Jeff Tanner, MD 

(OMFS)

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Mandibular and Maxillary Osteotomy

**These are guidelines. Please use medical judgement

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I. Preoperative

1. Anesthesiologist to order ERAS meds:

   1. Gabapentin PO

   2. Acetaminophen PO or IV

   3. Pepcid PO or IV

   4. Mobic PO

2. OMFS to order:

   1. Afrin Nasal spray – 2 sprays to right and left nare 

   2. Scopolamine patch

 

II. Intraoperative

1. Briefing: Discuss case per usual

   1. OMFS team will pull up CT scan to determine which nare is the most patent for intubation

   2. Discuss premedications, TXA, anesthetic plan, BP goals etc.

2. Induction: per anesthesiologist

   1. Lidocaine, Propofol, Fentanyl, muscle relaxant

   2. Antibiotics per surgery: cefazolin 2gm IV q4h (for adults less than 120kg), cefazolin 3gm IV q4h (for adults greater than 120kg)

   3. Decadron 8mg IV pre-incision

   4. Dexmedetomidine 0.3-0.5mcg/kg IV titrated bolus up front

3. Equipment:

   1. Elective McGrath for all cases to minimize throat pain, trauma

   2. Parker tip nasal rae ETT

   3. Magill forceps

4. Monitors:

   1. Sedline: this will have considerable artifact given the location and positioning of surgeon, use trends

      1. Recommend index 25-50

      2. Less than 25, consider decreasing anesthesia

      3. Greater than 50, consider increasing anesthesia

   2. Standard ASA monitors, nerve stimulator

5. Maintenance:

   1. Propofol: start at 150 mcg/kg/min and titrate down according to and BIS (40-60 index) and vital signs, recommend <75 mcg/kg/min for case and <50 mcg/kg/min if using remifentanil in conjunction. Use ideal body weight when programming pump.

   2. Optional: Remifentanil: 0.1 – 0.2 mcg/kg/min. Recommended use only during maxillary osteotomy when there is need for hypotension. 

   3. Sevoflorane: 0.5 MAC

   4. Fentanyl: generally not a painful surgery (nerves are paresthetic due to stretching during surgery), Limit total fentanyl to 100 mcg. Please notify MD if more opioid is required.

   5. NDMR: relaxation recommended

   6. Tranexamic acid 1 g IV x 1 per surgeon.

      1. (contraindication: thrombotic disorder, morbid obesity, Hx of DVT/PE)

      2. Surgeon to order

      3. Administer ideally prior to maxilla or when surgeon requests   

   7. IVF: maintenance 75ml/hr, recommend 1L for case

   8. For permissive hypotension consider titration of Remifentanil, nitroglycerin/nitroprusside (1 - 5 mcg/kg/min or bolus), esmolol, or discuss with MD (see MAP goals below). AVOID LONG ACTING ANTIHYPERTENSIVES

6. Maxillary Osteotomy: 

   1. Surgical team to notify anesthesia prior to start of maxillary osteotomy

   2. Goal MAP 65-75 for first 15-20 mins 

   3. approx 30 minutes later, once the maxilla is down-fractured, allow BP to rise up to least MAP >75 (allows identification of any bleeders prior to closing)

7. Mandibular Osteotomy: no specific BP

8. Local Anesthetic infiltration: to be done by OMFS team; 1% lido with 1:200k epi at beginning of case; 0.25% bupivacaine with 1:200k epi at middle of case.

 

III. Emergence

1. Stop propofol infusion at least 45-60 mins prior to finish

2. Stop remifentanil infusion at least 20 minutes prior to finish if not already off prior to mandibular osteotomy

3. Ondansetron 4mg IV

4. Reversal with neostigmine and glycopyrrolate

5. Optional: 2-3 mls of lidocaine 4% down ETT as soon as drapes come down.

6. If mouth is banded shut, OMFS to place nasal trumpet carefully on opposite nare of ETT prior to extubation and suction only thru nasal trumpet or mouth with soft suction catheter; do not want to dislodge clot.

 

IV. Postoperative orders/medications

1. 1st line therapy:

   1. Hycet oral solution 7.5/325mg PO x1 dose PRN mild or moderate pain

   2. Fentanyl 25-50mcg IV PRN x1 doses for severe pain

2. PACU RN to page MD if more pain meds are needed

3. AVOID hydromorphone or morphine

4.  PACU RN to call MD if more pain meds needed

5. Anti-emetics: Zofran 4mg IV, Reglan 10mg IV, avoid benadryl

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