Multimodal Protocol Reduces Incidence of Postoperative Nausea and Vomiting in Patients Undergoing Maxillary Osteotomy: A Preliminary Report
Methods: Subjects undergoing maxillary osteotomy with or without additional procedures at a single academic institution were recruited as the intervention cohort for an IRB-approved study. Informed consent process was approved by the IRB and consistent with ClinicalTrials.org guidelines. This cohort was managed with a multimodal antiemetic protocol during hospitalization. The protocol included total intravenous anesthetic technique; prophylactic ondansetron, steroids, scopolamine, and droperidol; gastric decompression at the end of the procedure; opioid sparing analgesia; specific avoidance of morphine and codeine; erythromycin for prokinesis; and hydration to 25 mL/kg. The control group was comprised of a subset of subjects from a larger study who underwent maxillary osteotomy with or without additional procedures at the same institution prior to protocol implementation. Data including presence of PONV were extracted from medical records. Data were analyzed with Fisher’s Exact Test and Wilcoxon Rank Sum Test. P<0.05 was considered significant.
Results: The intervention (n=33) and control (n=137) groups were similar in terms of gender (64% and 65% female, respectively, P=0.89), race (79% and 69% Caucasian, P=0.28), and proportion of subjects with a given number of known risk factors for PONV (P=0.94). A similar percentage of intervention and control subjects underwent bimaxillary surgery (61% and 60%, respectively) and segmental maxillary osteotomy (36% and 34%). Surgery time was greater than 180 minutes for more subjects in the intervention than the control group (73% versus 59%) but the difference was not statistically significant (P=0.15).
Incidence of post-operative nausea was significantly lower in the intervention group than the control group (18% versus 70%, P<0.0001). Incidence of post-operative vomiting was likewise significantly lower in the intervention group than the control group (6% versus 29%, P=0.007).
Conclusion: This multimodal protocol appears to substantially reduce the incidence of post-operative nausea and vomiting in subjects undergoing maxillary osteotomy with or without additional procedures. Enrollment in the intervention cohort is ongoing to assess the stability of reduction in PONV.
References:
1) Silva AC, O'Ryan F, Poor DB. Postoperative nausea and vomiting (PONV) after orthognathic surgery: A retrospective study and literature review. J Oral Maxillofac Surg. 2006;64:1385-1397.
2) Scuderi PE, James RL, Harris L, et al. Multimodal antiemetic management prevents early postoperative vomiting after outpatient laparoscopy. Anesth Analg 2000;91:1408-1414.