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

Pharmacological Strategies for Postdischarge Nausea and Vomiting: Evidence-based Review Update

PURPOSE

Evaluate the effectiveness of various drugs in preventing postdischarge nausea and vomiting (PDNV).

DESIGN

Systematic review.

METHODS

A search for evidence was conducted in PubMed, CINAHL, Cochrane Collaboration, and Google Scholar and gray literature. Only randomized controlled trials examining a pharmacological agent to prevent PDNV were included in the study. The quality appraisal of the literature was conducted using the proposed algorithm described in the Johns Hopkins Nursing Evidence-Based Practice Evidence Level and Quality Guide.

FINDINGS

A total of 8 randomized controlled trials involving 1,441 patients were analyzed. The efficacy of pharmacological agents, including dexamethasone, olanzapine, ondansetron, palonosetron, ramosetron, promethazine, and casopitant in the prevention of PDNV, varied. Additionally, a combination of two or more drugs is a more effective therapy than using a single drug in mitigating PDNV. The review also underscored the individual patient factors that can play a significant role in identifying appropriate prevention and treatment modalities.

CONCLUSIONS

There is limited evidence on the efficacy of pharmacological agents in preventing PDNV. The scarcity of large-scale, clinical trials specifically focusing on PDNV restricts the ability to recommend prophylactic drug therapy for reducing its incidence.

Perioperative care in orthognathic surgery - A systematic review and meta-analysis for enhanced recovery after surgery

The aim of this study was to determine whether implementing ERAS (Enhanced Recovery After Surgery) elements/protocols improves outcomes in orthognathic surgery (OGS) compared to conventional care. To achieve this, ERAS-specific perioperative elements were identified and literature on ERAS for OGS was systematically reviewed. Using PRISMA methodology and GRADE approach, 44 studies with 49 perioperative care elements (13 pre-, 15 intra-, 21 postoperative) were analyzed. While 39 studies focused on single elements, only five presented multimodal protocols, with three related to ERAS. Preoperative elements included antimicrobial and steroid prophylaxis and prevention of postoperative nausea and vomiting. Intraoperative aspects, especially anesthesiological, showed high evidence. Outcome parameters were heterogeneous: complications and postoperative pain were well-investigated with high evidence, while length of stay (LOS) and patient satisfaction received low to medium evidence. ICU LOS, healthcare costs, and readmission rates were underreported. The meta-analysis revealed significant results for pain reduction and trends towards fewer complications and shorter LOS in the ERAS group. Overall, ERAS protocols are not established in OMFS, particularly OGS. Further research is needed in pre- and postoperative care and standardized multimodal analgesia. The next step should be developing a comprehensive OGS protocol through a consensus conference and implementing it in clinical practice.

Comparative Efficacy of Granisetron and Droperidol After Orthognathic Surgery for Prophylaxis of Postoperative Nausea and Vomiting: A Retrospective Study

BACKGROUND

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.

PURPOSE

We compare the efficacy of droperidol and granisetron for PONV prophylaxis following orthognathic surgery.

STUDY DESIGN, SETTING, SAMPLE

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.

PREDICTOR VARIABLE

PONV prophylactic therapy included isolated droperidol, isolated granisetron, and droperidol with granisetron administration.

OUTCOME VARIABLES

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.

COVARIATES

Age, sex, body mass index, Apfel's score, duration of surgery, duration of anesthesia, intraoperative blood loss, and type of surgery.

ANALYSES

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.

RESULTS

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.

CONCLUSIONS AND RELEVANCE

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

PURPOSE

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.

DESIGN

This study used a prospective, cross-sectional, observational design.

METHODS

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.

FINDINGS

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.

CONCLUSIONS

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.

Efficacy of PECS block in addition to multimodal analgesia for postoperative pain management in patients undergoing outpatient elective breast surgery: A retrospective study

Background

Pectoralis nerve blocks (PECS) have been shown in numerous studies to be a safe and effective method to treat postoperative pain and reduce postoperative opioid consumption after breast surgery. However, there are few publications evaluating the PECS block effectiveness in conjunction with multimodal analgesia (MMA) in outpatient breast surgery. This retrospective study aims to evaluate the efficacy of PECS's blocks on perioperative pain management and opioid consumption.

Methods

We conducted a retrospective study to assess the efficacy of preoperative PECS block in addition to preoperative MMA (oral acetaminophen and/or gabapentin) in reducing opioid consumption in adult female subjects undergoing outpatient elective breast surgery between 2015 and 2020. A total of 228 subjects were included in the study and divided in two groups: PECS block group (received PECS block + MMA) and control Group (received only MMA). The primary outcome was to compare postoperative opioid consumption between both groups. The secondary outcome was intergroup comparisons of the following: postoperative nausea and vomiting (PONV), incidence of rescue antiemetic medication, PACU non-opioid analgesic medication required, length of PACU stay and the incidence of 30-day postoperative complications between both groups.

Results

Two hundred and twenty-eight subjects (n = 228) were included in the study. A total of 174 subjects were allocated in the control group and 54 subjects were allocated in the PECS block group. Breast reduction and mastectomy/lumpectomy surgeries were the most commonly performed procedures (48% and 28%, respectively). The total amount of perioperative (intraoperative and PACU) MME was 27 [19, 38] in the control group and 28.5 [22, 38] in the PECS groups (p = 0.21). PACU opioid consumption was 14.3 [7, 24.5] MME for the control group and 17 [8, 23] MME (p = 0.732) for the PECS group. Lastly, the mean overall incidence of postsurgical complications at 30 days was 3% (N = 5), being wound infection, the only complication observed in the PECS groups (N = 2), and hematoma (N = 2) and wound dehiscence (N = 1) in the control group.

Conclusion

PECS block combined with MMA may not reduce intraoperative and/or PACU opioid consumption in patients undergoing outpatient elective breast surgery.

Postoperative nausea and vomiting in patients undergoing colorectal surgery within an institutional enhanced recovery after surgery protocol: comparison of two prophylactic antiemetic regimens

BACKGROUND

Enhanced recovery protocols (ERP) provide optimal perioperative care for surgical patients. Postoperative nausea and vomiting (PONV) is common after colorectal surgery (CRS). We aim to compare the efficacy of aprepitant to a cost-effective alternative, perphenazine, as components of triple antiemetic prophylaxis in ERP patients.

METHODS

Patients who underwent ERP CRS at a single institution from July 2015 to July 2017 were evaluated retrospectively. Only subjects who received aprepitant (Group 1) or perphenazine (Group 2) preoperatively for PONV prophylaxis were included. Patient characteristics, simplified Apfel PONV scores, perioperative medications, and PONV incidence were compared between the groups. PONV was defined as the need for rescue antiemetics on postoperative days (POD) 0-5.

RESULTS

Five hundred ninety-seven patients underwent CRS of which 498 met the inclusion criteria. Two hundred thirty-one (46.4%) received aprepitant and 267 (53.6%) received perphenazine. The incidence of early PONV (POD 0-1) was comparable between the two groups: 44.2% in Group 1 and 44.6% in Group 2 (P = 0.926). Late PONV (POD 2-5) occurred less often in Group 1 than Group 2, respectively (35.9% vs. 45.7%, P = 0.027). After matching the groups for preoperative, procedural, and anesthesia characteristics (164 pairs), no difference in early or late PONV could be demonstrated between the groups.

CONCLUSIONS

The incidence of PONV remains high despite most patients receiving three prophylactic antiemetic medications. Perphenazine can be considered a cost-effective alternative to oral aprepitant for prophylaxis of PONV in patients undergoing CRS within an ERP.