Aromatherapy for treatment of postoperative nausea and vomiting

Sonia Hines; Elizabeth Steels; Anne Chang; Kristen Gibbons

doi:10.1002/14651858.CD007598.pub3

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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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