title: Multimodal protocol reduces postoperative nausea and vomiting in patients undergoing Le Fort I osteotomy.
abstract: OBJECTIVE
  To assess the impact of a multimodal antiemetic protocol on postoperative nausea and vomiting (PONV) after Le Fort I osteotomy.
  
  
  METHODS
  Consecutive patients undergoing Le Fort I osteotomy with or without additional procedures at a single academic institution were recruited as 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, 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 fluids at a minimum of 25 mL/kg. The comparison group consisted of consecutive patients from a larger study who underwent similar surgical procedures before protocol implementation. Data, including occurrence of PONV, were extracted from medical records. Data were analyzed in bivariate fashion with the Fisher exact and Wilcoxon rank-sum tests. Logistic regression was used to compare the likelihood of nausea and vomiting in the 2 cohorts after controlling for demographic and surgical characteristics. A P value less than .05 was considered significant.
  
  
  RESULTS
  The intervention (n = 93) and comparison (n = 137) groups were similar in gender (58% and 65% female patients; P = .29), race (72% and 71% Caucasian; P = .85), age (median, 19 and 20 years old; P = .75), proportion of patients with known risk factors for PONV (P = .34), percentage undergoing bimaxillary surgery (60% for the 2 groups), and percentage for whom surgery time was longer than 180 minutes (63% and 59%; P = .51). Prevalence of postoperative nausea was significantly lower in the intervention group than in the comparison group (24% vs 70%; P < .0001). Prevalence of postoperative vomiting was likewise significantly lower in the intervention group (11% vs 28%; P = .0013). The likelihood that patients in the comparison group would develop nausea was 8.9 and that for vomiting was 3.7 times higher than in the intervention group.
  
  
  CONCLUSIONS
  This multimodal protocol was associated with substantially decreased prevalence of PONV in patients undergoing Le Fort I osteotomy.
authors.affiliation: Chief Resident, Department of Oral and Maxillofacial Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.
authors.forename: Carolyn Dicus
authors.initials: CD
authors.lastname: Brookes
authors.affiliation: Chief Resident, Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
authors.forename: John
authors.initials: J
authors.lastname: Berry
authors.affiliation: Research Associate, Department of Orthodontics, University of North Carolina at Chapel Hill, Chapel Hill, NC.
authors.forename: Josiah
authors.initials: J
authors.lastname: Rich
authors.affiliation: Clinical Assistant Professor, Department of Oral and Maxillofacial Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.
authors.forename: Brent A
authors.initials: BA
authors.lastname: Golden
authors.affiliation: Professor and Chairman, Department of Oral and Maxillofacial Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.
authors.forename: Timothy A
authors.initials: TA
authors.lastname: Turvey
authors.affiliation: Raymond P. White Distinguished Associate Professor and Program Director, Department of Oral and Maxillofacial Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.
authors.forename: George
authors.initials: G
authors.lastname: Blakey
authors.affiliation: Professor, Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
authors.forename: Vincent
authors.initials: V
authors.lastname: Kopp
authors.affiliation: Professor, Department of Orthodontics, University of North Carolina at Chapel Hill, Chapel Hill, NC.
authors.forename: Ceib
authors.initials: C
authors.lastname: Phillips
authors.affiliation: Associate Professor, Departments of Anesthesiology and Oral and Maxillofacial Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC. Electronic address: janderson@aims.unc.edu.
authors.forename: Jay
authors.initials: J
authors.lastname: Anderson
mesh_terms: D000293:Adolescent; D000328:Adult; D000932:Antiemetics / Q000008:administration & dosage*; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D008297:Male; D019340:Osteotomy, Le Fort / Q000009:adverse effects / Q000379:methods*; D020250:Postoperative Nausea and Vomiting / Q000517:prevention & control*; D055815:Young Adult
chemical_list: D000932:Antiemetics