Background & Significance

Postoperative nausea and vomiting (PONV) are one of the greatest concerns following surgery under general anesthesia, occurring in approximately one-third of the 75 million patients who have surgery annually. (1) Adverse effects associated with vomiting include prolonged hospital stay, unanticipated hospital admissions, wound dehiscence, aspiration, esophageal tears, electrolyte imbalance, bilateral pneumothorax, increased intracranial pressure, and delay in return to patient’s functional ability. (1,2,3,4) Patients report fear of experiencing PONV more than they fear pain or the entire surgical experience itself. (1,3,5) The financial impact posed by PONV is believed to cost hundreds of millions of dollars per year in the US. (1,6) There are risk factors that predict the occurrence of PONV. Depending on the total number of risk factors, the occurrence of PONV can be as high as 87%. (7,8,9)

The American Society of PeriAnesthesia Nurses (ASPAN) has addressed this immense problem by developing guidelines for the treatment of PONV as well as Post Discharge Nausea and Vomiting (PDNV). The guidelines recommend a multimodal approach for the treatment of PONV and have included aromatherapy amongst other modalities in these guidelines. (8,10) Collins, Mamaril et al, Chiravalle, and Sandlin describe the use of alternative complementary therapies such as acupuncture, acupressure, aromatherapy, and music therapies as effective for treatment for/prevention of PONV. (2,11,12,13) Research by White, et al., Apfel, et al., and Fan, et al demonstrated that multimodal antiemetic regimens that included noninvasive P6 acupressure to be more effective for the treatment of PONV compared to those that used medication only. (14, 15, 16)

Aromatherapy Quease Ease (QE) was used for this EBP project for the management of PONV. QE consists of a blend of pure and natural essential oils of Peppermint, Ginger, Spearmint, and Lavender. It works via the sense of smell. The aroma sends its message to the olfactory bulb where the impulses are processed and transmitted to the limbic system of the brain and then to the central nervous system. Aromatherapy offers a complementary and alternative effective treatment for PONV. (2,4,13,17) Aromatherapy presents a low cost and a noninvasive treatment for PONV. (9) At the time, the only form of aromatherapy available to nurses employed at Houston Methodist Willowbrook was an alcohol wipe and many nurses are unaware of complementary treatments such as aromatherapy for PONV.

Purpose:

This Evidence Based Practice (EBP) project includes aromatherapy Quease Ease (QE) to the current use of antiemetic medication for the management of PONV. Adding the aromatherapy provides a multimodal approach for the management of PONV as recommended by The American Society of PeriAnesthesia Nurses (ASPAN). (10) The purpose of this EVP project was to demonstrate the following benefits:

• A reduction of nausea experienced with the use of the aromatherapy
• A reduction of additional antiemetic treatment required by patients after using the aromatherapy
• A reduction in the use of Promethazine and Ondansetron
• A reduction in Post Anesthesia Care Unit (PACU) recovery time

Population:

Patients were screened preoperatively during the preoperative testing (PAT) or during the preoperative phase for inclusion criteria for eligibility to receive QE for treatment of postoperative nausea and vomiting. Inclusion criteria were: adult surgical patients, planned surgery with the use of volatile gas anesthesia, and no known allergy to the aromatherapy essential oils contained in QE. Patient risk factors for PONV were also assessed during this time. Exclusion criteria were: children, non-surgical patients, and those allergic to any of the essential oils contained in the aromatherapy.

Method:

This project was conducted in a 340-bed hospital with a self-standing out-patient orthopedic surgery center. The project was reviewed by the Internal Review Board (IRB) and was determined to be an Evidence Base Practice (EBP) project rather than a research study. Several studies have been done on the use of aromatherapy for the treatment of PONV and the evidence demonstrates that it is effective. Patient eligibility to receive the aromatherapy was determined during the PAT or preoperative phase. There were 330 eligible patients for the project. 12 patients were excluded because of possible allergy or they did not want the aromatherapy. The project involved adding the use of aromatherapy QE for the treatment of PONV to the current antiemetic medication regimen. A total of 318 postoperative surgical adult patients in three PACU locations were treated with aromatherapy QE as the first line antiemetic for PONV. QE is a handheld self-administered aromatherapy that the patient can hold under the nose and take several deep breaths.

The treatment is continued for 3 to 5 minutes. QE contains a combination of 4 essential oils: Ginger, Peppermint, Spearmint, and Lavender. Patients in phase 1 PACU may be too sleepy to hold the QE therefore making it necessary for the nurse to hold it for the patient. The three PACU locations are PACU North, AOD North, and Centerfield. PACU North provides Phase 1 recovery for In-Patients and Out-Patients undergoing various surgeries, the Cath Lab, and Interventional Radiology procedures. AOD North provides phase 2 recovery for Out-Patients following phase 1 recovery. Centerfield provides a combined phase 1 and phase 2 recovery for Out-Patient Orthopedic surgeries. Pre-data that was collected prior to beginning the project included the length of time spent in the 3 PACU locations by surgical adult patients who experienced PONV.

First Measurement:

Patients in the Post Anesthesia Care Unit who experienced PONV were asked to rate their nausea on a Verbal Descriptive Scale (VDS) from 0-10. A 10 point Likert-type scale (0=none and 10 =the worse possible) was used for the VDS scoring. A total of 2 ratings were obtained while the patients were in PACU. The first VDS rating was obtained upon onset of PONV and again after 3-5 minutes following treatment with the aromatherapy. The pre-treatment and post-treatment VDS scores were recorded, averaged, and then compared. This data was collected on a data collection tool sheet which followed the patient for further data collection throughout their recovery in the PACU.

Second measurement:

Patients who were treated with the aromatherapy and achieved a VDS of 3 or less were asked if they required further treatment with antiemetic medication. The number of those that did not require further antiemetic treatment was recorded and totaled separately from those who did. A percentage of each total was obtained.

Third measurement:

The quantity of the antiemetic medication use of Promethazine and Ondansetron was measured by the clinical pharmacist. He totaled the use of each medication for 3 months pre-treatment and compared it to 3 months post-treatment with aromatherapy. The clinical pharmacist concluded that to have a more accurate comparison, he would exclude the month of February 2015, as it has fewer days. The medication count was done during November 2014, December 2014, and January 2015 for the pre-treatment months. The post-treatment count during March 2015, April 2015, and May 2015 was then compared.

Fourth measurement:

The amount of time spent in each of the four PACU settings by patients experiencing PONV was recorded. The comparison was made between pre-treatment months and the post-treatment months.

Findings:

First measurement finding:

The average pre-intervention VDS score was 6.11. The average post-intervention VDS score was reduced to 2.82 following treatment with aromatherapy. See Figure1.

Second measurement finding:

About 37% of patients treated with the aromatherapy did not need additional treatment for  PONV after the use of Quease Ease. See Figure 2.

Third measurement finding:

The medication use of Promethazine and Ondansetron during 3 months pre-treatment and 3 months post-treatment with aromatherapy were compared. The pre-treatment months were November 2014 through January 2015. The post-treatment months were March 2015 through May 2015. The amount of medication used was obtained by the clinical pharmacist from the medication dispensing units (PIXIS) located in the recovery areas. A significant reduction was seen in the use of these 2 medications during the post-treatment months of aromatherapy.

The Promethazine pre-treatment count was 181. Post-treatment, the count dropped to 138, yielding a savings of 43 doses.

The Ondansetron pre-treatment count was 367. Post-treatment, the count dropped to 333, yielding a savings of 34 doses. See Figure 3.

Fourth measurement finding:

An average reduction of 6 minutes of recovery time was seen in the recovery areas.

The decrease in recovery time during the post-treatment months was expected to be greater; however, room delays prolonged the recovery times. Room delays are delays in the PACU due to bed unavailability for patients awaiting an in-patient room. There were a larger number of room delays experienced during the post-treatment months. During the pre-treatment months, there were 448 room delays in PACU North. During the post-treatment months, there were 534 room delays. There were 86 more room delays seen during the post-treatment months than during the pre-treatment months. Figure 4 compares pre-treatment months to post-treatment months.

Figures:

Figure 1

Figure 2

Figure 3

Figure 4

Conclusion

Adding aromatherapy for the management of PONV gives the RN needed tools to provide a more comprehensive and multimodal treatment regimen as recommended by the ASPAN guidelines for the treatment of PONV. The patients benefitted from the additional treatment modality that was made available. Including the aromatherapy for PONV showed very significant results in all four measurements. The effectiveness of QE was evidenced by:

1. A decrease in the nausea VDS rating from 6.11 to a 2.82 following treatment with QE
2. A reduction of 37% of patients that did not require further antiemetic treatment after receiving the aromatherapy
3. A reduction of 43 Promethazine doses and 34 Ondansetron doses during the post-treatment months
4. An overall reduction of 6 minutes of recovery time spent during the post-treatment months

Limitations

Room availability prolonged the actual time that the patient could have gone to their room when a room was not available. In retrospect, the project tool could have measured the time that the patient met the criteria to be discharged from PACU instead of the time when they were discharged from the PACU. The project tool measured the time that the patient was discharged from the PACU instead.

References:

1. Apfel, C. C., Korttila, K., Abdalla, M., Kerger, H., Turan, A., Vedder, I., . . . Roewer, N. (2004, June). A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. The New England Journal of Medicine, 350(24), 2441-2451.
2. Collins, A. S. (2011, December). Postoperative nausea and vomiting in adults: Implications for critical care. Critical Care Nurse, 31(6), 36-45.
3. Dienemann, J., Hudgens, A. N., Martin, D., Jones, H., Hunt, R., Blackwell, R., . . . Divine, G. (2012, August 252-258). Risk factors of patients with and without postoperative nausea (PON). Journal of PeriAnesthesia Nursing, 27(4). doi:10.1016/j.jopan.2012.05.011.
4. Hodge, N. S., McCarthy, M. S., & Pierce, R. M. (2014, February). A prospective randomized study of the effectiveness of aromatherapy for relief of postoperative nausea and vomiting. Journal of PerAnesthesia Nursing, 29(1), 5-11. doi:10.1016/j.jopan.2012.12.004.
5. Cotton, J. W., Rowell, L. R., Hood, R. R., & Pellegrini, J. E. (2007, February). A comparative analysis of isopropyl alcohol and ondansetron in the treatment of postoperative nausea and vomiting from the hospital setting to the home. American Association of Nurse Anesthetist Journal, 75(1), 21-26. doi:10.1002/14651858.CD007598.pub2.
6. Sites, D. S., Johnson, N. T., Miller, J. A., Torbush, P. H., Harding, J. S., Knowles, S. S., . . . Tart, R. C. (2014, February). Controlled breathing with or without peppermint aromatherapy for postoperative nausea and/or vomiting symptom relief: A randomized controlled trial. Journal of PerAnesthesia Nursing, 29(1), 12-18. doi:10.1016/j.jopan.2013.09.008.
7. Pellegrini, J., DeLoge, J., Bennett, J., & Kelly, J. (2009, August). Comparison of inhalation of isopropyl alcohol vs promethazine in the treatment of postoperative nausea and vomiting (PONV) in patients identified as at high risk for developing PONV. American Association Nurse Anesthetist Journal, 77(4), 293-299.
8. Golembiewski, J. and Tokumaru, S. (2006). Pharmacological prophylaxis and management of adult postoperative / postdischarge nausea and vomiting. Journal of PerAnesthesia Nursing.21(1),385-397

9. Hunt, R., Dienemann, J., Norton, J., Hartley, W., Hudgens, A., Stern, T., & Divine, G. (2013). Aromatherapy as treatment for postoperative nausea: A randomized trial. Anesthesia and Analgesia, 117(3), 597-604. doi:10.1213/ANE.0b013e31824a0b1c
10. ASPAN’S evidence-based clinical practice guideline for the prevention and/or management of PONV/PDNV. (2006, August). Journal of PeriAnesthesia Nursing, 21(4), 230-250. doi: http://dx.doi.org/10.1016/j.jopan.2006.06.003
11. Mamaril, M.E., Windle, P.E., and Burkard, J.F. (2006). Prevention and management of postoperative nausea and vomiting: A look at complementary techniques. Journal of PerAnesthesia Nursing, 21(1), 404–411

12. Chiravalle, P, McCaffrey R(2005). Alternative therapy for postoperative nausea and vomiting. Holistic Nursing Practice 19(1), 207-210

13. Sandlin, D. (2006, December). Alternative Treatment Options for Postoperative Nausea and Vomiting. Journal of PeriAnesthesia Nursing, 21(6), 436–438
14. White, P. F., Zhao, M., Tang, J., Wender, R. H., Yumul, R., Sloninsky, A. V., . . . Cunneen, S. (2012, July). Use of a disposable acupressure device as part of a multimodal antiemetic strategy for reducing postoperative nausea and vomiting. Anesthesia and Analgesia, 115(1), 31-37. doi:10.1213/ANE.0b013e3182536f27
15. Apfel CC, Kinjo S. (2009) Acustimulation of P6: an antiemetic alternative with no risk of drug-induced side-effects. British Journal of Anesthesia 102(1), 585–587.

16. Fan CF, Tanhui E, Joshi S, Trivedi S, Hong Y, Shevde K. (1997) Acupressure treatment for prevention of postoperative nausea and vomiting. Anesthesia and Analgesia 84(4), 821–825.

17. Quease/Ease. (n.d.). Retrieved from Soothing Scents: https://soothing-scents.com/

Acknowledgements:

Lourdes De Leon, BSN, RN; Lisa Jones, BSN, RN; Dolores Reyes, BSN, RN; Honey Magto, BSN, RN;  Barbara Mullen, BSN, RN; Peter Gray, RN; Lawrence N. Hough

Bio:

Jennifer Amedio, BSN, RN, CPAN, CAPA, CCRN, PCCN has been a nurse for the past 40 years. She conducted an evidence based practice study in 2015 at the hospital where she works in NW Houston,Texas. She has given podium presentations at nursing conferences, and she enjoys spending time with her grandchildren and gardening.