Auricular Acupressure for Managing Nausea–Vomiting, Pain and Fatigue After Liver Arterial Chemoembolization and Hepatic Arterial Infusion Chemotherapy

Summary

A standardized auricular acupressure protocol integrated into peri–interventional nursing care may help relieve nausea, vomiting, pain, fatigue, sleep disturbance, and appetite loss after liver arterial chemoembolization and hepatic arterial infusion chemotherapy while providing a practical and reproducible supportive care workflow for routine clinical implementation and symptom management during hospitalization.

Abstract

Patients undergoing transarterial chemoembolization or hepatic arterial infusion chemotherapy frequently experience nausea, vomiting, pain, fatigue, sleep disturbance, and appetite loss during hospitalization, yet standardized nonpharmacologic supportive care protocols remain limited. This study aimed to describe a standardized auricular acupressure protocol integrated into peri–interventional nursing care and to evaluate its feasibility, tolerability, and symptom–related outcomes. In this single–center, prospective, nonrandomized, quasi-experimental study, 102 consecutive eligible patients treated between January 2022 and December 2024 received either auricular acupressure plus routine nursing care (n = 52) or routine nursing care alone (n = 50). After receiving standardized information about both nursing care pathways, patients selected their preferred pathway. No random sequence or allocation concealment was used. Because the auricular patches were visible and the intervention required active nursing instruction, neither the participants nor the intervention nurses were blinded. The protocol included standardized acupoint selection, vaccaria seed application, nurse–guided self–acupressure training, fidelity monitoring, and symptom assessment before intervention, at 24 h and 48 h after treatment, and before discharge. Auricular acupressure was associated with lower nausea scores at 24 h (3.9 ± 1.2 vs. 4.8 ± 1.4, p = 0.002), 48 h (2.8 ± 1.1 vs. 4.1 ± 1.3, p < 0.001), and before discharge (1.9 ± 0.9 vs. 3.2 ± 1.2, p < 0.001). Vomiting occurrence at 48 h was also lower (26.9% vs. 52.0%, p = 0.009). Patients receiving auricular acupressure additionally showed lower pain and fatigue scores, earlier oral intake, less rescue antiemetic use, and higher satisfaction. No severe intervention–related adverse events occurred. These findings support the feasibility of this nursing protocol but should be interpreted as associations, given the nonrandomized allocation of treatment.

Introduction

Primary liver cancer remains a major cause of cancer–related morbidity and mortality worldwide, and hepatocellular carcinoma accounts for most cases encountered in clinical practice. Many patients are diagnosed at an intermediate or advanced stage, when surgical resection, liver transplantation, or local ablation is no longer feasible. Liver–directed interventional treatments have therefore become an important component of multidisciplinary management. Recent clinical studies have demonstrated the expanding role of transarterial chemoembolization (TACE) in patients with large or unresectable tumors¹. Hepatic arterial infusion chemotherapy (HAIC) has also emerged as an important regional treatment option, particularly for patients with advanced disease or vascular invasion^2,3. Comparative imaging and treatment studies have further supported the growing use of these procedures in contemporary liver cancer care⁴. The choice between TACE and HAIC is influenced by tumor size and distribution, vascular invasion, liver function, previous treatment, and the anticipated balance between tumor control and treatment burden. A randomized phase III trial suggested that HAIC may provide an alternative to TACE for selected patients with large hepatocellular carcinoma⁵. Other comparative studies have evaluated liver injury, treatment safety, and clinical efficacy following HAIC, TACE, or sequential treatment^6,7. Propensity–score analyses have also examined combined TACE–HAIC strategies in patients with portal vein tumor thrombosis⁸. Additional studies have explored HAIC regimens for patients who are unsuitable for or refractory to TACE⁹. Together, these advances have increased the number of patients receiving repeated or intensified arterial interventions and have placed greater demands on peri–interventional nursing care.

The therapeutic landscape has become more complex as HAIC and TACE are increasingly combined with targeted agents or immune checkpoint inhibitors. HAIC combined with toripalimab has been evaluated as an alternative systemic–regional strategy for advanced hepatocellular carcinoma¹⁰. Similar combination approaches involving lenvatinib and programmed cell death protein 1 inhibitors have also been investigated¹¹. Comparative studies continue to assess TACE and HAIC in patients with macrovascular invasion¹², while multicenter cohorts have examined combined arterial and systemic regimens in patients with high tumor burden¹³. Conversion–treatment studies have further highlighted the importance of patient selection and supportive management during intensive multimodal therapy¹⁴. Although these strategies may improve tumor control in appropriately selected patients, they may also be accompanied by nausea, vomiting, abdominal discomfort, pain, fatigue, appetite loss, sleep disturbance, and generalized weakness during hospitalization. Symptom severity varies with treatment type, chemotherapy regimen, extent of embolization, tumor burden, liver function, prior treatment, and individual susceptibility. Studies of high–tumor–burden populations have shown that treatment history and regimen intensity can influence both tolerance and recovery^15,16. Meta–analytic and comparative evidence also indicate that outcomes differ between TACE and HAIC pathways^17,18. Surgical conversion and sequential treatment studies further illustrate the cumulative burden associated with repeated liver–directed therapy^19,20. These findings emphasize the need for supportive nursing strategies that can be applied flexibly across different interventional pathways.

Symptoms after TACE or HAIC often occur as an interacting cluster rather than as isolated events. Persistent nausea may reduce oral intake and aggravate fatigue; abdominal pain may interfere with sleep and mobilization; and poor sleep may further impair appetite and emotional well–being. Pharmacologic management with antiemetics, analgesics, corticosteroids, acid–suppressive agents, sedatives, and nutritional support remains essential, but symptom relief may be incomplete when several symptoms occur simultaneously. Additional medication may also contribute to constipation, dizziness, sedation, gastrointestinal discomfort, or drug interactions, particularly in older patients and those with reduced liver function. Auricular acupressure is a noninvasive complementary nursing intervention in which vaccaria seed patches or similar devices are applied to selected auricular points to provide sustained mechanical stimulation²¹. Controlled studies have examined its potential effects on chemotherapy–related nausea and vomiting and postoperative symptom relief^22,23. Other studies have explored possible benefits for cancer–related fatigue, sleep disturbance, and broader symptom management^24,25.

Integrating auricular acupressure with routine peri–interventional nursing care is necessary because it is intended as an adjunct rather than a replacement for standard symptom management. Patients undergoing TACE or HAIC still require routine hydration, nutritional support, antiemetic and analgesic medication when clinically indicated, postprocedural monitoring, and mobilization guidance. Auricular acupressure may complement these measures by providing repeated, patient–participatory stimulation between scheduled nursing assessments and medication administrations. The need for an integrated protocol is particularly relevant during the early post–treatment period, when several symptoms may emerge simultaneously, change rapidly, and affect oral intake, sleep, mobilization, and willingness to continue subsequent treatment cycles. Without a standardized workflow, acupoint selection, stimulation frequency, patient instruction, safety monitoring, and documentation may vary considerably among nurses and institutions.

Auricular acupressure does not require needle insertion and allows patients to participate in symptom self–management after nursing instruction, making it potentially suitable for repeated liver arterial interventions. However, existing studies vary substantially in acupoint selection, localization methods, stimulation intensity, pressing frequency, intervention duration, adherence monitoring, and outcome assessment. Most previous studies have focused on a single symptom or a general oncology population, and few have provided a reproducible peri–interventional protocol addressing the concurrent nausea, vomiting, pain, fatigue, sleep disturbance, and appetite loss experienced by patients undergoing TACE or HAIC. This methodological gap limits cross–study comparison, replication across institutions, and integration into routine nursing workflows. The protocol was developed through iterative refinement based on published auricular acupressure literature^{21,22,23,24,25}, institutional peri-interventional nursing practice, and multidisciplinary discussion among hepatobiliary surgeons, pain specialists, and senior traditional Chinese medicine nurses. Before prospective clinical implementation, the workflow, acupoint selection, intervention sequence, nursing documentation, and assessment schedule were standardized, and competency-based nurse training and fidelity-monitoring procedures were incorporated to improve reproducibility across operators.

Protocol

This study was conducted in accordance with the Declaration of Helsinki and institutional guidelines for research involving human participants. The Ethics Committee of the Second Affiliated Hospital of Xi’an Jiaotong University approved the study before participant enrollment (approval no. 2026YS462). Written informed consent was obtained from each participant before assigning participants to groups and initiating the nursing intervention. All clinical records, nursing forms, and statistical datasets were de-identified before analysis. The standardized auricular acupressure protocol was developed with reference to published studies on auricular acupressure for nausea, vomiting, pain, fatigue, sleep disturbance, and symptom management in patients with cancer^{21,22,23,24,25}. The intervention workflow was adapted to the institutional peri-interventional nursing setting.

1. Prepare the study and nursing team

1. Define the study design
   1. Conduct a single-center, prospective, nonrandomized controlled quasi-experimental study comparing auricular acupressure plus routine nursing care with routine nursing care alone.
   2. Enroll consecutive eligible patients undergoing transarterial chemoembolization (TACE) or hepatic arterial infusion chemotherapy (HAIC). Apply identical eligibility criteria, routine nursing procedures, outcome-assessment schedules, and rescue-medication criteria to both groups.
      NOTE: Classify the study as quasi-experimental because trained nurses prospectively implement the intervention. Classify it as nonrandomized because participants select their preferred nursing pathway after receiving standardized information.
2. Screen eligible patients
   1. Confirm that the patient is at least 18 years old and has a primary or secondary liver malignancy established by imaging, pathology, or multidisciplinary clinical diagnosis.
   2. Confirm an Eastern Cooperative Oncology Group performance status of 0–2 and the ability to communicate, understand the intervention, cooperate with nursing assessments, and complete symptom-rating instruments.
   3. Include patients who provide written informed consent and agree to complete all predefined assessments regardless of the selected nursing pathway.
   4. Exclude patients with severe psychiatric or cognitive disorders, unstable hemodynamic status, active auricular dermatitis, auricular ulceration or infection, substantial external ear injury, or incomplete clinical information.
3. Assign the nursing pathway
   1. Explain routine peri-interventional nursing care and the additional auricular acupressure procedure to each eligible patient using the same standardized information. Describe the procedure, expected sensations, possible benefits, potential local reactions, and required self-acupressure activities.
   2. Allow the patient to select the preferred nursing pathway. Assign patients selecting auricular acupressure to the intervention group and all other participating patients to the routine nursing care group.
      ​NOTE: Do not generate a random allocation sequence or use allocation concealment.
   3. Record the selected pathway, assignment date, and responsible staff member before initiating the intervention. Document refusals, withdrawals, crossovers, missed interventions, and other protocol deviations.
4. Reduce assessment and analysis bias
   1. Assign trained nurses who are not involved in group selection or intervention delivery to perform outcome assessments whenever staffing permits. Instruct participants not to disclose their nursing pathway during assessment.
   2. Apply identical instruments, verbal instructions, outcome definitions, assessment time points, and rescue-medication criteria to both groups.
   3. Code the dataset with neutral group labels. Keep the statistician blinded to the meaning of the labels until completion of the primary analyses.
      NOTE: Do not attempt to blind participants or nurses delivering auricular acupressure because the patches are visible and the intervention requires active instruction.
5. Record baseline characteristics
   1. Record age, sex, body mass index, tumor type, underlying liver disease, Child–Pugh classification, and Eastern Cooperative Oncology Group performance status.
   2. Record treatment type, previous interventional treatment, treatment cycle, routine supportive medication use, and expected hospitalization duration.
   3. Assess baseline nausea, vomiting, pain, fatigue, sleep disturbance, appetite loss, and treatment-related discomfort.
6. Train intervention nurses
   1. Assign two senior registered nurses with at least 8 years of relevant clinical experience and institutional competency in auricular therapy as trainers.
   2. Provide all intervention nurses with a standardized 6 h training program consisting of 2 h of theoretical instruction, 2 h of demonstration and simulation, and 2 h of supervised practice.
   3. Cover auricular anatomy, acupoint localization, indications, contraindications, patch application, stimulation technique, infection control, patient education, symptom assessment, adverse-event recognition, and documentation.
   4. Train each nurse to identify Shenmen (TF4), Stomach (CO4), Sympathetic (AH6a), Subcortex (AT4), Liver (CO12), Spleen (CO13), and Occiput (AT3). Demonstrate patch placement, manual stimulation, and patient self-acupressure instruction using an auricular map and procedural checklist.
   5. Require each nurse to identify all seven points correctly and complete at least 90% of a 20-item competency checklist during two consecutive return demonstrations. Retrain and reassess nurses who do not meet the competency standard.
   6. Conduct quarterly refresher training and provide case-based feedback on localization, stimulation, documentation, and adverse-event management.
7. Prepare materials
   1. Prepare sterile vaccaria seed auricular patches, sterile tweezers, sterile cotton swabs, 75% alcohol solution, a blunt-ended acupoint probe, disposable gloves, standardized symptom-rating forms, vomiting records, adherence records, and nursing documentation sheets.
   2. Check package integrity, expiration dates, and cleanliness. Arrange the materials on a clean treatment tray before beginning the procedure.

2. Determine and enroll the study sample

1. Estimate the required sample size using the change in nausea visual analog scale (VAS) score as the primary endpoint. Use a two-sided significance level of 0.05, 80% power, an expected difference of 1.2 points, and a standard deviation of 1.2 points.
2. Set a minimum target of 44 participants per group. Increase planned enrollment to approximately 100 participants to allow for incomplete assessments, premature discharge, treatment interruption, or withdrawal.
3. Enroll consecutive eligible participants until the target is reached. Confirm that the final analytic sample exceeds the calculated minimum before performing inferential analyses.
   NOTE: Use the sample-size formula only for planning. Analyze outcomes by comparing two independent cohorts.

3. Prepare the patient

1. Explain the intervention
   1. Explain the purpose, procedure, expected sensations, stimulation schedule, and safety precautions.
   2. Tell the patient that appropriate stimulation can produce mild soreness, warmth, numbness, distension, or tolerable tenderness. Instruct the patient to report sharp pain, dizziness, itching, burning, substantial skin discomfort, or patch loosening immediately.
2. Position and examine the patient
   1. Place the patient in a seated or semi-recumbent position in a quiet area. Adjust the head to expose the external ear while maintaining comfort and stability.
   2. Inspect both ears for dermatitis, erythema, edema, ulceration, infection, bleeding, tenderness, scarring, or other skin injury.
   3. Select an ear without visible skin injury. Delay auricular acupressure when active auricular disease, severe irritation, or substantial tissue damage is present.
3. Clean the auricular skin
   1. Put on disposable gloves. Clean the selected auricular surface with a sterile cotton swab moistened with 75% alcohol, moving from the central region outward.
   2. Allow the skin to air-dry completely before applying the patches.
      CAUTION: Alcohol solution is flammable. Keep it away from ignition sources and prevent contact with the eyes and mucosal surfaces.

4. Locate and select the auricular acupoints

1. Locate the primary points
   1. Identify Shenmen (TF4) in the triangular fossa. Use this point for pain-related discomfort, emotional tension, and general symptom regulation.
   2. Identify the Stomach (CO4) in the cavum conchae. Use this point for nausea, vomiting, loss of appetite, and upper abdominal discomfort.
   3. Identify Sympathetic (AH6a) near the junction of the inferior antihelix crus and the helix. Use this point for autonomic regulation and gastrointestinal symptoms.
   4. Identify Subcortex (AT4) on the inner antitragus. Use this point for fatigue, sleep disturbance, and treatment-related tension.
2. Locate optional points
   1. Identify Liver (CO12) and Spleen (CO13) according to the standardized auricular map. Add either point when digestive, hepatic, appetite-related, or fatigue-related symptoms predominate.
   2. Identify Occiput (AT3) when the patient reports sleep disturbance, anxiety, restlessness, or headache-related discomfort.
3. Confirm the placement sites
   1. Apply gentle pressure around each candidate point using a blunt-ended probe. Identify the site producing the greatest tolerable tenderness, soreness, warmth, numbness, or distension within the standardized anatomical region.
   2. Use the identified sensitive site as the final patch location. Do not use tenderness testing as a diagnostic procedure or outcome assessment.
      NOTE: Select only the points required for the dominant symptom pattern. Avoid excessive patch placement to reduce local irritation.

5. Apply auricular acupressure

1. Apply the patches
   1. Use sterile tweezers to pick up one vaccaria seed patch. Center the seed over the selected acupoint and press the adhesive surface firmly against the skin.
   2. Apply patches to three or four points on one ear during each treatment cycle. Prioritize Shenmen, Stomach, Sympathetic, and Subcortex for patients with nausea, vomiting, pain, and fatigue.
   3. Substitute or add Liver, Spleen, or Occiput according to the dominant symptoms while maintaining a maximum of four stimulated points.
2. Provide initial stimulation
   1. Apply intermittent vertical compression and release directly over each seed for 15–20 s after placement. Do not rub, slide, twist, or rotate the patch.
   2. Increase pressure gradually until the patient reports tolerable soreness, warmth, numbness, distension, or mild tenderness.
   3. Reduce or stop pressure immediately when the patient reports sharp pain, burning, marked dizziness, or intolerable tenderness, or when persistent blanching or skin injury appears.
3. Teach self-acupressure
   1. Demonstrate vertical compression and release using the thumb and index finger with the seed centered between them. Instruct the patient not to use circular rubbing or lateral movement.
   2. Ask the patient to repeat the technique under direct nursing supervision. Correct finger placement, direction, pressure, and timing as necessary.
   3. Instruct the patient to stimulate every applied patch for approximately 1 min per point, three to five times daily. Use sufficient pressure to produce tolerable sensations without sharp pain or burning.
   4. Instruct the patient to perform an additional session when nausea, vomiting, abdominal discomfort, pain, or fatigue becomes more noticeable.
4. Replace patches and alternate ears
   1. Replace the patches every 48 h during hospitalization. Gently remove each patch in the direction of the skin folds and inspect the underlying skin.
   2. Clean the opposite ear and apply new patches using the same localization and placement procedure.
      PAUSE POINT: Suspend stimulation when redness, swelling, severe tenderness, itching, allergic reaction, pressure injury, or other substantial irritation occurs. Resume only after a qualified nurse confirms skin recovery.
5. Continue and document the intervention
   1. Initiate auricular acupressure within 24 h before TACE or HAIC and continue it throughout hospitalization.
   2. Repeat the procedure during subsequent admissions when the patient undergoes additional TACE or HAIC cycles and remains eligible.
   3. Record the selected points, treated ear, application, and replacement times, stimulation instruction, patient tolerance, skin findings, adherence, adverse reactions, and deviations.
   4. Record the time required for initial application and patch replacement. Document the nursing personnel, standard supplies, and training resources used for implementation.

6. Provide routine care and monitor intervention fidelity

1. Provide routine peri-interventional nursing care
   1. Apply the same institutional monitoring, hydration management, nutritional guidance, rescue-medication criteria, and mobilization support to both groups.
   2. Do not apply auricular patches or provide self-acupressure instruction to participants in the routine nursing care group.
   3. Monitor nausea, vomiting, abdominal pain, fatigue, sleep disturbance, appetite loss, and general comfort during every nursing shift. Record clinically relevant changes in the nursing documentation system.
   4. Administer antiemetic, analgesic, hydration, nutritional, and other supportive treatments according to clinical orders and patient condition.
   5. Encourage gradual oral intake when nausea decreases and the patient can tolerate food or fluids. Encourage mobilization after clinical stability is confirmed.
2. Monitor patient adherence
   1. Provide each intervention participant with a daily self-acupressure record. Ask the patient or caregiver to document completed stimulation sessions.
   2. Review the record daily and directly observe at least one self-acupressure session during nursing rounds.
   3. Correct inaccurate point location, finger position, stimulation duration, or pressure. Document missed sessions, patch detachment, skin discomfort, and temporary interruptions.
3. Monitor nurse-delivery fidelity
   1. Use a standardized checklist covering patient preparation, ear examination, point localization, patch placement, initial stimulation, patient education, safety assessment, and documentation.
   2. Complete the checklist during every initial application and patch replacement. Calculate fidelity as the number of completed applicable items divided by the total number of applicable items and multiplied by 100%.
   3. Train designated observers using the protocol, checklist, instructional materials, and example procedures. Conduct calibration exercises before independent fidelity assessment.
   4. Ask a senior trainer to review checklists and adherence records weekly. Directly observe at least 20% of patch application or replacement procedures.
   5. Record missed steps, incorrect stimulation, premature patch detachment, incomplete documentation, skin irritation, and temporary suspension as protocol deviations. Correct deviations through retraining, supervised technique review, patch replacement, or temporary interruption.

7. Assess outcomes and safety

1. Follow the assessment schedule
   1. Complete the baseline assessment within 24 h before TACE or HAIC and before initiating the assigned nursing pathway. Repeat the assessment at 24 h, 48 h, and before discharge.
   2. Administer patient-reported instruments face-to-face using the same standardized wording. Record responses without reinterpretation.
   3. Use the preceding 24 h as the recall period unless the instrument requests current symptom intensity.
   4. Record vomiting continuously and summarize episodes for the 24 h before treatment, 0–24 h after treatment, 24–48 h after treatment, and the period from 48 h to discharge.
   5. Record time to oral intake continuously after treatment, assess early mobilization within 24 h, evaluate satisfaction before discharge, and inspect for adverse events daily.
2. Assess nausea
   1. Present a horizontal 10 cm VAS labeled 0, no nausea, at the left anchor and 10, worst imaginable nausea, at the right anchor²⁶.
   2. Ask the patient to mark the point representing current nausea. Measure the distance from the zero anchor and record it to the nearest 0.1 cm.
3. Record vomiting
   1. Define vomiting as the forceful expulsion of gastric contents. Do not count retching without expulsion.
   2. Count repeated expulsions within a continuous 5 min period as one episode. Verify reported events against nursing observation and medication-administration records.
4. Assess pain and fatigue
   1. Ask the patient to rate current abdominal or treatment-related pain on an 11-point Numeric Rating Scale from 0, no pain, to 10, worst imaginable pain²⁷.
   2. Administer all nine items of the validated Chinese Brief Fatigue Inventory. Calculate the global score as the arithmetic mean of the completed items^28,29,30.
      ​NOTE: Do not calculate the global fatigue score when more than four items are missing.
   3. Read items verbatim to patients with reading difficulty or physical weakness. Do not suggest or interpret responses.
5. Assess sleep, appetite, recovery, and satisfaction
   1. Assess sleep disturbance and appetite loss using separate 0–10 scales referring to the preceding 24 h. Treat these measures as exploratory outcomes.
   2. Define improved sleep as a reduction of at least 2 points from baseline before discharge.
   3. Define time to oral intake recovery as the interval from completion of TACE or HAIC to the first food or fluid intake tolerated without vomiting for the subsequent 2 h.
   4. Define early mobilization as standing or walking out of bed, with or without assistance, within 24 h after treatment.
   5. Record antiemetic or analgesic medication administered beyond the routine regimen. Record hospital stay from admission to discharge.
   6. Assess satisfaction before discharge on a scale from 0, completely dissatisfied, to 10, completely satisfied. Treat satisfaction as an exploratory outcome.
6. Monitor safety
   1. Inspect the treated ear at least once daily. Record tenderness, erythema, swelling, pruritus, allergic reaction, dizziness, premature patch detachment, and pressure-related injury.
   2. Record event severity, management, temporary interruption, and permanent discontinuation. Remove the patches immediately when severe discomfort or visible injury occurs.
   3. Report severe or unexpected events promptly to the responsible physician and study coordinator.

8. Organize and analyze the data

1. Prepare the dataset
   1. Export demographic variables, clinical characteristics, symptom scores, medication use, recovery outcomes, adherence, fidelity, and adverse-event data from the clinical and nursing records.
   2. Enter one participant per row in spreadsheet software and assign an anonymous study code. Check for missing, impossible, duplicated, or inconsistent values before analysis.
   3. Define continuous and categorical variables before performing statistical tests. Treat sleep disturbance, appetite loss, and satisfaction as exploratory variables.
2. Summarize and compare outcomes
   1. Assess the distribution of continuous variables using descriptive statistics and normality plots.
   2. Present normally distributed variables as mean ± standard deviation and non-normally distributed variables as median with interquartile range. Present categorical variables as frequency and percentage.
   3. Compare normally distributed continuous variables using independent-samples t-tests and non-normally distributed variables using Mann–Whitney U tests.
   4. Compare categorical variables using chi-square tests. Use Fisher’s exact test when expected cell counts are small.
3. Perform adjusted analyses
   1. Fit a multiple linear regression model for the 48 h nausea VAS score. Include nursing pathway, age, Eastern Cooperative Oncology Group performance status, Child–Pugh class, treatment type, previous interventional treatment, and baseline nausea score.
   2. Perform exploratory linear regression analyses for 48 h pain and fatigue using the corresponding baseline score and the same clinical covariates.
   3. Fit a parsimonious logistic regression model for vomiting occurrence at 48 h. Include nursing pathway, baseline vomiting status, treatment type, Eastern Cooperative Oncology Group performance status, and Child–Pugh class.
   4. Report adjusted mean differences or odds ratios with 95% confidence intervals and two-sided p-values. Examine multicollinearity and consider variance inflation factors below 5 acceptable.
4. Conduct sensitivity analyses
   1. Estimate each participant’s propensity score using age, sex, body mass index, performance status, Child–Pugh class, treatment type, previous intervention, treatment cycle, and the corresponding baseline symptom.
   2. Apply propensity-score overlap weighting and evaluate balance using standardized mean differences. Consider an absolute standardized mean difference below 0.10 acceptable.
   3. Re-estimate 48 h nausea and vomiting outcomes in the weighted sample. Compare the direction and magnitude of weighted estimates with the conventional and regression-adjusted results.
   4. Analyze complete cases without imputation when all participants in the final analytic sample have complete prespecified outcomes.
   5. Calculate an E-value for the observed 48 h vomiting risk ratio to evaluate the strength of unmeasured confounding required to explain the association.
5. Define statistical significance
   1. Use two-sided tests and define statistical significance as p < 0.05. Report exact p-values whenever possible.

Results

Between January 2022 and December 2024, 118 consecutive patients scheduled to undergo TACE or HAIC were screened for eligibility. Sixteen patients were excluded due to incomplete symptom assessment data, refusal to participate, active auricular skin lesions, or inability to complete the peri-interventional nursing evaluation. The final analytic sample comprised 102 patients. After receiving standardized information regarding both nursing care pathways, 52 patients selected auricular acupressure plus routine nursing care,...

Discussion

The present study proposed a standardized auricular acupressure protocol as a supportive nursing intervention for patients undergoing TACE or HAIC. Unlike many previous studies that mainly focused on single symptoms or general oncology populations, the current protocol specifically targeted the combined symptom burden commonly observed after liver arterial interventional therapy, particularly nausea, vomiting, pain, and fatigue. The intervention integrated structured auricular acupoint selection, standardized stimulation...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
75% alcohol solution	Shandong Lircon Medical Technology Co., Ltd.	ALC-75-500	Used for routine cleaning of the auricular skin before patch application.
Adverse event record sheet	Participating hospital nursing department	AA-AE-2022	Used to document local redness, tenderness, allergy, patch detachment, dizziness, and other intervention-related events.
Auricular acupoint anatomical chart	Participating hospital nursing department	AA-Map-2022	Printed anatomical map used to standardize localization of Shenmen, Stomach, Sympathetic, Subcortex, Liver, Spleen, and Occiput points.
Auricular acupressure operation checklist	Participating hospital nursing department	AA-Checklist-2022	Checklist used by nursing staff to standardize skin inspection, cleaning, acupoint localization, patch placement, stimulation, replacement, and follow-up.
Auricular patch storage box	Participating hospital nursing department	AA-Storage-2022	Clean container used to store auricular patches before bedside use according to institutional nursing practice.
Blunt-ended auricular probe	Shanghai Acupuncture Instrument Factory	AP-102	Used to gently assess local tenderness and identify the most responsive area around each auricular acupoint before patch fixation.
Case report form	Participating hospital research office	CRF-AA-2022	Used to collect baseline characteristics, treatment details, symptom scores, medication use, safety outcomes, and recovery outcomes.
Clinical chemistry analyzer	Roche Diagnostics	cobas c 702	Used in the hospital laboratory for biochemical measurements, including alanine aminotransferase, aspartate aminotransferase, albumin, and total bilirubin.
Data management spreadsheet	Microsoft Corporation	Microsoft Excel 2021	Used for data entry, data checking, table preparation, and summary data management; RRID: SCR_016137.
Disposable medical gloves	Winner Medical Co., Ltd.	GL-2022	Used during auricular skin cleaning, patch placement, and patch replacement according to infection-control requirements.
Electronic medical record system	Participating hospital information center	EMR-2022	Used to retrieve demographic information, diagnosis, treatment regimen, hospitalization data, medication use, and laboratory results.
Electronic nursing documentation system	Participating hospital information center	Nursing-EMR-2022	Used to record nursing assessments, symptom observations, vomiting frequency, oral intake recovery, mobilization, and safety monitoring.
Hematology analyzer	Sysmex Corporation	XN-9000	Used in the hospital laboratory for routine blood tests, including hemoglobin measurement.
Hypoallergenic auricular adhesive patches	Shanghai Medical Materials Co., Ltd.	AP-118	Used to fix vaccaria seeds over selected auricular acupoints without skin penetration.
Intervention adherence record sheet	Participating hospital nursing department	AA-Adherence-2022	Used to record completion of self-acupressure training, daily pressing frequency, and scheduled patch replacement.
Laboratory information system	Participating hospital information center	LIS-2022	Used to retrieve validated laboratory values included in the baseline clinical characteristics table.
Medical waste container	Participating hospital central supply department	MWC-2022	Used for disposal of used cotton swabs, adhesive patches, and other single-use bedside materials.
Numeric Rating Scale form	Participating hospital nursing department	NRS-001	Used to assess pain intensity on a 0 to 10 scale, with higher scores indicating more severe pain.
Patch replacement record sheet	Participating hospital nursing department	AA-Replace-2022	Used to record 48 h patch replacement, ear alternation, skin findings, and temporary suspension when irritation occurred.
Patient education leaflet for auricular acupressure	Participating hospital nursing department	AA-Edu-2022	Used to explain expected sensations, self-acupressure technique, pressing frequency, patch protection, and when to report local discomfort.
Patient satisfaction scoring form	Participating hospital nursing department	SAT-AA-2022	Used to assess patient satisfaction with peri-interventional supportive care using a 10-point visual scoring system.
Routine antiseptic tray	Participating hospital central supply department	ANT-Tray-2022	Used to hold antiseptic materials and sterile accessories during bedside auricular preparation.
R statistical software	R Foundation for Statistical Computing	Version 4.3.2	Propensity-score weighting and sensitivity analyses
Self-acupressure instruction card	Participating hospital nursing department	AA-Card-2022	Bedside instruction card showing how to press each auricular point with thumb and index finger for about 1 min, three to five times daily.
Skin inspection flashlight	Shenzhen Mindray Bio-Medical Electronics Co., Ltd.	FL-01	Used during local ear skin inspection before application and during each patch replacement.
Standard hospital bed	Participating hospital equipment department	BED-2022	Used to position patients in a seated or semi-recumbent position during intervention.
Standard operating procedure manual	Participating hospital nursing department	SOP-AA-2022	Manual used for nurse training and procedural standardization before implementation.
Statistical analysis software	IBM Corp.	SPSS Statistics Version 27.0	Used for normality testing, t-tests, chi-square tests, Fisher exact tests, Wilcoxon signed-rank tests, and descriptive statistics; RRID: SCR_002865.
Sterile cotton swabs	Winner Medical Co., Ltd.	CS-210	Used for auricular skin cleaning with 75% alcohol solution before seed patch application.
Sterile gauze pads	Winner Medical Co., Ltd.	GZ-2022	Used for local skin drying or gentle cleaning when needed during patch replacement.
Sterile tweezers	Jiangsu Kangjian Medical Apparatus Co., Ltd.	TW-305	Used to pick up and place vaccaria seed patches onto selected auricular acupoints.
Stopwatch or timer	Casio Computer Co., Ltd.	HS-80TW	Used to standardize 15 to 20 s initial pressing by nurses and approximately 1 min self-acupressure per point.
Symptom assessment record sheet	Participating hospital nursing department	SYM-AA-2022	Used to record nausea, vomiting, pain, fatigue, sleep quality, appetite, treatment comfort, and adverse events at predefined time points.
Vaccaria seed auricular patches	Suzhou Medical Appliance Factory	VA-2022	Sterile vaccaria seeds mounted on adhesive patches and used to provide continuous mechanical stimulation of selected auricular acupoints.
Visual Analog Scale form	Participating hospital nursing department	VAS-001	Used to assess nausea severity on a 0 to 10 scale, with higher scores indicating more severe nausea.