Multimodal Protocol Reduces Postoperative Nausea and Vomiting in Patients Undergoing Le Fort I Osteotomy

Abstract

Purpose-To assess the impact of a multimodal antiemetic protocol on postoperative nausea and vomiting (PONV) after LeFort I osteotomy.Methods-Consecutive subjects undergoing LeFort I osteotomy with or without additional procedures at a single academic institution were recruited as the intervention cohort for an IRBapproved prospective clinical trial with a retrospective comparison group. The intervention 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 consisted of consecutive subjects from a larger study who underwent similar surgical procedures prior to protocol implementation. Data including Please address correspondence to: Dr. Jay Anderson, 101 Manning Dr CB 7450, Chapel Hill, NC 27599, janderson@aims.unc.edu, 919.537.3721 phone, 919.537.3407 fax. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Results-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), age (median 19 and 20 years old, P=0.75), proportion of subjects with known risk factors for PONV (P=0.34), percentage undergoing bimaxillary surgery (60% for both groups), and percentage for whom surgery time was over 180 minutes (63% versus 59%, P=0.51). NIH Public AccessPrevalence of PON was significantly lower in the intervention group than the comparison group (24% versus 70%, P<0.0001). Prevalence of POV was likewise significantly lower in the intervention group (11% versus 28%, P=0.0013). The likelihood that subjects in the comparison group would experience nausea was 8.9 and vomiting 3.7 times higher than in the intervention group.Conclusion-This multimodal protocol was associated with substantially decreased prevalence of PONV in subjects undergoing LeFort I osteotomy.

Postdischarge Nausea and Vomiting Remains Frequent After Le Fort I Osteotomy Despite Implementation of a Multimodal Antiemetic Protocol Effective in Reducing Postoperative Nausea and Vomiting

“…1,16-29 The protocol was based largely on consensus guidelines. 2 A detailed rationale for protocol development and a description of inclusion and exclusion criteria have been reported.…”

“…2 A detailed rationale for protocol development and a description of inclusion and exclusion criteria have been reported. 1 …”

“…Guidelines have been developed to help minimize PONV, and implementation of a multi-modal protocol has recently been shown to effectively decrease PONV in the orthognathic surgical population. 1-3 Postdischarge nausea and vomiting (PDNV), although also common, is less well understood. 4 The recently updated Society for Ambulatory Anesthesia guidelines for the management of PONV emphasize that “PDNV is still a significant problem” despite advances in the prevention of PONV.…”

“…14,15 A multimodal protocol that decreased prevalence of PONV after Le Fort I osteotomy with or without additional procedures has recently been reported. 1 The preponderance of studies evaluating modalities to address PONV simply have evaluated effectiveness at discharge from the recovery room or at 24 hours postoperatively; thus, this study also was designed to evaluate PDNV. The purposes of this study were to assess the prevalence of PDNV after Le Fort I osteotomy, with or without additional procedures, and to evaluate the impact of the multimodal protocol on PDNV.…”

Best Practices for Management of Pain, Swelling, Nausea, and Vomiting in Dentoalveolar Surgery

“…The same antiemetic medication should not necessarily be used again as rescue therapy if initial treatment of PONV fails. Silva and colleagues 55 called for development of protocols for preventing PONV in the orthognathic surgery population in 2006, and today Brookes and colleagues 44 have addressed these needs based on good science and understanding of multimodal approach to managing PONV in the orthognathic surgery population. Perhaps these protocols can be studied and modified for our outpatient surgical procedures in the future.…”