Randomized trial of acupuncture with antiemetics for reducing postoperative nausea in children
Study type: Single centre RCT from Oregon, USA, of acupuncture in addition to routine antiemetic prophylaxis, for postoperative nausea and vomiting (PONV) in children having adenotonsillectomy.
Inclusion: 3-9 year-old children undergoing day-case tonsillectomy +/- adenoidectomy. Exclusion: History of PONV/motion sickness, on steroids, BMI>35, OSA.
Intervention: Acupuncture needles inserted at pericardium 6 (P6) point (in both wrists) after induction, removed prior to emergence, versus dressings only (sham acupuncture). All patients also received prophylactic dexamethasone and ondansetron. Analgesia given was pre-operative paracetamol, intra-operative morphine 0.04mg/kg, and paracetamol/ibuprofen/oxycodone prn at home.
Primary outcome: Incidence of nausea and vomiting in recovery and postoperative day 1 (POD1). Sample size 161 (86 acupuncture, 75 sham).
Findings: The primary outcome is divided into phases, recovery, and POD1. There is a statistically significant reduction with acupuncture, of PONV in recovery, from 34.7% to 6% (P<.001), but not on POD1, or overall. The difference is due to a reduction in nausea, as vomiting was low in both groups.
Take home message
PONV is a significant issue post tonsillectomy, and as such the study addresses an important question. There is an evidence base for the use of P6 acupuncture for early PONV in adults, and in children compared to no antiemetics, but this is the first study in children using acupuncture in addition to antiemetics. The study was generally well designed, although I am uncertain as to whether splitting the primary outcome into 2 phases was pre-specified. The acupuncture in this study was provided by professional acupuncturists, anaesthetists trained in acupuncture, and anaesthetists specifically trained in P6 needling for the study. Acupuncture in addition to antiemetic prophylaxis may reduce early nausea (not vomiting) according to the results, but by POD1 there is no difference. As the PONV post tonsillectomy is known to be protracted, there may be little benefit in securing the training and resources required for this intervention to become routine practice.
Reviewed by: Dr Claire Furyk