(41) Does Preoperative Aprepitant Reduce Nausea and Emesis After Orthognathic Surgery?

Abstract:
Statement of the Problem: Postoperative nausea and vomiting (PONV) are frequent undesirable side effects encountered following orthognathic surgery. Aprepitant, a neurokinin-1 (NK1) receptor antagonist, demonstrates excellent antiemetic properties and was integrated into our enhanced recovery after surgery (ERAS) protocol to decrease rates of PONV following orthognathic surgery.^1,2 This study aims to elucidate the effect of pre-operative aprepitant use on PONV and post-operative antiemetic requirements.
Materials and

Methods: This is a retrospective cohort study of patients who underwent orthognathic surgery (Le Fort I, BSSO, and BiMax) at Boston Children’s Hospital between January 1, 2024, and December 31, 2024. Hospital records were queried to identify eligible patients. Patients undergoing re-do orthognathic procedures were excluded.

The primary predictor variable was whether a patient was provided a prescription for aprepitant. All subjects who received a prescription were instructed to take one 40-milligram aprepitant capsule three hours prior to surgery. The primary outcome variable was PONV. The secondary outcome variable was the need for rescue antiemetics. Procedure type was analyzed as a covariate.

Descriptive statistics were calculated. Independent Samples T-tests, Chi-Squared tests, and Fisher’s Exact tests were used to analyze associations between variables and outcomes. A P value less than .05 was considered significant.
Results and Outcomes Data: A total of 126 subjects underwent orthognathic surgery during the study period. There were 59 subjects (46.8%) who received an aprepitant prescription. Postoperative emesis significantly differed between subjects who did and did not receive an aprepitant prescription (8.5% vs 25.4%, P = .013). No significant difference was observed in post-operative nausea or postoperative antiemetic requirements between subjects who did and did not receive an aprepitant prescription (37.3% vs 35.8%, P = .864; 59.3% vs 73.1%, P = .101). When stratified by procedure type, subjects who underwent a bimaxillary procedure (Le Fort I and BSSO) experienced significantly less postoperative emesis and postoperative antiemetic requirements when given aprepitant preoperatively (11.1% vs 37.9%, P = .030; 51.9% vs 82.8%, P = .021).

Conclusions: Preoperative aprepitant had greater influence on reducing emesis rather than nausea after orthognathic surgery. The most significant impact of aprepitant use was on subjects undergoing bimaxillary orthognathic procedures, indicating the potential benefit of a more focused approach to prescribing aprepitant.

References:
1. Gan TJ, Apfel CC, Kovac A, Philip BK, Singla N, Minkowitz H, Habib AS, Knighton J, Carides AD, Zhang H, Horgan KJ, Evans JK, Lawson FC; Aprepitant-PONV Study Group. A randomized, double-blind comparison of the NK1 antagonist, aprepitant, versus ondansetron for the prevention of postoperative nausea and vomiting. Anesth Analg. 2007 May;104(5):1082-9.
2. Alam M, Shakeri A, Khorsand A, Nasseri K, Nasseri S. Assessing the impact of aprepitant and ondansetron on postoperative nausea and vomiting in orthognathic surgeries: a randomized controlled trial. BMC Anesthesiol.2023;23(1):412.
Table 1. Aprepitant use vs primary and secondary outcomes