The intraoperative use of multimodal analgesia in controlling post-operative pain in the orthognathic patient

Multimodal analgesia is becoming an increasingly popular approach in controlling postoperative pain in the ambulatory setting.  It is an approach that involves administering a combination of opioid and non-opioid analgesics that act on different sites¹. The purpose of this retrospective study is to evaluate the intraoperative use of multimodal analgesia using dexmedetomidine (precedex) via intravenous (IV) infusion and an IV bolus of methadone^2,3 and ketamine, and its effects on postoperative pain control in the orthognathic patient. 

We reviewed 9 orthognathic patients aged 16-45 years (mean 25.55 years +/- 10.74), subdivided into two groups, the study group which consisted of four patients and a control group of five, who were operated on from 2011-2012.  Only patients who underwent double jaw surgery (Lefort I osteotomy with bilateral sagittal split osteotomies or intraoral vertical ramus osteotomies) were included for review.  Patients in the study group received 10mg methadone and 30mg  ketamine both administered as an IV bolus, and were started on a continuous precedex infusion prior to surgical incision.  Precedex was started at a 0.5 mcg/kg/hr infusion and was ceased 45 minutes prior to surgical end time.  Our study population was cross-compared with a control group who received standard inhalational general endotracheal anesthesia, in regards to overall length of stay, postoperative narcotic use, and overall subjective patient comfort.   All patients were admitted on the day of surgery and were placed on a standard dilaudid or morphine patient controlled analgesia (PCA) until oral pain medication was tolerated.  Once the PCA was discontinued, the patient was placed on 5mg/325 mg oxycodone/acetaminophen in either an elixir or tablet form.  The criteria for discharge were pain which was well controlled with oral medications, ambulation, voiding, and tolerating PO intake.

In our review all opiods were converted to a morphine equianalgesic dose⁴.  The multimodal group received an average of 11.2 mg of morphine equivalent via IV and 21.25 mg of morphine equivalent via PO compared to the control group, who received an average of 51.3 mg of morphine equivalent via IV and 180 mg of morphine equivalent via PO.  With regards to length of stay, the multimodal group had a shorter length of stay with the average being 1.5 days while the control group stayed an average of 3 days.  The patients in the study group ambulated without any pain or discomfort within 6 hours post-operatively, while those in the control group did not ambulate until the next day.

The use of intraoperative multimodal analgesia has the capacity to greatly reduce postoperative pain, decrease the amount of post-operative narcotic use and in turn decrease the risks of respiratory depression, and thus reduce overall hospital stay in the orthognathic patient.  The results of this review are very encouraging and this pilot review will serve as a foundation towards a future prospective study evaluating multimodal analgesia.

1. The role of multimodal analgesia in pain management after ambulatory surgery.  Ofelia L. Elvir-Lazo et al.  Current Opinion in Anesthesiology 2010, 23:697-703
2. Intraoperative Methadone Improves Postoperative Pain Control in Patients Undergoing Complex Spine Surgery. Antje Gottschalk et al.  International Anesthesia Research Society Jan 2011, 112:218-23
3. A Double-comparison of the Efficacy of Methadone and Morphine in Postoperative Pain Control.  Gourlay, Geoffrey et al.  Anesthesiology 1986, 64:322-27
4. Anesthesia Secrets, 3^rd Edition.  James Duke.  Mosby Elsevier Inc.  2006.