Postoperativ oppkast hos barn Pragmatisk randomisert kontrollert studie - et design for kunnskapsutvikling i sykepleie

Bakgrunn Implementeringsstudien: Medikamentell behandling av postoperativ oppkast er bare delvis effektivt og kan forårsake en rekke bivirkninger. Det er derfor hensiktsmessig å vurdere bruk av ikke-medikamentelle behandlingsformer. Artikkelen rapporterer fra en studie av akupunktur/akupressur som symptomhåndteringsstrategi for å redusere forekomst av postoperativ oppkast. Refleksjonsoppgaven: Utfordringer ved forskning innen komplementær og alternativ medisin og innen sykepleie har klare likheter. Det pragmatiske randomiserte kontrollerte studien (RCT) blir anbefalt ved utforskning av nytteeffekt ved komplementær og alternativ medisin, og det er derfor interessant å belyse og diskutere det pragmatiske RCT-designet for kunnskapsutvikling i sykepleie. Formål 1) Undersøke nytteeffekten av akupunktur/akupressur for å forebygge postoperativ oppkast hos barn som gjennomgår adenotomi og/eller tonsillektomi og om behandlingen er egnet til å innføre i en dagkirurgisk avdeling 2) Diskutere det pragmatiske RCT-designets relevans for kunnskapsutvikling i sykepleie Design og metoder I implementeringsstudien ble det brukt et åpent, pragmatisk RCT-design. 164 barn som skulle gjennomgå tonsillektomi og/eller adenotomi ble inkludert og randomisert til enten behandling med akupunktur/akupressur og standard behandling, eller standard behandling. I refleksjonsoppgaven blir det pragmatiske designet belyst og diskutert i forhold til kunnskapsbasert praksis og effektforskning i sykepleie. Resultater Implementeringsstudien viste at barna i intervensjonsgruppen opplevde mindre oppkast enn barna i kontrollgruppen, henholdsvis 46,8 % og 66,2 % (n=164). Intervensjonen krevde ingen ekstra ressurser. Det pragmatiske RCT-designet var godt egnet for å belyse forskningsspørsmålet. Konklusjon Implementeringsstudien viser at akupunktur/akupressur kan være en god tilleggsbehandling, og den er enkel å gjennomføre i praksis. Det pragmatiske RCT-designet tar høyde for komplekse, kontekstavhengige behandlingsformer. Designet er derfor godt egnet ved effektforskning innen sykepleie, og kunnskapen som blir produsert bør få en høy status i kunnskapshierarkiet

Acupuncture for postoperative morbidities in children, and placebo by proxy

Acupuncture may be beneficial for the prevention of postoperative nausea and vomiting in children and is associated with minor adverse events. The two RCTs in this dissertation investigated the effects of acupuncture by means of a pragmatic randomised controlled trial design. Placebo effects are affected by patient expectancy towards the treatment. The present survey explored the placebo effects by proxy which is a rather unexplored field. A narrative review summarised research on acupuncture and acupressure in ambulatory anaesthesia. Conclusions • When investigating the system effect, acupuncture during anaesthesia followed by postoperative acupressure seems to reduce vomiting in children after tonsillectomy and/or adenoidectomy. • When investigating the specific effect with the intention to exclude placebo effects, acupuncture during anaesthesia does not seem to reduce nausea and vomiting in children after tonsillectomy and/or adenoidectomy. • The survey on preoperative parental expectancy to treatment efficacy was not able to detect any such placebo effect by proxy. • There may have been a placebo effect that was not captured by our measure of parental preoperative expectancy, and the explanations for the manifest discrepancy between the RCTs should be sought understood by the following factors: o Placebo effects not accounted for by preoperative parental expectancy: Placebo effects emerging into and throughout the postoperative period on/by parents and children. o Placebo effects conveyed by care-givers and assessor in the postoperative period. o Nocebo effects in the Paper I study conveyed by all involved persons (children, parents, care-giver, and assessor), knowing that the children were allocated to control group. o A specific effect of acupressure in the postoperative period, as opposed to only acupuncture during anaesthesia. • The review showed that it is reasonable to consider acupuncture as part of ambulatory anaesthesia. However, since conclusive evidence regarding acupuncture effect is lacking, there have to be a trade-off between these treatments and other strategies in the future. • Studies investigating acupuncture treatment for children should manage a balance between an adequate acupuncture dose and technique, and a child-friendly approach. • Interesting issues for the future may be research on different acupuncture techniques and characteristics – in addition to the essential question about specific effects versus placebo effects.

Placebo effect is probably what we refer to as patient healing power. A qualitative pilot study among complementary therapists in Norway.

Background Complementary therapists spend considerable time with their patients, especially in the first consultation. The communication between patients and their therapists is important for raising consciousness and activation of the patient’s self-healing power. Thus, the aims in this study were to delineate what complementary therapists regard as essential in patient consultations, their view of the healing process, and how the therapists understand the placebo effect and its position in the healing process. Methods Semi-structured individual interviews (n = 4), focus group interview (n = 1) and participant observation were conducted among four different complementary therapists in a Norwegian community. The text data was transcribed verbatim and the analysis of the material was conducted according to conventional and direct content analysis. Some codes were predefined and others were defined during the analysis. Results The pilot study showed that the implemented methods seems feasible and fit well with the aims of this study. Complementary therapists (chiropractor, naprapath (musculoskeletal therapist), acupuncturist and acupuncturist/homeopath) representing four different complementary modalities participated. A combination of the conversation and examination during the first consultation formed the basis for the therapist’s choice of treatment. A successful consultation was characterized by a fruitful relationship between the therapist and the patient. Moreover, the therapist needs to be humble and show the patient respect. Patients’ positive beliefs and expectations about the treatment play a significant role in the healing process. The more hope the therapist can bring about, the more easily the patient can start believing that it is possible to get well. Conclusion This was a pilot study. Therefore the findings should be appreciated as limited and preliminary. Therapists’ and patients’ mutual understanding and treatment goals were essential for a successful consultation. The therapists emphasized their professional skills and therapeutic competence as important when building fruitful relationships with their patients. Exerting authority and making the patient feel confident were essential factors for a successful healing process. The complementary therapists understood the placebo effect as the patient’s self-healing power, resulting from establishing trust and belief in the treatment process

Placebo by proxy expectations toward acupuncture change over time: a survey comparing parental expectations to acupuncture pre- and postoperatively

Abstract Background Patients entering a treatment have expectancy to outcome based on their previous experience, the information received, and the credibility of the treatment. Once the treatment has started, patients may detect and interpret contextual cues and somatic state. Influenced and conditioned by positive or negative interpretations, their reappraisal may improve or worsen the treatment outcome. The aims were to investigate whether parental pre-treatment expectancies towards acupuncture differ compared to post-treatment expectancies, and assess predictors for possible change of parental expectancy. Further, we wanted to explore whether the change correlates with the treatment outcome, i.e. postoperative vomiting in children. Methods Two hundred and eighty-two parents completed per- and 24 h postoperatively a survey on their expectancy to acupuncture treatment for alleviation of postoperative vomiting in children. The survey was embedded in a randomised controlled trial. Results Parental expectancy to acupuncture treatment changed over time. The changes were predicted by several variables such as children’s gender, parents’ age and education, previous experiences, and assignment to treatment group. The strongest predictor was parental anxiety to their child undergoing surgery. Further, the change of parental expectancy was correlated with postoperative vomiting. Conclusions Anxious parents are prone to change their expectancy in a positive direction during the treatment period, which in turn may improve treatment outcome. Acupuncture therapists in clinical practice should pay a special attention to the potential that lies here, and acknowledge parental anxiety as a possible facilitator, and not a barrier, to elicit placebo by proxy effects. Further research to expand the findings of the present study into other treatments is in order. Future research should also provide more knowledge about how parental expectancy changes over time, and how different factors predict and produce change of parental expectancy. Trial registration ClinicalTrials.gov NCT01729052. Registered November 20, 2012

Placebo by proxy expectations toward acupuncture change over time: A survey comparing parental expectations to acupuncture pre- and postoperatively

Background: Patients entering a treatment have expectancy to outcome based on their previous experience, the information received, and the credibility of the treatment. Once the treatment has started, patients may detect and interpret contextual cues and somatic state. Influenced and conditioned by positive or negative interpretations, their reappraisal may improve or worsen the treatment outcome. The aims were to investigate whether parental pre-treatment expectancies towards acupuncture differ compared to post-treatment expectancies, and assess predictors for possible change of parental expectancy. Further, we wanted to explore whether the change correlates with the treatment outcome, i.e. postoperative vomiting in children. Methods: Two hundred and eighty-two parents completed per- and 24 h postoperatively a survey on their expectancy to acupuncture treatment for alleviation of postoperative vomiting in children. The survey was embedded in a randomised controlled trial. Results: Parental expectancy to acupuncture treatment changed over time. The changes were predicted by several variables such as children’s gender, parents’ age and education, previous experiences, and assignment to treatment group. The strongest predictor was parental anxiety to their child undergoing surgery. Further, the change of parental expectancy was correlated with postoperative vomiting. Conclusions: Anxious parents are prone to change their expectancy in a positive direction during the treatment period, which in turn may improve treatment outcome. Acupuncture therapists in clinical practice should pay a special attention to the potential that lies here, and acknowledge parental anxiety as a possible facilitator, and not a barrier, to elicit placebo by proxy effects. Further research to expand the findings of the present study into other treatments is in order. Future research should also provide more knowledge about how parental expectancy changes over time, and how different factors predict and produce change of parental expectancy

Ambulatory Anesthesia Dovepress Acupuncture in ambulatory anesthesia: a review

Background: Post-anesthetic morbidities remain challenging in our daily practice of anesthesia. Meta-analyses and reviews of acupuncture and related techniques for postoperative nausea and vomiting (POVN) and postoperative vomiting (POV) show promising results while many clinicians remain skeptical of the value of acupuncture. Given the interest in finding safe nonpharmacological approaches toward postoperative care, this body of knowledge needs to be considered. This review critically appraises and summarizes the research on acupuncture and acupressure in ambulatory anesthesia during the last 15 years. Methods: Articles were identified through searches of Medline, PubMed, and Embase using the search terms "acupuncture" or "acupuncture therapy" in combination with "ambulatory anesthesia" or "ambulatory surgery" or "day surgery" or "postoperative". A corresponding search was done using "acupressure" and "wristbands". The searches generated a total of 104, 118, and 122 references, respectively. Results: Sixteen studies were included; eight studies reported on acupuncture and eight on acupressure. Nine studies found acupuncture or acupressure effective on primary endpoints including postoperative nausea and vomiting, postoperative pain, sore throat, and emergence agitation. Four studies found acupuncture had a similar effect to antiemetic medication. Conclusion: Overall, the studies were of fairly good quality. A large proportion of the reviewed papers highlights an effect of acupuncture or acupressure on postoperative morbidities in an ambulatory setting. However, one should bear in mind that research on acupuncture/acupressure in an ambulatory setting contributes to ambiguous conclusions. Hence, we have addressed some of the issues related to this diversity in acupuncture research

Additional file 1: of Placebo by proxy expectations toward acupuncture change over time: a survey comparing parental expectations to acupuncture pre- and postoperatively

Questionnaire: Parental expectancy, anxiety and previous experience with acupuncture assessed by a questionnaire constituting three sections of questions with response options on visual analogue scales from 0 to 9. (DOCX 24 kb

Nurse anaesthetist students’ experiences of patient dignity in perioperative practice.

Aim : The aim of the study was to describe how nurse anaesthetist students experi- enced patient dignity in perioperative practice. Design : A hermeneutical design and the critical incident technique were used to ob- tain experiences from practice. Method : In the Autumn of 2015, after participating in a mandatory lecture on ethics, 23 nurse anaesthetist students reported their experiences and interpretation concern- ing violation and preservation of patients’ dignity in the operating theatre. The text, which was a compilation of descriptions of 35 incidents, was analysed by using herme- neutical text interpretation. Findings : The text revealed three main themes preserving patients’ dignity: allocating time to the patient, inviting the patient to participate and shielding the patient’s body. Furthermore, three main themes of dignity violation were identified: alienation, back- biting and violation of intimate sphere. Conclusion : Discussion and reflection based on the personal experience of the stu- dents during their practice are ways to strengthen ethical awareness and promote an ethical and dignified caring culture

Additional file 1: of "Placebo effect is probably what we refer to as patient healing power": A qualitative pilot study examining how Norwegian complementary therapists reflect on their practice

Interview Guide. (DOCX 23 kb

Acupuncture versus usual care for postoperative nausea and vomiting in children after tonsillectomy/adenoidectomy: a pragmatic, multicenter, double-blinded, randomized trial

Objectives To investigate the effect of a standardised acupuncture on nausea and vomiting in children after tonsillectomy with or without adenoidectomy when possible placebo effects were precluded. Methods A pragmatic, multicentre, doubleblinded, randomised controlled trial. The study was conducted over 10 months in 2012–2013 at three ambulatory clinics. Two hundred and eighty-two children, age 1–11 years, American Society of Anesthesiologists grade ≤II, were included. To equalise expectancy effects, all parents were told that their child would receive acupuncture. However, children were randomly allocated to perioperative bilateral needling acupuncture at PC6, depth 7 mm, mean time 17 min (SD 5–45) during anaesthesia plus usual care, or to usual care only. The regional ethics committee approved this approach. Primary endpoints were nausea and vomiting 24 h postoperatively.Results This study did not demonstrate any effect of acupuncture (95% CI) compared with standard care. The overall vomiting in the acupuncture and usual-care groups was 44.2% and 47.9%, respectively. Nausea was experienced by 31.7% in the acupuncture group and by 32.6% in the usual-care group. The test power was acceptable for comparisons of vomiting. Conclusions The findings suggest that when controlling for possible placebo effects standardised PC6 acupuncture needling during anaesthesia without further stimulation of PC6 is not effective in reducing nausea and vomiting in children after tonsillectomy with or without adenoidectomy. Future studies should investigate acupuncture treatment which balances adequate dose and technique and a feasible, child-friendly acupuncture treatment