Wouldn’t it be great to have something quick, safe,
ubiquitous, non-invasive and cheap to give patients with nausea in the ED? How
about getting them to sniff on an alcohol wipe?
Yes, you heard me correctly.
But unfortunately, it is probably no better than proper placebo and may cause downstream harm.
There have been some prior studies of alcohol nasal
inhalation in the post-operative literature. In addition, aromatherapy has been
used in other studies investigating treatments for nausea. So why not bring it
to the ED?
This was a randomized
double blind, placebo controlled trial performed in a single military ED in
Texas. Inclusion criteria were patients aged 18 to 65 with a chief complaint of
nausea >3/10 on a numerical rating scale (NRS).
Patients were randomized to hold either an alcohol prep pad or sterile saline wipe about 2.5cm from their
nose. They were instructed to nasally inhale deeply for no more than 60 seconds
and told to stop if the nausea was completely relieved. This was repeated at
the 2 and 4 minute mark if they did not have success.
The primary outcome measure was nausea as reported on the NRS
at 10 minutes.
Results? Only 80 patients were recruited but it didn’t
matter because there was a huge treatment effect. At ten minutes, the NRS for
the alcohol arm dropped from 6 to 3. The placebo had no effect at all. This is
great stuff!
But not so fast…
For a placebo to have no effect for nausea is astounding.
The vast majority of studies quote about a 30% reduction in nausea when using
placebo. The results of this study would have been remarkably different had
they used a proper placebo.
Another interesting piece of data was the use of subsequent antiemetics. They were
given in only 72% of the placebo group but were required in 89% of the alcohol group. This 17% (95%CI -0.5 to 34.8)
increase was not statistically significant but quite clearly worrisome. Could
the alcohol sniffing cause paradoxical increased antiemetic requirements?
Probably the biggest argument for skepticism is simple
methodology. Small studies demonstrating large treatment effects are usually proven
wrong. In statistical speak, this is very likely a type I error.
Despite what you may have heard on the social media echo-chamber of the underqualified, we should
not be getting our patients to sniff alcohol. This is unless it is a beautiful
glass of Penfolds Grange Hermitage.
Bon appetit!
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