Postoperative Nausea and Vomiting (PONV) After Orthognathic Surgery: A Retrospective Study and Literature Review

doi:10.1016/j.joms.2006.05.024

Journal of Oral and Maxillofacial Surgery

Volume 64, Issue 9, September 2006, Pages 1385-1397

https://doi.org/10.1016/j.joms.2006.05.024 Get rights and content

Purpose

Postoperative nausea and vomiting (PONV) is the most common postoperative complication after surgery and general anesthesia. PONV occurs primarily within the first 24 hours and can lead to significant morbidity, delayed hospital discharge, increased hospital costs and perhaps most importantly, poor patient satisfaction. We sought, in this study, to determine the prevalence of PONV and to identify risk factors in patients who underwent orthognathic surgery.

Patients and Methods

We conducted a retrospective cross-sectional analytic survey of 553 consecutive patients over 14 years of age, who underwent maxillary and/or mandibular osteotomies at Kaiser Permanente Hospital (Oakland, CA), between January 2003 and March 2004. Patient-, anesthesia- and surgery-related factors that were considered to have a possible effect on the prevalence of PONV events were evaluated.

Results

A total of 514 patients met the inclusion criteria. Among these patients, 40.08% experienced PONV during the first 24 hours after surgery. The most important predictive factors associated with an increased risk of PONV were female gender, young patients (15 to 25 years old), nonsmoking status, presence of predisposing factors (ie, prior history of motion sickness and/or PONV, vertigo or migraine headaches), use of volatile general anesthetics, maxillary surgery, postoperative pain level (PACU) and the use of postoperative analgesic opioid drugs. We found a directly proportional relationship between the number of risk factors and the prevalence of PONV.

Conclusion

We found PONV had a high prevalence among patients undergoing orthognathic surgery. Further studies are needed to develop effective protocols for preventing this common and unpleasant problem.

Section snippets

Pathophysiology of Emesis

The physiology of the vomiting reflex is well understood; however, the pathways involved in the control of nausea and vomiting are not well-known. The act of vomiting, or the vomiting reflex, is coordinated by the vomiting center. This center is located in the lateral reticular formation of the medulla oblongata of the mid-brainstem, close to the fourth cerebral ventricle, to the nucleus of the solitary tract and to the area postrema at the level of the dorsal motor nucleus of the vagus nerve.

Patients and Methods

This study was designed as a retrospective cross-sectional analytic survey to assess the prevalence and possible risk factors for PONV in patients who underwent orthognathic surgery at the Division of Maxillofacial Surgery at Kaiser Permanente Oakland Medical Center (Oakland, CA) between January 2003 and March 2004. After obtaining approval from the Kaiser Permanente Institutional Review Board, a retrospective analysis of the medical records of all patients over 14 years of age who underwent

Preoperative factors and PONV

A total of 553 charts were analyzed in this survey; however, 39 medical records were incomplete and therefore excluded; 514 patients met the inclusion criteria. Of the 514 patients enrolled in this study, an overall prevalence of PONV of 40.08% (206/514) was found. Among the patients who experienced PONV, 63.11% (130/206) occurred only in PACU, 23.79% (49/206) occurred only in the SSU, and 13.11% (27/206) experienced PONV in both (PACU and SSU).

Discussion

The results of this study showed a high prevalence (40.08%) of PONV among orthognathic surgery patients during their hospital stay. This number likely underestimated the actual prevalence of PONV in our patient population as we did not evaluate PONV after our patients were discharged from the hospital. We verified Apfel’s⁷ 4-factor risk score in our patient population and found that multimodal prophylaxis for PONV was not particularly effective in high-risk patients (Fig 3). We found that the

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Is Postoperative Pain Associated With Nausea and Vomiting Following Orthognathic Surgery?
2024, Journal of Oral and Maxillofacial Surgery
Postoperative nausea and vomiting (PONV) is a common adverse side-effect following orthognathic surgery, with pain potentially contributing as a risk factor.
The study's purpose was to measure the association between postoperative pain and PONV.
This prospective cohort study involved patients who underwent bimaxillary surgery at Erciyes University, Oral and Maxillofacial Surgery Hospital. Patients with a history of routine antiemetic use, pregnancy, breastfeeding, morbid obesity, cardiac dysrhythmia, mental retardation, or psychiatric illness were excluded.
The predictor variable was postoperative pain, which was measured using a 100-mm visual analogue scale (VAS). VAS scores were documented at the 30-minute postoperative mark (referred to as VAS1), and the mean of hourly VAS scores over the initial three postoperative hours (denoted as VAS2).
The primary outcome was the occurrence of PONV, defined as active vomiting, retching, or nausea leading to vomiting. The secondary outcome was the timing of PONV, categorized as early (within 6 hours), late (6-24 hours), and delayed (beyond 24 hours postoperatively).
The study's covariates were age, sex, body mass index, Apfel risk scores, surgery duration, history of PONV or motion sickness, and smoking status.
Descriptive statistics and χ² tests were used for data analysis, with statistical significance set at P value < .05.
The sample was composed of 86 subjects with a median age of 20 years (range: 18-30 years), of which 37.2% were male. The frequency of PONV was 50%. Postoperative pain, as measured by VAS scores, was significantly higher in the PONV group compared to the non-PONV group. The median VAS1 score was 60.0 (PONV group, range 40–90) versus 50.0 (non-PONV, range 0–90) (P = .041); for VAS2, it was 60.0 (PONV, range 40–80) compared to 40.0 (non-PONV, range 30–60) (P < .001).
The frequency of PONV observed in patients undergoing bimaxillary surgery is substantial, necessitating the identification and management of risk factors to enhance perioperative care and patient outcomes. By improving PONV management and addressing postoperative pain, health-care providers can enhance the perioperative experience and patient outcomes in bimaxillary surgery.
Does Anesthesiologist Experience Influence Early Postoperative Outcomes Following Orthognathic Surgery?
2024, Journal of Oral and Maxillofacial Surgery
Anesthesia provider experience impacts nausea and vomiting in other surgical specialties but its influence within orthognathic surgery remains unclear.
The study purpose was to evaluate whether anesthesiologist experience with orthognathic surgery impacts postoperative outcomes, including nausea, emesis, narcotic use, and perioperative adverse events, for patients undergoing orthognathic surgery.
This is a retrospective cohort study of subjects aged 12 to 35 years old who underwent orthognathic surgery, including Le Fort 1 osteotomy ± bilateral sagittal split osteotomy, at Boston Children's Hospital from August 2018 to January 2022. Subjects were excluded if they had incomplete medical records, a syndromic diagnosis, or a hospital stay of greater than 2 days.
The predictor variable was attending anesthesia provider experience with orthognathic surgery. Providers were classified as experienced or inexperienced, with experienced providers defined as having anesthetized ≥10 orthognathic operations during the study period.
The primary outcome variable was postoperative nausea. Secondary outcome variables were emesis, narcotic use in the hospital, and perioperative adverse events within 30 days of their operation.
Study covariates included age, sex, race, comorbidities (body mass index, history of psychiatric illness, cleft lip and/or palate, chronic pain, postoperative nausea/vomiting, gastrointestinal conditions), enhanced recovery after surgery protocol enrollment, and intraoperative factors (operation performed, anesthesia/procedure times, estimated blood loss, intravenous fluid and narcotic administration, and anesthesiologist's years in practice).
χ² and unpaired t-tests were used to compare primary predictor and covariates against outcome variables. A P-value <.05 was considered significant.
There were 118 subjects included in the study after 4 were excluded (51.7% female, mean age 19.1 ± 3.30 years). There were 71 operations performed by 5 experienced anesthesiologists (mean cases/provider 15.4 ± 5.95) and 47 cases by 22 different inexperienced providers (mean cases/provider 1.91 ± 1.16). The nausea rate was 52.1% for experienced providers and 53.2% for inexperienced providers (P = .909). There were no statistically significant associations between anesthesiologist experience and any outcome variable (P > .341).
Anesthesia providers' experience with orthognathic surgery did not significantly influence postoperative nausea, emesis, narcotic use, or perioperative adverse events.
Enhanced recovery pathways for head and neck surgery with free tissue transfer reconstruction
2024, Auris Nasus Larynx
The enhanced recovery after surgery (ERAS) pathway is designed to facilitate recovery after surgery by packaging evidence-based protocols specific to each aspect of the perioperative period, including the preoperative, intraoperative, postoperative, and post-discharge periods. The ERAS pathway, which was originally developed for use with colonic resection, is now being expanded to include a variety of surgical procedures, and the ERAS Society has published a consensus review of the ERAS pathway for head and neck surgery with free tissue transfer reconstruction (HNS-FTTR). The ERAS pathway for HNS-FTTR consists of various important protocols, including early postoperative mobilization, early postoperative enteral nutrition, abolition of preoperative fasting, preoperative enteral fluid loading, multimodal pain management, and prevention of postoperative nausea and vomiting. In recent years, meta-analyses investigating the utility of the ERAS pathway in head and neck cancer surgery have also been presented, and all reports showed that the length of the postoperative hospital stay was reduced by the implementation of the ERAS pathway. The ERAS pathway is now gaining traction in the field of head and neck surgery; however, the details of its efficacy remain uncertain. We believe the future direction will require research focused on improving the quality of postoperative patient recovery and patient satisfaction. It will be important to use patient-reported outcomes to determine whether the ERAS pathway is actually beneficial.
The online attention analysis on orthognathic surgery research
2024, Journal of Stomatology, Oral and Maxillofacial Surgery
Altmetrics is one of the fields of bibliometrics that seeks to assess the impact and interest of a given subject through Internet users. The aim of this study is to make an altmetric analysis of the orthognathic surgery literature.
A literature search was conducted using Dimensions app up to December 2023. A list of the 100 most mentioned articles on the topic was compiled. A Google Trends search was performed with same strategy to visualize important data regarding internet search. Charts and tables were created using Microsoft Excel and VOSviewer software to allow bibliometric visualization.
There was a very poor correlation between the number of mentions and the number of citations (r = 0.0202). Most articles discussed on technical innovations associated to orthognathic surgery, majority related to virtual planning (n = 26). Other topics considered interesting to internet readers were complications (n = 18), surgical technique (n = 14), and psychological aspects/quality of life (n = 13).
Online interest in orthognathic surgery closely aligns with the level of academic interest but is also influenced by factors such as location and economic status. The internet is a powerful tool for disseminating scientific research to a broad audience, making it more accessible and engaging than traditional academic channels.
Comparative Efficacy of Granisetron and Droperidol After Orthognathic Surgery for Prophylaxis of Postoperative Nausea and Vomiting: A Retrospective Study
2023, Journal of Oral and Maxillofacial Surgery
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.
Enhanced Recovery After Surgery for Head and Neck Oncologic Surgery Requiring Microvascular Reconstruction
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Basic and patient-oriented researchPostoperative Nausea and Vomiting (PONV) After Orthognathic Surgery: A Retrospective Study and Literature Review

Purpose

Patients and Methods

Results

Conclusion

Section snippets

Pathophysiology of Emesis

Patients and Methods

Preoperative factors and PONV

Discussion

J Oral Maxillofac Surg

Br J Anaesth

J Clin Anesth

J Oral Maxillofac Surg

J Oral Maxillofac Surg

Br J Anaesth

J Perianesth Nurs

Br J Anaesth

Br J Anaesth

Br J Anaesth

J Clin Anesth

Br J Anaesth

Br J Anaesth

Ambul Surg

Br J Anaesth

Gastroenterology

Br J Anaesth

Prevention and treatment of postoperative nausea and vomiting

Drugs

Postoperative nausea and vomitingIts etiology, treatment and prevention

Anesthesiology

The postoperative interviewAssessing risk factors for nausea and vomiting

Anesth Analg

Studies in postoperative sequelae. Nausea and vomiting—Still a problem

Anaesthesia

A simplified risk score for predicting postoperative nausea and vomitingConclusions from cross-validations between two centers

Anesthesiology

Postoperative nausea and vomitingDevelopment of a management protocol

Anaesth Intensive Care

Risk factors for postoperative nausea and vomiting

Anesthesia

Unanticipated admission to the hospital following ambulatory surgery

JAMA

Recommendations for randomized controlled trials to prevent or treat postoperative nausea and vomiting

Anasthesiol Intensivmed Notfallmed Schmerzther

Anesthesia and emesis: I. Etiology

Can Anaesth Soc J

Anesthesia and emesis: II. Prevention and management

Can Anaesth Soc J

The efficacy of ondansetron, droperidol, perphenazine and metoclopramidee in the prevention of nausea and vomiting after major gynecologic surgery

Anesth Analg

Single dose intravenous ondansetron for the 24-hour treatment of postoperative nausea and vomiting

Anesthesia

Postoperative symptoms 24h after ambulatory anesthesia

Can J Anaesth

A survey of postoperative nausea and vomiting

Anaesthesia

Physiology and pharmacology of postoperative nausea and vomiting

Anesthesia

Neuropharmacology of chemoteraphy-induced emesis

Drugs

Does postoperative pain induce emesis?

Clin J Pain

The vomiting centera critical experimental analysis

Arch Neuro Psych

Postoperative nausea and vomitingA review of current literature

Singapore Med J

Basic and patient-oriented research
Postoperative Nausea and Vomiting (PONV) After Orthognathic Surgery: A Retrospective Study and Literature Review