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

doi:10.1016/j.joms.2015.01.015

Journal of Oral and Maxillofacial Surgery

Volume 73, Issue 7, July 2015, Pages 1259-1266

https://doi.org/10.1016/j.joms.2015.01.015 Get rights and content

Purpose

To assess the prevalence of postdischarge nausea and vomiting (PDNV) after Le Fort I osteotomy with and without the use of a multimodal antiemetic protocol shown to decrease postoperative nausea and vomiting (PONV).

Materials and Methods

Consecutive patients undergoing Le Fort I osteotomy with or without additional procedures at a single academic institution formed the intervention cohort for an institutional review board–approved prospective clinical trial with a retrospective comparison group. The intervention cohort was managed with a multimodal antiemetic protocol. The comparison group consisted of consecutive patients who underwent similar surgical procedures at the same institution before protocol implementation. All patients were asked to complete a postdischarge diary documenting the occurrence of nausea and vomiting. Those who completed the diaries were included in this analysis. Data were analyzed with the Fisher exact test and the Wilcoxon rank sum test. A P value less than .05 was considered significant.

Results

Diaries were completed by 85% of patients in the intervention group (79 of 93) and 75% of patients in the comparison group (103 of 137). Patients in the intervention (n = 79) and comparison (n = 103) groups were similar in the proportion of patients with validated risk factors for PDNV, including female gender, history of PONV, age younger than 50 years, opioid use in the postanesthesia care unit (PACU), and nausea in the PACU (P = .37). The prevalence of PDNV was unaffected by the antiemetic protocol. After discharge, nausea was reported by 72% of patients in the intervention group and 60% of patients in the comparison group (P = .13) and vomiting was reported by 22% of patients in the intervention group and 29% of patients in the comparison group (P = .40).

Conclusion

Modalities that successfully address PONV after Le Fort I osteotomy might fail to affect PDNV, which is prevalent in this population. Future investigation will focus on methods to minimize PDNV.

Section snippets

Materials and Methods

A prospective, institutional review board–approved clinical trial (919.966.3113, University of North Carolina, Chapel Hill) with a retrospective comparison group was registered with ClinicalTrials.gov. (NCT01592708) This study showed a statistical decrease in postoperative nausea (PON) and postoperative vomiting (POV) experienced by patients undergoing Le Fort I osteotomy, with or without additional procedures, after the introduction of a multimodal antiemetic protocol. PDNV was studied in the

Results

Diaries were completed by 85% of patients in the intervention group (n = 79) and 75% of patients in the comparison group (n = 103). The total intervention (n = 93) and comparison (n = 137) groups were similar in gender (P = .29), race (P = .85), age (P = .75), proportion of patients with known risk factors for PONV (including female gender, nonsmoking status, history of PONV or motion sickness, and history of migraine headaches; P = .34), percentage undergoing bimaxillary surgery (60% in each

Discussion

The authors hypothesized that the prevalence of PDNV would be high after Le Fort I surgery and that the prevalence would be decreased by the antiemetic protocol. The prevalence of PDNV was indeed very high in this patient population. However, although this multimodal antiemetic protocol statistically decreased PON and POV,¹ it had no statistical impact on PDNV. There was a trend toward slightly more PDN that lasted slightly longer in the intervention group, but a trend toward more PDV in the

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Comparative Efficacy of Granisetron and Droperidol After Orthognathic Surgery for Prophylaxis of Postoperative Nausea and Vomiting: A Retrospective Study
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In the fall of 2021, granisetron was approved for postoperative nausea and vomiting (PONV) management in Japan. However, the comparative efficacy of droperidol and granisetron in the field of orthognathic surgery has not been determined.
We compare the efficacy of droperidol and granisetron for PONV prophylaxis following orthognathic surgery.
We performed a retrospective cohort study of patients who underwent orthognathic surgery at a single institution from September 2020 to December 2022. Patients who had undergone Le Fort I osteotomy with sagittal split ramus osteotomy or isolated sagittal split ramus osteotomy were included. Patients were divided into three groups; the isolated droperidol (D), isolated granisetron (G), and droperidol with granisetron (DG) groups. General anesthesia was performed using total intravenous anesthesia for all patients; however, droperidol and granisetron were administered at the anesthesiologist's discretion.
PONV prophylactic therapy included isolated droperidol, isolated granisetron, and droperidol with granisetron administration.
Postoperative nausea (PON) and postoperative vomiting (POV) were determined through medical examination within 48 hours following surgery. Secondary outcomes included complications due to droperidol and/or granisetron administration.
Age, sex, body mass index, Apfel's score, duration of surgery, duration of anesthesia, intraoperative blood loss, and type of surgery.
Statistical analysis was conducted using Fisher exact test, Mann–Whitney U test with Bonferroni correction for univariate comparison, and modified Poisson regression for comparison of PON and POV prophylactic efficacy for multivariate analyses. P values <.05 were considered statistically significant.
Our study included 218 participants. There were no significant differences in covariates between groups D (n = 111), G (n = 52), and DG (n = 55). No significant difference in PON incidence was observed between groups. However, POV incidence was significantly lower in group DG than group D (relative risk, 0.21; 95% confidence interval, 0.05 to 0.86; P = .03). No significant difference in complication incidence was observed between groups.
Granisetron was as effective as droperidol for PONV management, while droperidol combined with granisetron was more effective than isolated droperidol for POV management. As compared to the use of each drug separately, their combination was considered safe, with no increase in complication rates.
Postdischarge Nausea and Vomiting and Co-occurring Symptoms in Women Following Breast Cancer Surgery
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The purpose of this study was to investigate the influence of potential co-occurring symptoms, including fatigue, sleep disturbance, anxiety, depressive symptoms, and pain, on the incidence of postdischarge nausea (PDN) measured two days following discharge to home after surgery for breast cancer.
This study used a prospective, cross-sectional, observational design.
The sample was 334 women aged 27 to 88 years of age. Demographic data were collected from the patient and the medical record before surgery. Symptom data were collected 48 hours following surgery using the Patient Reported Outcome Measurement System (PROMIS) and numerical nausea and pain scales.
Eighty-five (25.4%) of study participants reported some nausea two days after discharge. Study participants who experienced PDN frequently described that it occurred after they left the hospital to drive home following their surgery. Unadjusted odds ratios showed the presence of co-occurring symptoms of anxiety, fatigue, sleep disturbance, and pain were all significantly associated with the presence of nausea 48 hours following surgery. Other significant factors associated with (PDN) were history of motion sickness, history of pregnancy-induced nausea, use of opioids, and type of surgery.
Same-day surgery nurses providing postoperative education for women following surgery for breast cancer should explain to patients that nausea may occur after they are discharged, especially those with known motion sickness. In addition, patients should be informed that other symptoms, especially fatigue, sleep disturbance, and anxiety, may co-occur.
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This evidence-based QI project sample included 294 adult female patients scheduled for gynecologic or breast surgery in the ambulatory setting. They were observed for PONV in the postanesthesia care unit. In addition, compliance of Apfel risk-assessment score documentation on the preanesthesia evaluation form was assessed.
Postimplementation of the guideline, the overall incidence of PONV was significantly lower (9.5% vs 21.1%, P = .009) and anesthesia providers' adherence to Apfel risk score documentation significantly increased (63.3% vs 49%, P = .019).
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Twenty-four consecutive patients treated at a single academic institution were included in this double-blinded randomized control trial and were divided into control (n = 12) and study (n = 12) groups. Patients underwent orthognathic surgery, and the same anesthetic protocol was used for the 2 groups. The only difference between groups was the performance of gastric aspiration in the study group. Patients were observed during the first postoperative day, and information concerning PONV was collected and statistically analyzed.
The 2 groups were similar in age, gender, and medical history. There was no statistically relevant difference between the control and study groups in the overall incidence of PONV (33.3 vs 33.3%). However, there was a significant correlation between the presence of PONV after turbinectomy (P = .011) and patient dissatisfaction (P = .049).
The results of this study could not associate the performance of gastric aspiration with a decrease in the incidence of PONV after orthognathic surgery.
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: This research was funded by National Institutes of Health grant R01 DE 005215.

: Conflict of Interest Disclosures: None of the authors reported any disclosures.

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

Purpose

Materials and Methods

Results

Conclusion

Section snippets

Materials and Methods

Results

Discussion

Multimodal protocol reduces post-operative nausea and vomiting in patients undergoing Le Fort I osteotomy

J Oral Maxillofac Surg

Society for Ambulatory Anesthesia guidelines for the management of postoperative nausea and vomiting

Anesth Analg

Consensus guidelines for the management of postoperative nausea and vomiting

Anesth Analg

Post-discharge nausea and vomiting: An overlooked aspect of ambulatory anesthesia?

Can J Anaesth

Systematic review and analysis of postdischarge symptoms after outpatient surgery

Anesthesiology

Does the routine prophylactic use of antiemetics affect the incidence of postdischarge nausea and vomiting following ambulatory surgery?

Anesthesiology

Postoperative nausea and vomiting after discharge from outpatient surgery centers

Anesth Analg

Unanticipated admission to the hospital following ambulatory surgery

JAMA

Patients’ assessment of ambulatory anesthesia and surgery

J Clin Anesth

Postoperative patient complaints: A prospective interview study of 12,276 patients

J Clin Anesth

Patient satisfaction after anaesthesia and surgery: Results of a prospective survey of 10,811 patients

Br J Anaesth

Which clinical anesthesia outcomes are important to avoid? The perspective of patients

Anesth Analg

Who is at risk for postdischarge nausea and vomiting after ambulatory surgery?

Anesthesiology

Postoperative nausea and vomiting (PONV) after orthognathic surgery: A retrospective study and literature review

J Oral Maxillofac Surg

Post-operative nausea and vomiting following orthognathic surgery

Int J Oral Maxillofac Surg

The efficacy and safety of transdermal scopolamine for the prevention of postoperative nausea and vomiting: A quantitative systematic review

Anesth Analg

Intravenous erythromycin promotes gastric emptying prior to emergency anesthesia

Anesthesiology

Erythromycin mimics exogenous motilin in gastrointestinal contractile activity in the dog

Am J Physiol Gastrointest Liver Physiol

International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding

Ann Int Med

Prokinetics in acute upper GI bleeding: A meta-analysis

Gastrointest Endosc

A factorial trial of six interventions for the prevention of postoperative nausea and vomiting

N Engl J Med

Propofol anaesthesia and postoperative nausea and vomiting: Quantitative systematic review of randomized controlled studies

Br J Anesth

Omitting antagonism of neuromuscular blockade: Effect on postoperative nausea and vomiting and risk of residual paralysis. A systematic review

Br J Anaesth

The effectiveness of rescue antiemetics after failure of prophylaxis with ondansetron or droperidol: A preliminary report

J Clin Anesth

Multimodal antiemetic management prevents early postoperative vomiting after outpatient laparoscopy

Anesth Analg

A comparison of patient-controlled and fixed schedule analgesia after orthognathic surgery

J Oral Maxillofac Surg

Anesthesia/facial pain
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