Post-Discharge Nausea and Vomiting Remains Frequent After Le Fort I Osteotomy Despite Implementation of Multimodal Protocol Effective in Reducing Post-Operative Nausea and Vomiting.

Carolyn C Dicus Brookes DMD, MD, Department of Oral and Maxillofacial Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
John Berry MD, Anesthesiology, UNC-Chapel Hill, Chapel Hill, NC
Josiah Rich DDS, Orthodontics, UNC-Chapel Hill, Chapel Hill, NC
Brent A Golden DDS, MD, Department of Oral and Maxillofacial Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
Timothy A. Turvey DDS, Department of Oral & Maxillofacial Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
Ceib Phillips MPH, PhD, Department of Orthodontics, University of North Carolina at Chapel Hill, Chapel Hill, NC
Jay Anderson DDS, MD, Oral & Maxillofacial Surgery, UNC-Chapel Hill, Chapel Hill, NC
David Rasmussen DMD, MD, Durham, North Carolina, Durham, NC
Post-operative nausea and vomiting (PONV) has received considerable attention. Post-discharge nausea and vomiting (PDNV) is less well understood and can result in readmission, wound complications, and patient dissatisfaction. The purpose of this study is to assess the impact of a multimodal protocol that has successfully decreased PONV on experience of PDNV after LeFort I osteotomy.

Consecutive subjects undergoing LeFort I osteotomy with or without additional procedures at a single academic institution were recruited as the intervention cohort for an IRB-approved study. This cohort was managed with a multimodal antiemetic protocol including total intravenous anesthesia; prophylactic ondansetron, steroids, scopolamine, and droperidol; gastric decompression at surgery end; opioid-sparing analgesia; avoidance of morphine and codeine; prokinetic erythromycin; and minimum 25 mL/kg fluids. The comparison group was comprised of consecutive subjects from a larger study who underwent similar procedures prior to protocol implementation. Data were extracted from medical records; data regarding occurrence of PDNV were derived from patient diaries. Data were analyzed with Fisher’s Exact Test and Wilcoxon Rank Sum Test. P<0.05 was considered significant.

The intervention (n=93) and comparison (n=137) groups were similar in terms of gender (58% and 65% female, P=0.29), race (72% and 71% Caucasian, P=0.85), proportion of subjects with known risk factors for PONV (P=0.34), percentage undergoing bimaxillary surgery (60% in each group), and percentage for whom surgery time was over 180 minutes (63% versus 59%, P=0.51). Diaries were completed by 85% of intervention subjects and 75% of comparison subjects.

Prevalence of PON was significantly lower in the intervention group than the comparison group (24% versus 70%, P<0.0001). Incidence of POV was likewise significantly lower in the intervention group (11% versus 29%, P=0.0013).

Prevalence of PDNV, though, was unaffected by the protocol. PDN was reported by 72% of the intervention subjects and 60% of the comparison subjects who completed the diaries (P=0.09). PDV was reported by 22% of the intervention subjects and 29% of the comparison subjects (P = 0.24).

This study suggests that modalities that successfully address PONV may fail to impact PDNV. Additional investigation into PDNV is merited.

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