Postoperative nausea and vomiting after oral and maxillofacial surgery: a prospective study. Dobbeleir M, De Coster J, Coucke W, Politis C.
International Journal of Oral and Maxillofacial Surgery 2018 doi:10.1016/j.ijom.2017.11.018
Presented by: Dr A Phillips
- Post-operative nausea and vomiting (PONV) is common after general anaesthesia
- PONV leads to longer hospitalisation, higher costs, lower patient satisfaction
- Risk scores (e.g. Apfel) exist but limited data on maxillofacial surgery (OMFS) as a risk factor for PONV
- This study aimed to identify which types of OMFS are more related to PONV
Design & Setting
- Single centre observational study
- Participants categorised into bleeding risk based on type of surgery
- PONV score calculated pre-op and anaesthetic tailored to minimise PONV
- Anaesthesia non-standardised. Sevoflurane/desflurane/Propofol Target-controlled infusion (TCI) all used and non-standardised anti-emetic use.
- Online questionnaire completed at day 3 post-op to determine if the patient had PONV
- 308 patients age between 8 to 87 years undergoing general anaesthesia for OMFS
- Exclusion: cancer cases requiring post-operative high dependency unit care (HDU)
- A variety of maxillofacial surgeries from dental extractions to osteotomy
- Primary outcome was self-reported post-operative nausea and vomiting questions (multiple choice answers) in the 3 days after surgery via an online questionnaire.
- 46.1% post-op nausea (PON) and 21.1% post-op vomiting (POV) overall
- PON statistically significantly higher in the bimaxillary surgery (BIMAX)/ bilateral sagittal split osteotomy (BSSO) groups versus “other minor surgery” and dental extraction groups (P <0.05)
- Similar pattern between POV groups but no statistical difference between BSSO and “other minor surgery” group
- Maxillary surgery and BSSO procedures induced significantly more PONV than the other OMFS procedures. These could be included as a parameter in the calculation of the Apfel score.
- Significantly less PON in anaesthesia maintained with sevoflurance vs. Propofol TCI
- An original study
- Highlights limitations in pre-operative PONV scores
- Observational study
- Small sample groups
- Not specified whether elective/emergency surgery
- No standardisation of anaesthetic or antiemetic use – higher PONV in Propofol TCI group is contrary to widespread evidence – suggests reverse causation
- Blood loss hypothesised as contributory factor toward PONV – no quantification of blood loss
- Ingestion of blood hypothesised as contributory factor toward PONV – no mention of the use throat packs
- Retrospective questionnaires are subject to recall bias
- Based on this study, we should consider patients undergoing BSSO/maxillary surgery to be at higher risk of PONV and alter anaesthetic practice accordingly
Potential for impact
- I don’t think it likely that practice would change based on this article. After all, one of the implications would be to avoid TIVA in those at higher risk of PONV!
- The article highlights the higher overall risk of PONV in more complex OMFS cases but does little to convince the reader that the surgeries themselves are independent risk factors for PONV.