British Journal of Anaesthesia 1992; 68: 633-637

CORRESPONDENCE

T. P. NASH

Basingstoke
1. Chan SHH, Fung SJ. Suppression of polysynaptic reflex by
electro-acupuncture and a possible underlying presynaptic
mechanism in the spinal cord of the cat. Experimental
Neurology 1975; 48: 366-342.
2. Fung DTH, Chan SHH. Electro-acupuncture suppression of
jaw depression reflex elicited by dentalgia in rabbits. Experimental Neurology 1975; 47: 367-369.
3. Pomeranz B, Palely D. Electro-acupuncture hypalgesia is
mediated by afferent nerve impulses: an electro-physiological
study in mice. Experimental Neurology 1979; 66: 398-402.
4. Stux, G, Pomeranz B. Basics of Acupuncture. Berlin: Springer
Verlag, 1991.
5. Yentis SM, Bissonnette B. P6 acupuncture and postoperative
vomiting after tonsillectomy in children. British Journal of
Anaesthesia 1991; 67: 779-780.
Sir,The paper by Yentis and Bissonnette [1] concerning P6
acupuncture in children undergoing tonsillectomy raises several
interesting points.
Dundee and colleagues [2] and Fry [3] have demonstrated that
P6 stimulation (acupuncture needling, electroacupuncture or noninvasive acupressure) is an effective postoperative antiemetic in
adults. Yentis and Bissonnette [1] suggest that children often
respond well to acupuncture and are included in the group termed
"strong reactors". However, their findings would suggest otherwise and are in agreement with the only other comparable study
in children using P6 acupressure, in which a non-invasive stimulus
was used 1 h before surgery [4] in order to overcome the objection
of Dundee [5] that, for acupuncture (and presumably acupressure)
to be effective, it must be applied before the emetic stimulus.
Yentis and Bissonnette [1] indicated correctly that acupuncture
was likely to be unacceptable to both children and parents before
anaesthesia. Their children received 5 min of manual needling at
the left P6 wrist point immediately after intubation of the trachea,
but before the start of surgery. It may be argued that several
emetic stimuli occurred before acupuncture was applied, including thiopentone, nitrous oxide and pharyngeal stimulation.
Only one study [6] has found P6 stimulation (acupuncture
needling) to be ineffective in adults for treatment of postoperative
emesis. This failure also may have been a result of the timing of
acupuncture [5], as discussed above, or a result of the small
number of subjects. Of all the quoted studies concerning P6
stimulation, only Yentis and Bissonnette [1] and Lewis [4] defined
the "clinical antiemetic effect" (reduction in the incidence of
vomiting from control to test groups) which the study was
designed to detect, using power analysis [7] to link sample size,
antiemetic effect and significance level. However, Dundee [2]
indirectly compared P6 stimulation with antiemetic drugs, and
found it to be as effective as metoclopramide 10 mg and cyclizine
50 mg, but less effective than droperidol 2.5 mg.
Finally, there is a high incidence of postoperative vomiting after
discharge from hospital in children. Wilton and Burn [8] found
that 56% of children receiving perioperative papaveretum

vomited after discharge, within the first 24 h. The authors

suggested that early ambulation and travel may have contributed
to the incidence of emetic symptoms. Yentis and Bissonnette [1]
recorded only the overall incidence of vomiting in the first 19.6 h
(on average); it would have been interesting to record the
incidence of vomiting at home. Lewis and colleagues [4] found a
greater rate of vomiting at home than during the period within
hospital among children undergoing outpatient strabismus correction; this finding was similar for both control and acupressure
groups.
Current evidence suggests that P6 stimulation is ineffective as
an antiemetic in children. Even if a small antiemetic effect can be
demonstrated by large controlled studies, invasive acupuncture is
unlikely to become popular because of the problems of acceptability and timing. Acupressure is clearly more acceptable in
awake children; however, it appears to have a shorter duration of
action compared with invasive methods in adults [2]. Children are
unlikely to tolerate continuous, accurately applied, P6 acupressure
over long periods as a treatment for late postoperative vomiting.
I. H. LEWIS
N. C. T. WILTON

Ann Arbor, Michigan

1. Yentis SM, Bissonnette B. P6 acupuncture and postoperative
vomiting after tonsillectomy in children. British Journal of
Anaesthesia 1991; 67: 779-780.
2. Dundee JW, Ghaly RG, Bill KM, Chestnutt WN, Fitzpatrick
KTJ, Lynas AGA. Effect of stimulation of the P6 antiemetic
point on postoperative vomiting. British Journal of Anaesthesia 1989; 63: 612-618.
3. Fry ENS. Acupressure and postoperative vomiting. Anaesthesia 1986; 41: 661-662.
4. Lewis IH, Pryn SJ, Reynolds PI, Pandit UA, Wilton NCT.
Effect of P6 acupressure on postoperative vomiting in children
undergoing outpatient strabismus correction. British Journal
of Anaesthesia 1991; 67: 73-78.
5. Dundee JW, Ghaly RG. Does the timing of P6 acupuncture
influence its efficacy as a postoperative antiemetic? British
Journal of Anaesthesia 1989; 63: 630P.
6. Weightman WM, Zacharias M, Herbison P. Traditional
Chinese acupuncture as an antiemetic. British Medical Journal
1987;295: 1379-1380.
7. Kirkwood BR. Essentials of Medical Statistics. Oxford:
Blackwell Scientific Publications, 1988; 191-200.
8. Wilton NCT, Burn JM. Delayed vomiting after papaveretum
in paediatric outpatient surgery. Canadian Anaesthetists
Society Journal 1986; 33: 741-744.

Sir,Thank you for the opportunity to reply to these letters.

Whilst the mechanism of acupuncture antiemesis is unknown, it
would appear that acupuncture requires an intact nervous system,
as suggested by Dr Nash, as it has been shown to reduce vomiting
when administered before [1] and after [2], but not during [3],
anaesthesia. In addition, Ghaly and Dundee reported that local
anaesthetic infiltration of the P6 point prevented the antiemetic
effect of stimulation [4].
With regards to an induction period, I have used P6 acupuncture in a few cases of acute travel sickness and gastroenteritis,
and have found relief consistently to occur within a few minutes
of stimulation, although it is often short-lived. This is similar to
the rapid onset of relief that often follows acupuncture for other
conditions.
As Lewis and Wilton state in their letter, invasive P6
acupuncture is unlikely to become popular in paediatric anaesthesia. Dundee's suggestion that the acupuncture must precede
the emetic stimulus in order to be effective [1] is not supported by
the study of Ho and colleagues, in which postoperative acupuncture significantly reduced vomiting after gynaecological
surgery [2]. It is thus possible that anaesthesia suppresses the
antiemetic effect of acupuncture (and that is more important than
its timing), requiring administration to awake patients.

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ACUPUNCTURE AND POSTOPERATIVE VOMITING IN

CHILDREN
Sir,For acupuncture analgesia to be developed from stimulation
of an acupuncture point, an intact nervous system is required. It
has been shown [1-3] that injection of local anaesthetic to the
muscle beneath the acupuncture point abolishes and prevents the
development of acupuncture analgesia. This abolition of acupuncture analgesia is related to the blocking of De Qi sensation. It
is also accepted generally that acupuncture analgesia is of slow
onset and long duration and there is therefore an induction period
required for stimulation [4].
The paper by Yentis and Bissonnette [5] would therefore
confirm both the need for an intact nervous system, as all their
patients were anaesthetized before the acupuncture point was
stimulated, and the need for an induction period.