Predictors of Postoperative Nausea and Vomiting After Endoscopic Skull Base Surgery

Abstract

Objectives/Hypothesis: The objective of this study is to evaluate the impact of patient and surgical factors, including approach and reconstruction type, on postoperative nausea and vomiting episodes following endoscopic skull base surgery.Study Design: Retrospective review.Methods: We performed a retrospective chart review from July 2018 to August 2020 of 99 consecutive patients undergoing endoscopic skull base surgery at a tertiary academic skull base surgery program. All patients were treated with a standardized postoperative protocol consisting of scheduled ondansetron, along with promethazine and scopolamine for breakthrough nausea and vomiting episodes. Cumulative nausea and vomiting episodes throughout hospital stay were recorded for each patient.Results: Of the 99 patients identified, the mean number of nausea and vomiting episodes per patient were 0.4 AE 1.2 and 0.3 AE 0.7, respectively. Female sex (β = .65, P = .034) and extended surgical approach (β = .90, P = .027) were associated with increased risk for postoperative nausea. Furthermore, female sex (β = .44, P = .018), cavernous sinus dissection (β = .52, P = .002), and extended approach (β = .79, P = .025) significantly increased odds of postoperative vomiting episodes. There was no association between total operative time or total postoperative opioid dose and nausea and vomiting episodes (all Ps > .05). Neither increased nausea nor vomiting episodes significantly increased odds of prolonged hospitalization (P = .105 and .164, respectively).Conclusion: This report highlights novel risk factors for patients undergoing endoscopic skull base surgery. Upfront standing antiemetic therapy may be considered when treating patients with independent predictors of postoperative nausea and vomiting, including female sex, cavernous sinus dissection, and extended surgical approach.

Postoperative protocols following endoscopic skull base surgery: An evidence‐based review with recommendations

“…In a retrospective study of 99 ESBS patients receiving a standardized perioperative antiemetic regimen, Birkenbeuel et al. demonstrated that an extended surgical approach was associated with higher incidence of PONV 25 . Similarly, cavernous sinus tumor involvement was associated with an increased likelihood of postoperative vomiting only.…”

“…Additionally, providers should consider modifiable risk factors for PONV after ESBS, including, but not limited to, female sex, cavernous sinus dissection, and extended surgical approach, when designing an antiemetic protocol. 25 Similar to prophylactic antiemetics, there is little evidence on the role of prophylactic anticoagulation and restarting preoperative antiplatelet/anticoagulation agents after ESBS. However, with a low event rate overall and apparent minimal risk involved with both mechanical and chemical prophylaxis, consideration should be given to routine anticoagulation following ESBS.…”

“…Despite little evidence demonstrating the benefits of prophylactic antiemetics thus far, in the context of limited harm, consideration may be given to utilizing standing antiemetic regimens to prevent PONV; though future studies must investigate this topic further. Additionally, providers should consider modifiable risk factors for PONV after ESBS, including, but not limited to, female sex, cavernous sinus dissection, and extended surgical approach, when designing an antiemetic protocol 25 . Similar to prophylactic antiemetics, there is little evidence on the role of prophylactic anticoagulation and restarting preoperative antiplatelet/anticoagulation agents after ESBS.…”

“…24 In a retrospective study of 99 ESBS patients receiving a standardized periopera-tive antiemetic regimen, Birkenbeuel et al demonstrated that an extended surgical approach was associated with higher incidence of PONV. 25 Similarly, cavernous sinus tumor involvement was associated with an increased likelihood of postoperative vomiting only. However, the authors did not find a significant association between opioid use and nausea/vomiting episodes, precluding postoperative pain medications as a confounding factor in their observations.…”

In Response to Predictors of Postoperative Nausea and Vomiting After Endoscopic Skull Base Surgery

“…We would like to thank Onal and Onal for their letter to our manuscript entitled "Predictors of Postoperative Nausea and Vomiting After Endoscopic Skull Base Surgery" 1 and for the opportunity to respond to their comments. One of the concerns raised was that our analysis did not account for possible postoperative nausea and vomiting (PONV) events in the postanesthesia care unit (PACU), which Onal and Onal postulated may have extended patients' PACU stays and potentially leading to a nonsignificant finding in the study.…”