Stimulation of the wrist acupuncture point PC6 for preventing postoperative nausea and vomiting.
Stimulation of the wrist acupuncture point PC6 for preventing postoperative nausea and vomiting.
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DOI：
10.1002/14651858.cd003281.pub4
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发表时间：
2015-11-02
期刊：
影响因子：
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通讯作者：
Fan LT
中科院分区：
文献类型：
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作者：
Lee A;Chan SK;Fan LT
术后恶心和呕吐（PONV）是手术和麻醉后常见的并发症。止吐药对预防PONV仅部分有效。另一种方法是刺激手腕上的PC6穴位。这是对2004年首次发表的科克伦综述的更新，2009年更新，现在是2015年。确定PC6穴位刺激加或不加止吐药与假手术或止吐药相比预防手术患者PONV的有效性和安全性。我们检索了科克伦对照试验中心注册库（CENTRAL）（科克伦图书馆，2014年第12期）、MEDLINE（2008年1月至2014年12月）、EMBASE（2008年1月至2014年12月）、ISI Web of Science（2008年1月至2014年12月）、世界卫生组织临床试验注册库（ClinicalTrials.gov）和文献参考列表，以识别其他研究。我们没有语言限制。刺激PC6穴位与假治疗或药物治疗相比，或PC6穴位和药物治疗联合治疗与药物治疗相比，用于预防PONV的所有随机试验。这些试验中使用的干预措施包括针灸、电针、经皮穴位电刺激、经皮神经刺激、激光刺激、辣椒膏、针灸刺激装置和接受手术的人的穴位按压。主要结局为术后恶心和呕吐的发生率。次要结局是需要补救止吐治疗和不良反应。两名综述作者独立提取数据，并评估每个试验的偏倚风险。我们使用随机效应模型，并报告了风险比（RR）及其95%置信区间（95%CI）。我们使用试验序贯分析来帮助提供关于我们在主要结局的累积荟萃分析中何时达到可靠证据的信息，基于PONV风险比降低30%。我们纳入了59项试验，涉及7667名受试者。我们将两项试验在所有领域（选择、损耗、报告、盲法和其他）的偏倚风险评定为低。我们在一个或多个偏倚风险领域中将25项试验评为高风险。与假手术组相比，PC6穴位刺激可显著降低恶心的发生率（RR 0.68，95% CI 0.60 - 0.77; 40项试验，4742例受试者），呕吐（RR 0.60，95% CI 0.51 - 0.71; 45项试验，5147例受试者）和需要急救止吐药（RR 0.64，95% CI 0.55 - 0.73; 39项试验，4622例受试者）。由于试验之间的异质性很大，并且存在研究局限性，我们将证据质量评定为低。使用试验序贯分析，两个主要结局均达到了所需的信息量和获益边界。比较PC6穴位刺激与胃复安、赛克力嗪、丙氯拉嗪、氟哌利多等6种止吐药的止吐效果。昂丹司琼和地塞米松）。PC6穴位刺激与止吐药相比，恶心发生率无差异（RR 0.91，95% CI 0.75 - 1.10; 14项试验，1332例受试者），呕吐（RR 0.93，95% CI 0.74 - 1.17; 19项试验，1708例受试者）或需要急救止吐药（RR 0.87，95% CI 0.65 - 1.16; 9项试验，895例受试者）。由于研究的局限性，我们将证据的质量评定为中等。使用试验序贯分析，在超过两个主要结局所需的信息量之前越过无效边界。与止吐药物相比，PC6穴位刺激和止吐治疗的组合降低了呕吐的发生率（RR 0.56，95% CI 0.35至0.91; 9项试验，687名参与者），但没有降低恶心的发生率（RR 0.79，95% CI 0.55至1.13; 8项试验，642名参与者）。我们将证据的质量评定为非常低，这是由于试验间的大量异质性、研究的局限性和不精确性。使用试验序贯分析，PONV未跨越获益、损害或无效的边界。PC 6穴位刺激和止吐药联合组对补救止吐药的需求低于止吐药组（RR 0.61，95%CI 0.44至0.86; 5项试验，419名参与者）。在14项试验中，与PC6穴位刺激相关的副作用是轻微的、短暂的和自限性的（例如皮肤刺激、起泡、发红和疼痛）。发表偏倚在轮廓增强漏斗图中不明显。有低质量的证据支持使用PC6穴位刺激优于假手术。与2009年的最后一次更新相比，不需要进一步的假比较试验。我们发现，有中等质量的证据表明，PC6穴位刺激和止吐药物之间没有差异，以防止PONV。进一步的PC6穴位刺激与止吐试验在显示显著差异方面是徒劳的，这是本次更新中的一个新发现。目前尚无结论性证据支持使用PC6穴位刺激和止吐药物的联合策略优于药物预防，需要进一步的高质量试验。
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. 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. 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. 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. 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. 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. 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.