Aromatherapy for treatment of postoperative nausea and vomiting

Sonia Hines; Elizabeth Steels; Anne Chang; Kristen Gibbons

doi:10.1002/14651858.CD007598.pub3

Aromatherapie zur Behandlung von postoperativer Übelkeit und Erbrechen

Appendices

Appendix 1. Peppermint oil

Peppermint oil (Mentha piperita) is one of the oldest European herbs used for medicinal purposes. It is a hybrid species of spearmint (Mentha spicata) and water mint (Mentha aquatica) (Price 2007). The essential oil is derived by steam distillation of the fresh aerial parts of the flowering plant (Lis‐Balchin 2006). Peppermint oil is listed in the European Pharmacopeia, British Pharmacopoeia, and United States Pharmacopeia. The active ingredients of the peppermint essential oil (0.4% to 5%) are menthol (35% to 45%) and menthone (10% to 30%) (Lis‐Balchin 2006).

One possible mechanism of action of peppermint oil in the gastrointestinal system is inhibition of muscular contractions induced by serotonin and substance P (Hills 1991). Early studies (1969) showed that direct administration of peppermint oil to the stomach (27 patients) caused relaxation of the lower oesophageal sphincter (Sigmund 1969). Subsequent studies have shown that administration (dose of 0.1 mL peppermint oil in 20 mL of saline) to the sigmoid colon in five participants produced increased intraluminal pressure, abdominal cramps, and the urge to defecate and urinate, suggesting widespread stimulation of smooth muscle (Rogers 1988). In another study, peppermint oil injected into the colon (20 participants ) was shown to relieve colon spasms (Leicester 1982).

Peppermint oil has also been shown to accelerate the gastric emptying rate in dyspeptic patients as well as reduce the pain intensity (Dalvi 1991; May 1996). In a double‐blind study, it was shown that the incidence of postoperative nausea in 18 gynaecological patients was significantly reduced in those that inhaled the peppermint oil (Tate 1997). In another randomized double blind study, a liquid herbal extract containing peppermint oil as the principal ingredient was found to relieve the symptoms of pain, nausea, belching, and heartburn (Westphal 1996).

Appendix 2. Search strategies

1 Search strategy for CENTRAL, in the Cochrane Library

#1 MeSH descriptor Holistic Health explode all trees
#2 MeSH descriptor Aromatherapy explode all trees
#3 MeSH descriptor Medicine, Traditional explode all trees
#4 MeSH descriptor Naturopathy explode all trees
#5 MeSH descriptor Phytotherapy explode all trees
#6 MeSH descriptor Plants, Medicinal explode all trees
#7 MeSH descriptor Ginger explode all trees
#8 MeSH descriptor Mentha piperita explode all trees
#9 (Aromatherapy or "Holistic Health" or "Medicine, Traditional" or Naturopathy or Phytotherapy or "Plants, Medicinal" or Ginger or “Mentha piperita”):ti,ab
#10 (#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9)
#11 MeSH descriptor Postoperative Nausea and Vomiting explode all trees
#12 MeSH descriptor Postoperative Care explode all trees
#13 MeSH descriptor Recovery Room explode all trees
#14 MeSH descriptor Anesthesia Recovery Period explode all trees
#15 (postoperative* or post surg* or surgical or recovery) and (vomit* or nausea* or sick* or PONV)
#16 (#11 OR #12 OR #13 OR #14 OR #15)
#17 (#10 AND #16)

2. Search Strategy for MEDLINE ( Ovid SP)

1. exp Aromatherapy/ or exp Plants, Medicinal/ or exp Mentha piperita/ or exp Ginger/ or exp Complementary Therapies/ or exp Naturopathy/ or exp Phytotherapy/ or Holistic Health/ or (aromatherap* or ((plant* or traditional or complementary) adj3 medicin*) or ginger or peppermint or isopropyl alcohol or (holistic adj3 health) or naturopath* or phytotherap* or (mentha adj3 piperita)).mp.
2. exp "Postoperative Nausea and Vomiting"/ or exp Anesthesia Recovery Period/ or (postoperative adj3 (care or nausea or vomit*)).mp. or (recovery adj3 (room or an?esthesia or period)).mp. or PONV
3. ((randomized controlled trial or controlled clinical trial).pt. or randomized.ab. or placebo.ab. or clinical trials as topic.sh. or randomly.ab. or trial.ti.) not (animals not (humans and animals)).sh.
4. 1 and 2 and 3

3 Search strategy for Embase (Ovid SP)

1. exp aromatherapy/ or exp alternative medicine/ or exp medicinal plant/ or exp Mentha piperita/ or exp peppermint/ or exp ginger/ or exp phytotherapy/ or (aromatherap* or ((plant* or traditional or complementary) adj3 medicin*) or ginger or peppermint or isopropyl alcohol or (holistic adj3 health) or naturopath* or phytotherap* or (mentha adj3 piperita)).mp.
2. exp "postoperative nausea and vomiting"/ or exp anesthetic recovery/ or postoperative care/ or (postoperative adj3 (care or nausea or vomit*)).mp. or (recovery adj3 (room or an?esthesia or period)).mp. or PONV
3. (randomized‐controlled‐trial/ or randomization/ or controlled‐study/ or multicenter‐study/ or phase‐3‐clinical‐trial/ or phase‐4‐clinical‐trial/ or double‐blind‐procedure/ or single‐blind‐procedure/ or (random* or cross?over* or multicenter* or factorial* or placebo* or volunteer*).mp. or ((singl* or doubl* or trebl* or tripl*) adj3 (blind* or mask*)).ti,ab. or (latin adj square).mp.) not (animals not (humans and animals)).sh.
4. 1 and 2 and 3

4 Search strategy for CINAHL (EBSCOhost)

S1 (MH "Aromatherapy") or (MH "Holistic Health") or (MH "Medicine, Traditional+") or (MH "Medicine, Oriental Traditional+") or (MH "Medicine, Chinese Traditional+") or (MH "Medicine, Latin American Traditional") or (MH "Medicine, African Traditional") or (MH "Australian Traditional Medicine Society") or (MH "Medicine, Native American") or (MH "Traditional Healers") or (MH "Medicine, Arabic") or (MH "Naturopathy") or (MH "Medicine, Herbal+") or (MH "Plants, Medicinal+") or (MH "Medicine, Herbal+") or (MH "Ginger") or (MH "Peppermint") or ((aromatherap* or complementary or ginger or peppermint or isopropyl alcohol) and ((traditional or natural or alternat*) and (therap* or medicine or treatment*)))
S2 (MH "Nausea and Vomiting+") or (MH "Nausea") or (MH "Postoperative Care+") or (MH "Post Anesthesia Care Units") or (MH "Anesthesia Recovery") or ((postoperative* or post surg* or surgical or recovery) and (vomit* or nausea* or sick* or PONV))
S3 (MH "Clinical Trials") or (random* or multicenter or prospective) or ((single or double or triple or treble) and (mask* or blind*))
S4 S1 AND S2 AND S3

5 Search strategy for CAM on PubMed (1966 to 2010)

1	Search aromatherapy Limits: Complementary Medicine
2	Search peppermint Limits: Complementary Medicine
3	Search ginger Limits: Complementary Medicine
4	Search 1 OR 2 OR 3 Limits: Complementary Medicine
5	Search postoperative nausea vomiting Limits: Complementary Medicine
6	Search postoperative care Limits: Complementary Medicine
7	Search 5 OR 6 Limits: Complementary Medicine
8	Search 4 AND 7 Limits: Complementary Medicine

6 Search strategy for Meditext (Informit 1995 to 2010) (now Informit Health Collection from January 2010)

1.	(aromatherapy OR natural medicine OR traditional medicine OR phytotherapy OR medicinal plant OR holistic health OR ginger OR peppermint)
2.	((postoperative nausea and vomiting) OR postoperative care OR recovery room OR post‐anesthesia recovery period OR PONV)
3.	1 AND 2

7 Search strategy for LILACS database

(mentha piperita OR gengiber offinale OR peppermint OR ginger OR aromatherap$ OR terap$ herb$ OR medic$ herb$ OR complement$ medic$ OR (essential AND oil))

8 Search strategy for ISI Web of Science

#1. TS=((nausea or vomiting) SAME postoperativ*)

#2. TS=(aromatherap* or complementary or ginger or peppermint or isopropyl alcohol ) AND TS=((traditional or natural or alternat*) and (therap* or medicine or treatment*))

#3. #1 AND #2

Appendix 3. Verification of Study Eligibility Form

Aromatherapy for PONV

VERIFICATION OF STUDY ELIGILIBILITY

AUTHOR AND YEAR

JOURNAL

TITLE

NAME/CODE OF REVIEWER

Setting: Acute hospital or surgical day facility Yes No

Population: Adults or children having surgical procedures under anaesthesia Yes No

Intervention:Experimental group patients are receiving aromatherapy to treat PONV Yes No

Study Design: RCT or CCT Yes No

IF YOU HAVE NOT ANSWERED YES TO ALL OF THE ABOVE QUESTIONS, YOU SHOULD EXCLUDE THE STUDY. IF YOU ANSWERED YES TO ALL, PLEASE CONTINUE.

Language: Does the study require translation before it can be appraised? Yes No

If yes, please arrange for translation before proceeding

PLEASE RECORD ALL STUDY DETAILS AS PER THE DATA MANAGEMENT FLOW SHEET

Appendix 4. Data Extraction Form

AUTHOR AND YEAR
JOURNAL/SOURCE
TITLE INITIALS OF REVIEWER:
STUDY METHOD RCT ? Quasi RCT ? CCT ?
PARTICIPANT	Group	Group	Group	Group
Number in each group
Mean age and range
Gender
Population
Setting
Procedure/s
Participants excluded in selection criteria
Participants who left study and reasons why
INTERVENTION	Group	Group	Group	Group
Aromatherapy type
Method of administration
Dose (if stated)
Times administered
Cost (if stated)
Administered by?
Control
OUTCOMES	Group	Group	Group		Group
Nausea (severity score?)
Vomiting (severity score?)
Adverse reactions
Cost
Rescue antiemetics used
Author’s Conclusion

Figure 1

Study flow diagram

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Figure 2

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies

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Figure 3

Methodological quality summary: review authors' judgements about each methodological quality item for each included study

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Analysis 1.1

Comparison 1 Aromatherapy versus placebo, Outcome 1 Nausea severity at end of treatment.

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Analysis 1.2

Comparison 1 Aromatherapy versus placebo, Outcome 2 Duration of nausea measured as nausea‐free at the end of treatment.

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Analysis 1.3

Comparison 1 Aromatherapy versus placebo, Outcome 3 Proportion requiring rescue antiemetics.

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Analysis 2.1

Comparison 2 Peppermint versus placebo, Outcome 1 Nausea severity at 5 minutes post‐initial treatment.

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Analysis 3.1

Comparison 3 Isopropyl alcohol versus standard treatment for PONV, Outcome 1 Time (minutes) to 50% reduction in nausea score.

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Analysis 3.2

Comparison 3 Isopropyl alcohol versus standard treatment for PONV, Outcome 2 Proportion requiring antiemetics.

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Analysis 3.3

Comparison 3 Isopropyl alcohol versus standard treatment for PONV, Outcome 3 Patient satisfaction.

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Analysis 4.1

Comparison 4 Isopropyl alcohol versus saline, Outcome 1 Proportion requiring rescue antiemetics.

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Summary of findings for the main comparison. Aromatherapy compared to placebo for treatment of postoperative nausea and vomiting

Aromatherapy compared to placebo for treatment of postoperative nausea and vomiting
Patient or population: adults and children having any type of surgical procedure under general anaesthesia, regional anaesthesia or sedation, either as hospital inpatients or outpatients, with existing PONV Setting: hospital post‐anaesthesia care unit or same‐day surgery unit in USA and Iran Intervention: aromatherapy Comparison: placebo
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with placebo	Risk with aromatherapy
Nausea severity Assessed with VAS at end of treatment Scale from 0 to 10 (higher indicates worse nausea) Follow‐up: range 5 minutes to participant discharge	The mean nausea severity was 2.8 (SD = 10.39)	SMD 0.22 SD lower (0.63 lower to 0.18 higher)	‐	241 (6 RCTs)	⊕⊕⊝⊝ Low^{1, 2}	Risk in placebo group based on control group in Anderson 2004
Nausea duration (nausea‐free at end of treatment) Assessed by numbers of participants Follow‐up: range 5 minutes to participant discharge Measured by participant self‐report or medical or nursing observation	Study population		RR 3.25 (0.31 to 34.33)	193 (4 RCTs)	⊕⊝⊝⊝ Very low^{3, 4, 5}
	30 per 100	96 per 100 (9 to 100)
Proportion requiring rescue antiemetics Assessed by numbers of participants Follow up: range 5 minutes to participant discharge	Study population		RR 0.60 (0.37 to 0.97)	609 (7 RCTs)	⊕⊕⊝⊝ Low^{1, 2}
	68 per 100	41 per 100 (25 to 66)
Adverse events (common reactions to aromatherapy include skin rashes, dyspnoea, headache, cardiac arrhythmias, hypotension, hypertension or dizziness)	See comment		‐	‐	‐	The studies reporting this comparison did not report this outcome.
Patient satisfaction with treatment Measured by a validated scale	See comment		‐	‐	‐	The studies reporting this comparison did not report this outcome.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; PONV: postoperative nausea and vomiting; RCT: randomized controlled trial; RR: risk ratio; SD: standard deviation; SMD: standardized mean difference; VAS: visual analogue scale
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect
¹Risk of bias across all studies due to study designs, downgraded one level. ²Inconsistent results for aromatherapy, downgraded one level. ³High risk of bias in included studies due to study designs, downgraded two levels. ⁴Low numbers of participants and events leading to imprecision of results, downgraded one level. ⁵Very serious inconsistency between studies, downgraded two levels.

Summary of findings for the main comparison. Aromatherapy compared to placebo for treatment of postoperative nausea and vomiting

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Summary of findings 2. Peppermint compared to placebo for treatment of postoperative nausea and vomiting

Peppermint compared to placebo for treatment of postoperative nausea and vomiting
Patient or population: adults and children having any type of surgical procedure under general anaesthesia, regional anaesthesia or sedation, as hospital inpatients or outpatients, with existing PONV Setting: hospital post‐anaesthesia care unit or same‐day surgery unit in USA Intervention: peppermint Comparison: placebo
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with placebo	Risk with peppermint
Nausea severity Assessed with VAS at 5 minutes post‐initial treatment Scale from: 0 to 10 (higher indicates worse nausea)	The mean nausea severity was 2.8 (SD = 10.39)	SMD 0.18 SD lower (0.86 lower to 0.49 higher)	‐	115 (4 RCTs)	⊕⊕⊝⊝ Low^{1, 2}	Risk in placebo group based on control group in Anderson 2004
Nausea duration (nausea‐free at end of treatment) Measured by participant self‐report or medical or nursing observation	See comment		‐	‐	‐	The studies reporting this comparison did not report this outcome.
Use of rescue antiemetics	See comment		‐	‐	‐	The studies reporting this comparison did not report this outcome.
Adverse events (common reactions to aromatherapy include skin rashes, dyspnoea, headache, cardiac arrhythmias, hypotension, hypertension or dizziness)	See comment		‐	‐	‐	The studies reporting this comparison did not report this outcome.
Patient satisfaction with treatment Measured by a validated scale	See comment		‐	‐	‐	The studies reporting this comparison did not report this outcome.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; PONV: postoperative nausea and vomiting; RCT: randomized controlled trial; SD: standard deviation; SMD: standardized mean difference; VAS: visual analogue scale
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect
¹Risk of bias in included studies due to study designs, downgraded one level. ²Significant inconsistency between studies, downgraded one level.

Summary of findings 2. Peppermint compared to placebo for treatment of postoperative nausea and vomiting

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Summary of findings 3. Isopropyl alcohol compared to standard treatment for postoperative nausea and vomiting

Isopropyl alcohol compared to standard treatment for postoperative nausea and vomiting
Patient or population: adults and children having any type of surgical procedure under general anaesthesia, regional anaesthesia or sedation, as hospital inpatients or outpatients, with existing PONV Setting: hospital post‐anaesthesia care unit or same‐day surgery unit in USA Intervention: isopropyl alcohol Comparison: standard treatment for PONV
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with standard treatment for PONV	Risk with isopropyl alcohol
Nausea severity Measured by a validated scale or medical or nursing observation	See comment		‐	‐	‐	The studies reporting this comparison did not report this outcome.
Nausea duration (measured as nausea‐free at end of treatment) Assessed by time (minutes) to 50% reduction in nausea score Scale from: 0 to 120 Follow‐up: range 5 minutes to participant discharge Measured by participant self‐report or medical or nursing observation	The mean time to 50% reduction in nausea score was 20.5 minutes	SMD 1.10 SD lower (1.43 lower to 0.78 lower)	‐	176 (3 RCTs)	⊕⊕⊕⊝ Moderate¹	Risk in placebo group based on Pellegrini 2009
Use of rescue antiemetics Assessed by proportion requiring antiemetics Follow‐up: range 5 minutes to participant discharge	Study population		RR 0.67 (0.46 to 0.98)	215 (4 RCTs)	⊕⊕⊕⊝ Moderate²
	39 per 100	26 per 100 (18 to 38)
Patient satisfaction with treatment Assessed with Yes or No Measured by a validated scale	Study population		RR 1.12 (0.62 to 2.03)	172 (2 RCTs)	⊕⊝⊝⊝ Very low^{1, 3, 4}
	76 per 100	85 per 100 (47 to 100)
Adverse events (common reactions to aromatherapy include skin rashes, dyspnoea, headache, cardiac arrhythmias, hypotension, hypertension or dizziness)	See comment		‐	‐	‐	The studies reporting this comparison did not report this outcome.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; PONV: postoperative nausea and vomiting; RCT: randomized controlled trial; RR: risk ratio; SD: standard deviation; SMD: standardized mean difference
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect
¹No or unclear blinding in all included studies, downgraded one level. ²No or unclear blinding in three of the four included studies, downgraded one level. ³High heterogeneity between studies, downgraded one level. ⁴High imprecision due to wide confidence intervals and small numbers of participants, downgraded one level.

Summary of findings 3. Isopropyl alcohol compared to standard treatment for postoperative nausea and vomiting

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Summary of findings 4. Isopropyl alcohol compared to saline for treatment of postoperative nausea and vomiting

Isopropyl alcohol compared to saline for treatment of postoperative nausea and vomiting
Patient or population: adults and children having any type of surgical procedure under general anaesthesia, regional anaesthesia or sedation, as hospital inpatients or outpatients, with existing PONV Setting: hospital post‐anaesthesia care unit or same‐day surgery unit in USA and Iran Intervention: isopropyl alcohol Comparison: saline
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with saline	Risk with isopropyl alcohol
Nausea severity Measured by a validated scale or medical or nursing observation	See comment		‐	‐	‐	The studies reporting this comparison did not report this outcome.
Nausea duration (nausea‐free at end of treatment) Measured by participant self‐report or medical or nursing observation	See comment		‐	‐	‐	The studies reporting this comparison did not report this outcome.
Use of rescue antiemetics Assessed by proportion requiring rescue antiemetics Follow‐up: range 5 minutes to participant discharge	Study population		RR 0.39 (0.12 to 1.24)	291 (4 RCTs)	⊕⊝⊝⊝ Very low^{1, 2, 3}
	90 per 100	35 per 100 (11 to 100)
Adverse events (common reactions to aromatherapy include skin rashes, dyspnoea, headache, cardiac arrhythmias, hypotension, hypertension or dizziness)	See comment		‐	‐	‐	The studies reporting this comparison did not report this outcome.
Patient satisfaction with treatment Measured by a validated scale	See comment		‐	‐	‐	The studies reporting this comparison did not report this outcome.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; PONV: postoperative nausea and vomiting; RCT: randomized controlled trial; RR: risk ratio
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect
¹Poor reporting in Kamalipour 2002 and Langevin 1997 affect confidence in results, downgraded one level. ²Wide confidence interval for pooled results, downgraded one level. ³Very high heterogeneity between studies, downgraded two levels.

Summary of findings 4. Isopropyl alcohol compared to saline for treatment of postoperative nausea and vomiting

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Table 1. Patient satisfaction

Study	Design	Intervention/comparison	Measure	Satisfied
Anderson 2004	RCT	IPA/Saline/Peppermint	100 mm VAS (0 mm extremely dissatisfied; 100 mm fully satisfied)	IPA: 90.3 (SD: 14.9) peppermint: 86.3 (SD: 32.3) saline: 83.7 (SD: 25.6)
Cotton 2007	RCT	IPA/ondansetron	4‐point DOS (poor, fair, good, excellent)	Good or excellent: Intervention: 38/38 Comparison: 34/34
Pellegrini 2009	RCT	IPA/Promethazine	5‐point DOS (1 = totally unsatisfied, 5 = totally satisfied)	Both groups reported median score 4
Winston 2003	RCT	IPA/ondansetron	4‐point DOS (poor, fair, good, excellent)	Good or excellent: Intervention: 38/50 Comparison: 30/50
DOS: descriptive ordinal scale; IPA: isopropyl alcohol; RCT: randomized controlled trial; SD: standard deviation; VAS: visual analogue scale

Table 1. Patient satisfaction

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Comparison 1. Aromatherapy versus placebo

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Nausea severity at end of treatment Show forest plot	6	241	Std. Mean Difference (IV, Random, 95% CI)	‐0.22 [‐0.63, 0.18]

2 Duration of nausea measured as nausea‐free at the end of treatment Show forest plot	4	193	Risk Ratio (M‐H, Random, 95% CI)	3.25 [0.31, 34.33]

3 Proportion requiring rescue antiemetics Show forest plot	7	609	Risk Ratio (M‐H, Random, 95% CI)	0.60 [0.37, 0.97]

Comparison 1. Aromatherapy versus placebo

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Comparison 2. Peppermint versus placebo

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Nausea severity at 5 minutes post‐initial treatment Show forest plot	4	115	Std. Mean Difference (IV, Random, 95% CI)	‐0.18 [‐0.86, 0.49]

Comparison 2. Peppermint versus placebo

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Comparison 3. Isopropyl alcohol versus standard treatment for PONV

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Time (minutes) to 50% reduction in nausea score Show forest plot	3	176	Std. Mean Difference (IV, Random, 95% CI)	‐1.10 [‐1.43, ‐0.78]

2 Proportion requiring antiemetics Show forest plot	4	215	Risk Ratio (M‐H, Random, 95% CI)	0.67 [0.46, 0.98]

3 Patient satisfaction Show forest plot	2	172	Risk Ratio (M‐H, Random, 95% CI)	1.12 [0.62, 2.03]

Comparison 3. Isopropyl alcohol versus standard treatment for PONV

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Comparison 4. Isopropyl alcohol versus saline

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Proportion requiring rescue antiemetics Show forest plot	4	291	Risk Ratio (M‐H, Random, 95% CI)	0.39 [0.12, 1.24]

Comparison 4. Isopropyl alcohol versus saline

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Aromatherapie zur Behandlung von postoperativer Übelkeit und Erbrechen

Appendices

Appendix 1. Peppermint oil

Appendix 2. Search strategies

Appendix 3. Verification of Study Eligibility Form

Appendix 4. Data Extraction Form

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Instituciones a las que se accedió previamente

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Appendices

Appendix 1. Peppermint oil

Appendix 2. Search strategies

Appendix 3. Verification of Study Eligibility Form

Appendix 4. Data Extraction Form

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