess the levels of pain and nausea they

experienced during the 2nd, 6th and 24th postoperative hours. This scale consisted of numeric expressions ranging from 0 (I have no pain) to 10 (worst pain imaginable) (Hawker et al., 2011). It was

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used to evaluate the severity of nausea and pain as expressed by the patient by converting it into an objective number. 2.5.5. Satisfaction Evaluation Form The 'Satisfaction Evaluation Form' was prepared by the investigator, following a literature search, to receive feedback from patients in the intervention and placebo groups regarding the wristband implementation (Lee et al., 2015; Nunley et al., 2008; Turgut et al., 2007). The patients were asked to

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choose yes or no in response to the questions. They were also asked to make a numerical evaluation between 0 (none) and 10 (a lot) to determine their satisfaction with the wristbands in preventing postoperative nausea and vomiting, in addition to the sensation of pain and discomfort created by the wristband. 2.6. Sample Size Calculation Patients scheduled to undergo elective laparoscopic cholecystectomy in the clinic where the study was conducted, constituted the centre of the study. The sample size was calculated with G* power

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3.1.7. Assuming that the difference between the numeric rating scale values of the 3 groups would be

compared with one-way variance analysis, using a presumed alpha error of 5%, a power of 80%, and

an effect value of 0.3, it was calculated that 111 patients would be required with 37 in each group for

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the result to be clinically significant. 2.7. Blinding

The principal investigator of the study received training on the detection of acupressure points

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and pressure application. The study conduct and data collection were carried out by this investigator and the investigators were not blinded. All patients were informed about the purpose of the study and a

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copy of the patient information form was provided. The patients were informed that the volunteers were

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divided into three groups and one of two different wristbands could be randomly placed or there might be no intervention. Patients in the placebo group were not aware of their group. Statistical analysis was

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performed by a faculty staff member outside of the research team, who was blinded to the study.

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2.8. Data Collection

The collection of the data began the day before surgery and ended the day after surgery.

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2.8.1. Day Before Surgery

Patient demographic information was collected the day before surgery. The American Society of Anesthesiologists classification status and the Apfel Risk Score were determined, and the patients

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were asked to answer the State Anxiety Inventory and to evaluate their preoperative anxiety. 2.8.2. Day of Surgery

On the day of surgery, we documented the reported anaesthesia time and the duration of

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wristband use for each patient. Patients were interviewed at the 2nd and 6th postoperative hour to evaluate nausea and pain severity and the presence of nausea and vomiting; information regarding the administration of antiemetic and analgesic drugs at 0-2 and 2-6 hours were obtained. 2.8.3. First Postoperative Day The patient was visited at 24 hours after the surgery, and we collected information regarding the severity of nausea and pain, presence of nausea and vomiting and amount of antiemetic and

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analgesic drugs administered between 6-24 hours after surgery. The State Anxiety Inventory was administered again to evaluate the postoperative anxiety of the patients. Patients in the intervention and placebo groups were asked to provide feedback regarding the use of acupressure therapy, and the study was terminated. 2.9. Data Analyses The data obtained from this study were evaluated using the IBM SPSS Statistics for Windows (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0, Armonk, NY: IBM Corp.) 22.0

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software program. After the data were transferred to the database, data clearance was performed. Test

of normality of the continuous variables (age, BMI, duration of operation, wristband use, and anaesthesia, numeric ratio scale, etc.) was evaluated using the Kolmogorov-Smirnov test. The data

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obtained are presented as mean ± standard deviation (𝑋̅ ± SD) for the continuous variables and number (n) and percentage (%) for the categorical variables. The categorical variables did not comply with a normal distribution. The chi-square test was used for the comparison of the rate of categorical (absence of migraine, ASA Status, non-smokers, absence of nausea, vomiting, antiemetics, etc.) variables. The

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Kruskal-Wallis test was used to investigate the difference between the three groups for the continuous variables that did not comply with a normal distribution. One way ANOVA was used for the variable that

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complied with a normal distribution. Mann-Whitney post hoc tests with the Bonferroni correction were

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performed to determine the significant differences between groups. A p<0.05 value was accepted as

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statistically significant.

Assessed for eligibility (n=202) Excluded (n= 76)

(n=84)

Not meeting inclusion criteria (n= 68) Declined to participate (n=6) Receiving chemotherapy treatment (n=1) Using acupressure wristband previously

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Enrollment

Day Before Surgery (n=126) Preoperative data collection American Society of Anesthesiologists Score; Apfel Risk Score Administration of State Anxiety Inventory Giving preoperative patient education

Randomized (n=126)

Allocation

Applying acupressure wristband Training on acupressure wristband use Altı Patient visit

Applying placebo wristband dakikalık Patient visit yürüme test

uygulanması

Preoperatif döneme ait Surgery (n=126) verilerin toplanması (n=84)

Control Group (n=42)* Patient visit

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Intervention Group (n=43)*

Solunum fonksiyonlarının değerlendirmesi Placebo Group (n=41)*

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 İlk Değerlendirmenin yapılması

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Postoperative data collection Postoperative first day Administrating: State Anxiety Inventory Satisfaction Evaluation Form

Postoperative data collection Postoperative first day Administrating: State Anxiety Inventory

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Postoperative data collection Postoperative first day Administrating: State Anxiety Inventory Satisfaction Evaluation Form

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verilerin Control Group (n=42) Intervention Group (n=43) Sosyodemografik Placebo Group (n=41) Day of surgery Day oftoplanması surgery Day of surgery

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Follow-up

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Lost to follow-up (n=6) Laparotomy (n=5) Too tight of acupressure wristbands (n=1)

Analysis (n=37) Excluded (n=0)

Lost to follow-up (n= 4) Laparotomy (n=4)

Lost to follow-up (n=5) Laparotomy (n=5)

Analysis Analysis (n=37) Excluded (n=0)

Analysis (n=37) Excluded (n=0)

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*Because some patients were excluded from the study, we added six patients to the intervention group, four to the placebo group, and five to the control group, and a second randomization was performed at the end of the study to reach the targeted sample size.

Fig. 1. Study Flow Diagram 2.10. Ethical consideration

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Prior to beginning the study, verbal and written permission was obtained from the Head of the General Surgery Department. Written permission and approval was also obtained from the local clinical research ethics committee (approval number: 50687469-1491-48-15/SEK.1677). The patients were provided information regarding the study. Written consent was obtained and a copy of the form was given to the patients. 3. Results This study was conducted between March 2015 and March 2016 using female patients who

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underwent laparoscopic cholecystectomy. Of the 202 patients evaluated for suitability, 76 did not meet the inclusion criteria; these reasons included rejecting the application, receiving chemotherapy, and

having previous experience using an acupressure wristband, etc. We also excluded six patients from

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the intervention group, four from the placebo group, and five from the control group. To reach the

targeted sample size, we added six patients to the intervention group, four to the placebo group, and five to the control group, with a second randomization at the end. The study was conducted on 126 patients during the preoperative period and completed with a total of 111 patients (37 in each study

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group) (Fig. 1.).

BMI (kg/m )

49.95±10.35

45.95±12.62

48.86±10.89

0.438

28.77±5.49

29.06±5.32

26.85±4.59

0.131

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2

Intervention Group(n=37) Placebo Group (n=37)

Control Group (n=37)

n (%)

n (%)

n (%)

P

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Age (years)

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Table 1. The Descriptive Characteristics of The Patients and Risk Factors for Postoperative Nausea and Vomiting Intervention Group Placebo Group Control Group P (𝑋̅±SD) (𝑋̅±SD) (𝑋̅±SD)

6 (16.2)

8 (21.6)

4 (10.8)

0.451

ASA status

23 (62.2)

26 (70.3)

27 (73)

0.581

Non-smokers 29 (78.4) Earlier PONV / Motion 22 (59.5) sickness Postoperative Opioids 30 (81.1)

35 (94.6)

27 (73)

0.042c

20 (54.1)

16 (43.2)

0.364

31 (83.8)

25 (67.57)

0.205

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Migraine

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Statistical analyses with Kruskal Wallis Test for continuous variables and Chi Square Test for categorical variables. c Bonferroni Correction; difference between placebo and control groups 𝑋̅, Mean; SD, Standard Deviation; BMI; Body Mass Index; ASA, American Society of Anesthesiologists; PONV, postoperative nausea and vomiting

Patient demographic information and the distribution of the groups according to the

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postoperative nausea and vomiting risk factors are presented in Table 1. The majority of the patients were found to be aged adults and most of the patients were overweight. The differences between the groups in terms of age, BMI, migraine presence, American Society of Anesthesiologists classification status, history of nausea and vomiting, and postoperative opioid use were not statistically significant (p>0.05). The difference between the groups in terms of smoking status was statistically significant and,

13

further analysis revealed that this difference was noted between the placebo group and the control group (p<0.05). The difference between the groups in terms of the Apfel risk score was found not to be statistically significant, and patients in all three groups had a high degree of risk (p>0.05). The anaesthesia and surgical procedure duration are independent factors identifying postoperative nausea and vomiting risk in patients undergoing surgery. There was no statistically significant difference between the three groups in terms of anaesthesia duration (p>0.05). In addition,

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there was no statistically significant difference between the intervention and placebo groups in terms of wristband use duration (p>0.05).

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Table 2. Comparison of the Nausea Severity, Incidence of Nausea, Vomiting, and Rescue Antiemetic Between Groups Intervention Group Placebo Group Control Group p (𝑋̅±SD) (𝑋̅±SD) (𝑋̅±SD) Nausea Severity

1.43±1.85

0.016 d

1.43±2.44

0.235e

0.41±0.93

0.695e

0.97±1.69

2.38±2.35

6th hour

1.14±2.35

1.70±2.39

24th hour

0.68±1.53

0.46±1.14

Intervention Group (n=37)

Placebo Group (n=37)

Control Group (n=37)

n (%)

n (%)

n (%)

p

23(62.2)

17(45.9)

0.064

23(62,2)

13(35,1)

0.036 a,c

A

N

U

2nd hour

13(35.1)

2-6 hours

14(37,8)

6-24 hours Postoperative vomiting 0-2 hours

18(48.6)

16(43.2)

19(51.4)

0.777

2(5.4)

5(13.5)

-

0.055

2-6 hours

3(8,1)

-

0.077

5(13.5)

4(10.8)

0.600

PT

ED

M

Postoperative nausea 0-2 hours

5(13,5)

0-2 hours

8(21.6)

17(45.9)

4(10.8)

0.002c

2-6 hours

3(8,1)

5(13,5)

1(2,7)

0.234

6-24 hours

7(18.9)

10(27)

10(27)

0.644

6-24 hours

7(18.9)

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Rescue antiemetic

A

Statistical analyses with one way ANOVA and Kruskal Wallis Test for continuous variables and Chi Square Test for the categorical variables. d Statistical analyses with one way ANOVA; difference between intervention and placebo groups; e Statistical analyses with Kruskal Wallis Test a Bonferroni correction; difference between intervention and placebo groups; c Bonferroni correction; difference between placebo and control group

Postoperative nausea and vomiting experiences of the patients and the distribution of the patients receiving antiemetics by group is presented in Table 2. There was no statistically significant difference between the groups in terms of vomiting presence at 0-2, 2-6, or 6-24 postoperative hours

14

(p>0.05). There was a statistically significant difference between the groups in terms of the nausea severity scores, nausea presence, and antiemetic drug requirement at the postoperative period (p<0.05). On further analysis, it was found that nausea severity in the intervention group was less than that in the placebo groups at the 2nd postoperative hour; the presence of nausea was greater in the placebo group than in the intervention group and control group at 2-6 postoperative hours and the antiemetic drug requirement was less in the control group than in the placebo group at 0-2 postoperative hours.

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3.3. Other Results The differences between the groups in terms of postoperative pain severity, analgesic drug requirement, and anxiety, were not statistically significant (p>0.05). It was possible for 75.5% of the

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patients to detect the P6 acupoint and apply pressure themselves following training. The patients in the intervention and placebo groups were generally satisfied with the procedure (97.3%; 81.1%). The satisfaction score given by the patients was 8.46 ± 2.02 points in the intervention group and 8.16 ± 1.77 in the placebo group. The patients also stated they would wear the wristbands again (94.6%; 86.5%)

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and recommend them to their relatives (97.3%; 91.9%). The reported rates of discomfort (0.81 ± 1.84; 0.86 ± 2.35) and pain (0.27 ± 1.33; 0.11 ± 0.46) for the intervention and placebo wristbands were very

N

low. The satisfaction of the intervention group was higher than that of the placebo group, but there was

A

no statistically significant difference between the groups in terms of patient feedback (p>0.05).

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4. Discussion

This study evaluated the effect of P6 acupoint stimulation, using an acupressure wristband, on

ED

postoperative nausea and vomiting and the need for antiemetic drugs in female patients who undergo laparoscopic cholecystectomy. The acupressure application was statistically more effective than placebo in terms of decreasing the severity and number of episodes of nausea. However, there was no

PT

statistically significant difference between the intervention and control groups. Acupressure use was, therefore, not found to be clinically effective in decreasing vomiting and the need for antiemetic drugs in

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this study.

Nausea is described as an unpleasant subjective feeling indicating imminent vomiting. However,

nausea is not always followed by vomiting, and it is often difficult to evaluate (Abraham, 2008). We found a statistically significant difference between the three groups in terms of nausea severity at the 2nd hour,

A

which were derived from the lower scores of the intervention group than the placebo group; however, acupressure therapy was not effective in preventing nausea during the 0-2 postoperative hour period. The postoperative nausea and vomiting seen during this period is due to the effects of the anaesthetics. In the first 6 postoperative hours, the patients are still under the effect of prophylactic antiemetic drugs administered during the surgery, depending on the half-life of the drugs (Lv et. al., 2013). While acupressure use was not effective in terms of nausea and severity scores at the 6th postoperative hour, it resulted in less nausea at the 2-6 postoperative hours when compared to the placebo group. However,

15

acupressure was not thought to be clinically effective in preventing nausea, as there was no statistically significant difference between the control and intervention groups at 0-2 and 2-6 hours. Doran and Halm investigated the effect of acupressure applied with an acupressure wristband, electroacupuncture wristband, and finger pressure on decreasing postoperative nausea and vomiting, and they found it to be effective in their systematic review (Doran and Halm, 2010). Alkaissi et al. (2002) found the use of an acupressure wristband in patients who underwent gynaecologic surgery to be effective in preventing nausea when compared to the placebo and control groups. However, in the advanced analysis, acupressure was effective in preventing nausea in patients who underwent vaginal surgery but not a

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laparoscopic procedure (Alkaissi et al., 2002). Zhang et al. reported an unclear effect in their metaanalysis on the effect of an acupressure wristband on postoperative complications (Zhang et al., 2014). Similar to the results of our study, there are also other studies in the literature reporting that acupressure

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is not effective in decreasing postoperative nausea when compared to the placebo group (Adib-

Hajbaghery et al., 2013; Kwon et al., 2016; Majholm and Møller, 2011; Nilsson et al., 2015; Samad et al., 2003). Although no difference has been reported between invasive and non-invasive acupuncture in the literature, Cheong et al. reported that in terms of postoperative nausea and vomiting prevention efficacy, acupuncture came first, electroacupuncture second, and acupressure third in their meta-

N

U

analysis (Cheong et. al., 2013).

Although nausea is a subjective finding related to the verbal expression of the patient,

A

subsequent vomiting is an objective finding. The application of acupressure to the P6 point at 0-2 and 2-6 postoperative hours was not found to be effective in preventing vomiting in our study. Other studies

M

reporting that acupressure is not effective in decreasing vomiting, which is consistent with our study results (Nilsson et al., 2015; Samad et al., 2003). In contrast, some studies reported acupressure to be

ED

effective in decreasing vomiting when compared to placebo (Adib-Hajbaghery et al., 2013; Agarwal et al., 2002; Zhang et al., 2014). These results indicate that further studies on the effect of acupressure on

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vomiting are needed.

The need for antiemetic drugs in the postoperative period is an objective indicator of nausea and vomiting. Decreasing this need also decreases drug side-effects, drug interactions, and cost. We

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did not find using acupressure to be effective in decreasing the need for antiemetic drugs when compared to the placebo and control groups at 0-2 and 2-6 postoperative hours in our study. Similarly, other studies found that the acupressure wristband not to decrease the need for postoperative antiemetic drugs in patients who had undergone craniotomy (Nilsson et. al., 2015) or breast surgery

A

(Majholm and Møller, 2011). A Cochrane review performed by Lee et al. reported no difference in terms of postoperative nausea and vomiting and antiemetic drug requirement between the use of acupuncture therapy and antiemetic drugs (Lee et al., 2015). Doran and Halm found acupressure wristbands to be as effective as antiemetic drugs in their literature review on the effect of acupressure use on postoperative nausea and vomiting (Doran and Halm, 2010). These two studies are referring to the antiemetic effect of acupressure. Agraval et al. reported acupressure wristband use at 0-6 hours to be as effective as ondansetron in decreasing the postoperative antiemetic drug requirement. Clinical

16

practice guidelines recommend acupressure to be used at least as one of two interventions in patients with moderate to high risk (ASPAN, 2006; Gun et al., 2014; Hooper, 2015). Lee et al. reported that there is a need for evidence-based studies that examine the effect of stimulating the P6 acupoint together with antiemetic drugs vs antiemetic drugs alone. (Lee et al., 2015). Prophylactic antiemetic drugs are administered to patients during surgery, and a second antiemetic drug is administered in case nausea and vomiting occur after surgery in the clinic where the study was conducted. The acupressure wristband was used in addition to the prophylactic antiemetic drug administered during the surgery, and it was expected to decrease the patients’ postoperative antiemetic requirement in our study. However,

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the expected difference between the intervention group and the control group was not observed. We, therefore, did not find a beneficial effect of the acupressure wristband when compared with routine

clinical practice on decreasing the need for antiemetic drugs after laparoscopic cholecystectomy.

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Considering our results and the information in the literature, further clinical studies on the effect of the acupressure wristband in decreasing the postoperative need for antiemetic drugs is required.

Studies on the effect of acupressure on the P6 acupoint in preventing chemotherapy-related nausea and vomiting have reported that the effect continues even after the application is discontinued

U

(Kwon et al., 2016). We removed the acupressure wristbands at the 6th postoperative hour and

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performed another evaluation at the 24th postoperative hour. The various groups were found to be similar in terms of nausea and vomiting rates and the need for antiemetics in the 6-24-hour period, and

A

the effect, therefore, did not continue once the application to the P6 point was discontinued. Other studies similarly reported the effect of acupressure in preventing postoperative nausea and vomiting

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does not continue after the wristbands were removed (Agarwal et al., 2002; Gilbert et al., 2016; Kwon et al., 2016). However, there are other studies reporting that acupressure is effective in preventing

ED

nausea and vomiting during the 0-24-hour period following surgery (Cheong et al., 2013; Turgut et al., 2007). We did not find acupressure to be effective after the wristband use was discontinued. The current literature data suggesting that acupressure is effective for up to 24 hours, indicates that the effect may

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be prolonged if the applications lasts longer; this could be evaluated in future studies.

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4.1. Clinical implication

Evidence-based guidelines have revealed valid and reliable treatment regimens for many

diseases and complications. However, the transfer of these guidelines to practical use by physicians and nurses has not been at the desired level. These guidelines recommend the use of acupressure as a complementary method to prevent postoperative nausea and vomiting. However, there is no

A

established standard application method. In this study, we applied acupressure with a wristband, based on the guidelines of Society for Ambulatory Anesthesia and The American Society of PeriAnesthesia Nurses, to prevent postoperative nausea and vomiting in female patients who had undergone laparoscopic cholecystectomy. Taking both our findings and other studies into account, we did not find the stimulation of the P6 acupoint one hour before surgery until the 6th postoperative hour with the acupressure wristband to be clinically effective in decreasing postoperative nausea and vomiting or

17

postoperative antiemetic requirement in these patients. We believe that further research in identifying the effect of acupressure in decreasing postoperative nausea and vomiting and postoperative antiemetic requirement is needed. It would be beneficial to investigate the use of different acupressure methods while using a non-interventional control group and to continue the acupressure application for longer period, perhaps starting on the night prior to the surgery or before anaesthesia. 4.2. Limitations Our study had some limitations. This study was conducted on female patients who had preoperative

admission

procedures

and

were

about

to

undergo

laparoscopic

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completed

cholecystectomy at the general surgery department of a hospital. The results are therefore limited to the

sample in which the study was conducted and cannot be generalized to all patients undergoing surgery.

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Because male patients were not included, our results are not valid for the entire adult population. We also used an acupressure wristband for the acupressure, and the results cannot be generalized for all acupressure applications. The pressure applied by the wristbands may have varied according to the patient's wrist circumference, as a standard acupressure wristband was used, and it was not possible

U

to check the pressure applied by the wristbands.

N

Additionaly, the investigator was not blinded to the group allocations or data collection process, and patients were not blinded in the groups, which may have caused bias. Lastly, fifteen patients were

A

added with a second randomization for the study to have adequate power, since the number of surgical

M

procedures converted from laparoscopy to laparotomy could not be predicted; this may have created some bias in the interpretation of the results.

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5. Conclusion

The results relating to the effect of acupressure on preventing postoperative nausea and

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vomiting vary when comparing our study to those reported in the literature. This could be due to the lack of standard methods used to stimulate the P6 acupoint, timing and evaluate the results as related to preventing postoperative nausea and vomiting. The American Society of PeriAnesthesia Nurses

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recommends nurses to consider an over-the-counter acupressure stimulation device and train the patients regarding its use. However, in this study acupressure to the P6 point using an acupressure wristband one hour before surgery until the 6th postoperative hour was not found to be clinically effective in decreasing postoperative nausea and vomiting and the antiemetic drug requirement. We also found

A

acupressure not to be effective in decreasing postoperative pain severity, the need for analgesic drugs, or postoperative anxiety in these patients. Other information Funding

18

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Conflicts of interest No conflict of interest has been declared by the authors. Acknowledgements

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The authors of this study would like to thank all the patients who participated in the research.

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They would also like to thank the nurses and doctors in the research area for their support.

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References

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Abraham, J., 2008. Acupressure and acupuncture in preventing and managing postoperative nausea and vomiting in adults. The Journal of Perioperative Practice. 18(12), 543-551

A

Adib-Hajbaghery, M., Etri, M., Hosseainian, M., Mousavi, M. S., 2013. Pressure to the P6 Acupoint and

M

Post-Appendectomy Pain, Nausea, and Vomiting: A Randomized Clinical Trial. Journal of Caring Sciences. 2(2), 115-122

Agarwal, A., Bose, N., Gaur, A., Singh, U., Gupta, M.K., Singh, D., 2002. Acupressure and ondansetron

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for postoperative nausea and vomiting after laparoscopic cholecystectomy. Can J Anaesth. 49(6), 554560

Alkaissi, A., Evertsson, K., Johnsson, V. A., Ofenbartl, L., Kalman, S., 2002. P6 acupressure may relieve

PT

nausea and vomiting after gynecological surgery: an effectiveness study in 410 women. Canadian Journal of Anesthesia. 49(10), 1034-1039

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American Society of Perianesthesia Nurses PONV/PDNV Strategic Work Team. 2006. ASPAN'S Evidence-Based Clinical Practice Guideline for The Prevention and/or Management of PONV/PDNV. Journal of Perianesthesia Nursing. 21(4), 230-250 Bilgin, T. E., Altun, T., Saylam, B., Erdem, E., 2012. Effects of preoperative information team on postoperative pain and patient satisfaction. Turkish Journal of Urology. 38(2), 91-94.

A

Brenner, P., Kautz, D.D., 2015. Postoperative Care of Patients Undergoing Same-Day Laparoscopic Cholecystectomy. AORN Journal. 102(1), 15-32 Butcher, H.K., Bulechek, G.M., McCloskey Dochterman J.M., Wagner, C., 2013. Nursing Interventions Classification

(NIC).

Sixth

Edition.

Mosby.

138

https://books.google.com.tr/books?hl=tr&lr=&id=ZrjwAwAAQBAJ&oi=fnd&pg=PP1&dq=nursing+acupr

19

essure+nic&ots=6RnuOI8IL4&sig=fkXBfzD2Wi3wJwSexJBAmLUGE2M&redir_esc=y#v=onepage&q= acupressure&f=false] (accessed 25.04.2017) Cheong, K. B., Zhang, J. P., Huang, Y., Zhang, Z. J., 2013. The Effectiveness of Acupuncture in Prevention and Treatment of Postoperative Nausea and Vomiting - A Systematic Review and MetaAnalysis. PLoS ONE. 8(12), e82474, Collins, A. S., 2011. Postoperative nausea and vomiting in adults: implications for critical care. Critical Care Nurse. 31(6), 36-45 Daabiss M., 2011. American Society of Anaesthesiologists physical status classification. Indian J

IP T

Anaesth. 55(2), 111–115. Doran, K., Halm, M. A., 2010. Integrating acupressure to alleviate postoperative nausea and vomiting. American Journal of Critical Care. 19(6), 553-556

SC R

Ece, I., Ozturk, B., Yilmaz, H., Yormaz, S., Şahin, M., 2017. The effect of single incision laparoscopic

cholecystectomy on systemic oxidative stress: a prospective clinical trial. Annals of Surgical Treatment and Research. 92(4), 179-183

Fitz-Henry, J., 2011. The ASA classification and peri-operative risk. The Annals of The Royal College of Surgeons of England. 93(3), 185-187

U

Gan T.J., Meyer T.A., Apfel C.C., Chung, F., Davis, P.J., Habib, A.S., Hooper V.D., Kovac, A.L., Kranke,

N

P., Meyer, T.A., Philip B.K., Samsa, G., Sessler, D.I., Temo, J., Tramer, M.R., Kolk, C.V., Watcha, M., 2007. Society for Ambulatory Anesthesia guidelines for the management of postoperative nausea and

A

vomiting. Anesthesia & Analgesia. 105(6), 1615-1628

M

Gan, T. J., Meyer, T., Apfel, C. C., Chung, F., Davis, P. J., Eubanks, S., Kovac, A., Philip, B.K., Sessler, D.I., Temo, J., Tramèr, M. R., Watcha, M., 2003. Consensus guidelines for managing postoperative nausea and vomiting. Anesthesia & Analgesia. 97(1), 62-71

ED

Gan, T.J., Diemunsch P., Habib A.S,. Kovac, A., Kranke, P., Meyer, T.A., Watcha, M., Chung, F., Angus, S., Apfel, C.C., Bergese, S.D., Candiotti K.A., Chan M.T., Davis P.J., Hooper V.D., LagooDeenadayalan, S., Kranke, P., Nezat, G., Philip B.K., Tramer, M.R., 2014. Consensus guidelines for the

PT

management of postoperative nausea and vomiting, Anesthesia & Analgesia. 118(1), 85-113 Gilbert, R. T., Farish, N., Bergland, E., Conaway, M., Hance, J., Ketcham, S., Letzkus, L., Manz. M.,

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Podgorski, K., Quatrara, B., Ryman, R., Spry Anika 2017. The Use of Short-Term Acupressure to Prevent Long-Term PONV: Was This a Case of Too Little, Too Late?. Journal of PeriAnesthesia Nursing. 32(5), 445-452 Graham L. 2008. Care of patients undergoing laparoscopic cholecystectomy. Nursing Standard. 23(7), 41-48

A

Hawker, G. A., Mian, S., Kendzerska, T., French, M., 2011.Measures of adult pain: Visual analog scale for pain (vas pain), numeric rating scale for pain (nrs pain), mcgill pain questionnaire (mpq), short‐form mcgill pain questionnaire (sf‐mpq), chronic pain grade scale (cpgs), short form‐36 bodily pain scale (sf‐ 36 bps), and measure of intermittent and constant osteoarthritis pain (icoap). Arthritis care & research. 63(S11), S240-S252

20

Hofmann, D., Murray, C., Beck, J., Homann, R., 2016. Acupressure in Management of Postoperative Nausea and Vomiting in High-Risk Ambulatory Surgical Patients. Journal of PeriAnesthesia Nursing. 32(4), 271-278 Holmér Pettersson, P., Wengström, Y., 2012. Acupuncture prior to surgery to minimise postoperative nausea and vomiting: a systematic review. Journal of Clinical Nursing. 21(13‐14), 1799-1805 Hooper, V. D., 2015. SAMBA Consensus Guidelines for the Management of Postoperative Nausea and Vomiting: An Executive Summary for Perianesthesia Nurses. Journal of PeriAnesthesia Nursing. 30(5), 377-382

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Izveren, O.A., Dal, U., 2011. The Early Period Complications in Patients who were Performed Abdominal Surgery Intervention and the Nursing Practices for These Complication. Hacettepe University Faculty of Health Sciences Nursing Journal. 18(2), 036-046.

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Ko-iam, W., Sandhu, T., Paiboonworachat, S., Pongchairerks, P., Chotirosniramit, A., Chotirosniramit, N., Chandacham, K., Jirapongcharoenlap, T., Junrungsee,. S., 2017. Predictive Factors for a Long

Hospital Stay in Patients Undergoing Laparoscopic Cholecystectomy. International Journal of Hepatology. 2017

Kwon, J. H., Shin, Y., Juon, H. S., 2016. Effects of Nei-Guan (P6) Acupressure Wristband: On Nausea,

U

Vomiting, and Retching in Women After Thyroidectomy. Cancer Nursing. 39(1), 61-66

N

Le, T. P., Gan, T. J., 2010. Update on the management of postoperative nausea and vomiting and post discharge nausea and vomiting in ambulatory surgery. Anesthesiology Clinics. 28(2), 225-249

A

Lee, A., Chan, S. K., Fan, L. T., 2015. Stimulation of the wrist acupuncture point PC6 for preventing

M

postoperative nausea and vomiting. Cochrane Database of Systematic Reviews. 11 Lewthwaite, B. J., 2009. What do nurses know about post-operative nausea and vomiting?. MedSurg Nursing. 18(2), 110-113

ED

Lv, J. Q., Feng, R. Z., Li, N., 2013. P6 acupoint stimulation for prevention of postoperative nausea and vomiting in patients undergoing craniotomy: study protocol for a randomized controlled trial. Trials. 14(1), 1-7

PT

Majholm. B., Møller A.M., 2011. Acupressure at acupoint P6 for prevention of postoperative nausea and vomiting: a randomised clinical trial. Eur J Anaesthesiol. 28, 412–419

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McCracken, G., Houston, P., Lefebvre, G., 2008. Guideline for the management of postoperative nausea and vomiting. Journal of Obstetrics and Gynaecology Canada. 30(7), 600-607 Meffert, P. J., Schwittay, M. A., Lerch, M. M., 2016. Risk factor prevalence and their relative influence on fatty liver and gallstone disease: A cross-ethnic study comparing two high-risk popu-lations from Chile and Northeast Germany. Epidemiol Open J. 1(1), 40-52

A

Naik, S., Kujur, S., Debbarma, M., Murthy, M. G., 2017. Comparative study of acupressure wristband versus palonosetron for prophylaxis of postoperative nausea and vomiting in elective laparoscopic cholecystectomy under general anaesthesia. International Journal of Research in Medical Sciences. 5(1), 96-100 Nilsson, I., Karlsson, Å., Lindgren, L., Bergenheim, T., Koskinen, L. O., Nilsson, U., 2015. The efficacy of P6 acupressure with sea-band in reducing postoperative nausea and vomiting in patients undergoing

21

craniotomy: a randomized, double-blinded, placebo-controlled Study. Journal of Neurosurgical Anesthesiology. 27(1), 42-50 Noll, E., Shodhan, S., Madariaga, M. C., Page, C. R., Santangelo, D., Guo, X.,Bizri, E.A.,Pryor, A.D.,Romeiser,J., Bennett-Guerrero, E., 2017. Randomized trial of acupressure to improve patient satisfaction and quality of recovery in hospitalized patients: study protocol for a randomized controlled trial. Trials. 18(1), 110 Nunley, C., Wakim, J., Guinn, C., 2008. The effects of stimulation of acupressure point p6 on postoperative nausea and vomiting: a review of literature. Journal of PeriAnesthesia Nursing. 23(4),

IP T

247-261 Odom-Forren, J., & Wesmiller, S., 2017.Managing Symptoms: Enhancing Patients Self-Management Knowledge and Skills for Surgical Recovery. In Seminars in Oncology Nursing. WB Saunders. 33 (1),

SC R

52-60

Samad, K., Afshan, G., Kamal, R., 2003. Effect of acupressure on postoperative nausea and vomiting in laparoscopic cholecystectomy. Journal-Pakistan Medical Association. 53(2), 68-71

Smith, C. A., Ruth-Sahd, L., 2016. Reducing the incidence of postoperative nausea and vomiting begins with risk screening: an evaluation of the evidence. Journal of PeriAnesthesia Nursing. 31(2), 158-171

U

Song, H. J., Seo, H. J., Lee, H., Son, H., Choi, S. M., Lee, S., 2015. Effect of self-acupressure for

N

symptom management: a systematic review. Complementary therapies in medicine. 23(1), 68-78 Turgut, S., Özalp, G., Dikmen, S., Savli, S., Tuncel, G., Kadiogullari, N., 2007. Acupressure for

A

postoperative nausea and vomiting in gynaecological patients receiving patient-controlled analgesia.

M

European Journal of Anaesthesiology. 24(1), 87-91

Zhang, G. L., Yang, S. Y., Zhu, Z. L., Mu, P. X., 2014. Meta-analysis on postoperative complications of wristband acupoint pressure therapy. Journal of Biological Regulators and Homeostatic Agents. 29(1),

A

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187-193

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