SA2 - Intraoperative Hydromorphone Use Is Associated With Extended Hospital Length of Stay and Increased Postoperative Nausea and Vomiting Following Orthognathic Surgery

Abstract: Purpose: Hospital length of stay (LOS) and postoperative nausea and vomiting (PONV) are consequential outcomes following orthognathic surgery, impacting resource utilization, patient recovery, and satisfaction.¹ Intraoperative hydromorphone may serve as an accessible marker of surgical complexity and perioperative physiologic burden, with downstream effects on both outcomes.² This study examined whether intraoperative hydromorphone dose is associated with extended LOS and increased PONV in a large orthognathic surgery cohort.

Methods: A retrospective chart review of 628 consecutive patients undergoing orthognathic surgery at the University of Pennsylvania (2019-2024) was performed. The cohort included 412 females (65.6%) and 216 males (34.4%), with a median age of 23.5 years (range 14-74) and median BMI of 24.9 kg/m². Procedures included bimaxillary osteotomy (Le Fort I + mandibular; n = 236, 37.6%), isolated Le Fort I (n = 150, 23.9%), SARPE (n = 117, 18.6%), isolated mandibular osteotomy including advancements, setbacks, and segmental procedures (n = 108, 17.2%), and isolated genioplasty (n = 10, 1.6%). Spearman rank correlation assessed the hydromorphone-LOS relationship. Extended LOS was defined as >1 postoperative night. PONV was compared between extended and standard LOS groups by chi-square. Operative time, blood loss, procedure type, and postoperative oxycodone were evaluated as covariates. a = 0.05.

Results: LOS data were available for 626 patients; the majority were discharged after 1 postoperative night (n = 464, 74.4%), while 94 (15.1%) had extended LOS >1 night. Median hydromorphone was 1.00 mg (IQR 0.80-1.70 mg). Hydromorphone correlated significantly with LOS (Spearman r = 0.191, P < .001). Median hydromorphone increased monotonically across LOS strata: 1.00 mg for 1-night stays (IQR 0.80-1.55), 1.50 mg for 2-night stays (IQR 1.00-2.00), and 2.00 mg for =3-night stays (IQR 0.70-2.62; Kruskal-Wallis P = .002). Extended LOS patients received significantly more hydromorphone than standard LOS patients (1.50 vs 1.00 mg, P < .001). PONV was significantly more common in extended LOS patients (10.6% vs 4.5%, P = .015). Operative time was the strongest predictor of both hydromorphone use (r = 0.444, P < .001) and LOS (r = 0.486, P < .001), identifying procedure duration as the primary shared upstream driver.^4,5 Blood loss (r = 0.186, P < .001) and oxycodone use (r = 0.112, P = .005) also correlated independently with LOS. Procedure type significantly differentiated both outcomes (P < .001), with advancements carrying the highest median hydromorphone dose.

Conclusion: Higher intraoperative hydromorphone dosing was significantly associated with extended LOS (r = 0.191, P < .001; median 1.50 vs 1.00 mg, P < .001) and increased PONV (10.6% vs 4.5%, P = .015) in this cohort of 628 orthognathic surgery patients. These associations likely reflect operative complexity, particularly procedure duration, as a shared upstream driver. Intraoperative hydromorphone represents a readily available anesthesia metric that may identify patients at risk for prolonged recovery and PONV, enabling proactive discharge planning and targeted prophylaxis. Prospective evaluation of multimodal analgesia protocols aimed at reducing opioid requirements and their effect on LOS and PONV is warranted.


References

1. Soylu E, Kilavuz MS, Eren C, et al. Understanding Re-Operation in Orthognathic Surgery. J Cranio-Maxillofac Surg. 2025;53(7):977-982.

2. Gan TJ, Belani KG, Bergese S, et al. Fourth Consensus Guidelines for Management of Postoperative Nausea and Vomiting. Anesth Analg. 2020;131(2):411-448.