Aromatherapy with isopropyl alcohol for nausea

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In Review
April MD, et al. "Aromatherapy Versus Oral Ondansetron for Antiemetic Therapy Among Adult Emergency Department Patients: A Randomized Controlled Trial". Annals of Emergency Medicine. 2018. 72(2):184-193.
PubMed • Full text • ClinicalTrials.gov

Clinical Question

In adult patients that present to the ED with nausea and vomiting, does inhaled isopropyl alcohol as compared to oral ondansetron decrease symptoms.

Bottom Line

Among adult patient in the ED with nausea and vomiting who did not require immediate intravenous intervention, aromatherapy with isopropyl alcohol provides greater relief than oral ondansetron alone at 30 minutes.

Major Points

Isopropyl alcohol aromatherapy has been used in several trials, including for post-operative nausea, and have shown little side effects.[1] Common antiemetics including ondansetron, prochlorperazine, and dimenhydrinate have known side effects including constipation, extrapyramidal side effects, and are potentially teratogenic. One previous small trial evaluated the use of isopropyl alcohol versus for symptom control among ED patients with nausea and vomiting.[2] The relative efficacy for isopropyl alcohol versus more conventional antiemetics used in the ED was unknown.

Published in 2018, this paper by April and colleagues randomized 120 urban, tertiary care ED patients with nausea to one of 3 arms: inhaled isopropyl alcohol + oral ondansetron, inhaled isopropyl alcohol + oral placebo, or inhaled placebo + oral ondansetron. Employing a visual analogue scale (VAS), the primary outcome measure was change in VAS at 30 minutes. Overall the trial showed a benefit in the arms with isopropyl alcohol at 30 minutes but to do this patients were allowed unlimited amounts of alcohol pads and they did not describe the numbers of pads employed.

This trial offers a good alternative for patients presenting to the ED with acute nausea and vomiting. This trial is not without issue. It was in a single centre, had small numbers and may have been underpowered for several of the secondary outcomes, and blinding was lost in half of the patients.

Guidelines

As of May 2018, no guidelines have been published that reflect the results of this trial.

Design

  • Single-center, placebo-controlled, blinded, randomized trial
  • N=122
    • Isopropyl alcohol + ondansetron (n=40)
    • Isopropyl alcohol + placebo (n=40)
    • Placebo + ondansetron (n=40)
  • Setting: Urban tertiary care academic hospital
  • Analysis: Modified Intention to treat
  • Primary Outcome: Change of nausea score on a visual analogue scale at 30 min

Population

Inclusion Criteria

  • Age ≥18 years
  • Chief complaint of nausea / vomiting
  • Self-reported nausea severity of 3 or greater on a verbal numeric response scale (range 0 to 10)[3]

Exclusion Criteria

  • Known allergy to isopropyl alcohol or ondansetron
  • Inability to inhale through the nares (eg, rhinitis)
  • Recent intake of medications contraindicating alcohol administration (cefoperazone, disulfiram, or metronidazole)
  • Altered mental status precluding signed informed consent
  • Known history of QT-segment prolongation
  • Clinical suspicion for serotonin syndrome
  • Pregnancy[4]
  • Treating provider discretion

Baseline Characteristics

Isopropyl alcohol + ondansetron group displayed.

  • Demographics: mean age 30.5 years, 50% female
  • Anthropomorphics: mean weight 77 kg
  • Symptoms: mean duration 13.5 h, mean Initial nausea score 53, mean initial pain score 37
  • Presumed symptom cause: Infectious gastroenteritis 55%, food poisoning 8%, urinary track infection 5%, headache 3%, other 29%

Interventions

  • Inhaled isopropyl alcohol + oral ondansetron 4mg
  • Inhaled placebo (saline) Ondansetron 4mg orally
  • Inhaled isopropyl alcohol + placebo

Outcomes

Comparisons are Isopropyl alcohol + ondansetron vs. Isopropyl alcohol + Placebo vs. Placebo + ondansetron.

Primary Outcomes

Change in Visual Analogue Scale (VAS) at 30 min
30 mm (95% CI 22-37) vs. 32 mm (95% CI 25-39) vs. 9 mm (95% CI 5-14) [Effect size 1 vs. 2 20mm, 2 vs. 3 23mm]

Secondary Outcomes

VAS Pain Scale reduction, mean
10mm vs. 11mm vs. 3mm [Effect size 1 vs. 2 7mm, 2 vs. 3 8mm]
Final Nausea Score, mean
16 vs. 16 vs. 29 [Effect size 1 vs. 2 -13mm, 2 vs. 3 -13mm]
Final Pain Score, mean
18 vs. 22 vs. 30 [Effect size 1 vs. 2 -12mm, 2 vs. 3 -8mm]
Nausea Therapy Satisfaction, mean
19 vs. 22 vs. 44
Vomited during Emerg stay
7.5% vs. 0% vs. 7.5%
Receipt rescue antiemetics
28% vs. 25% vs. 45%
Emerg length of stay
217min vs. 224min vs. 210min
Admitted
12% vs. 2.5% vs. 0%

Criticisms

  • Adverse events not described
  • Selection Bias: general healthy population, less severe symptoms, convenience sample employed
  • Blinding was lost on 50% of patients
  • Subjective VAS used over objective measure
  • Unlimited isopropyl alcohol pads were available for duration of stay, number of pads utilized was not described

Funding

  • not described

Further Reading

  1. ↑ Hines S et al. Aromatherapy for treatment of postoperative nausea and vomiting. Cochrane Database Syst Rev 2012. :CD007598.
  2. ↑ Beadle KL et al. Isopropyl Alcohol Nasal Inhalation for Nausea in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med 2016. 68:1-9.e1.
  3. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named oldsniff
  4. ↑ Carstairs SD Ondansetron Use in Pregnancy and Birth Defects: A Systematic Review. Obstet Gynecol 2016. 127:878-83.
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