Medication Regimens for Orthognathic Surgery: Comparative Effects on Hemodynamics and Pain Control

BACKGROUND: Enhanced recovery after surgery protocols have been increasingly applied to orthognathic surgery, but the effects of standardized phase-specific anesthetic regimens on perioperative hemodynamics and pain control remain incompletely characterized. This study evaluated standardized induction and emergence protocols in patients undergoing orthognathic surgery. METHODS: A retrospective cohort study was performed of patients undergoing Le Fort I osteotomy at a single tertiary academic center between 2019 and 2025. Patients were stratified into 4 groups: both induction and emergence protocols, induction protocol only, emergence protocol only, and conventional anesthetic management. Primary outcomes included mean arterial pressure (MAP) and heart rate at standardized perioperative time points. Secondary outcomes included pain scores on postoperative days 0 through 2. A sub-analysis evaluated the isolated effect of tranexamic acid (TXA). RESULTS: The study included 171 patients: 137 controls, 12 induction-only, 18 emergence-only, and 4 both-protocol patients. Baseline clinical variables, including obstructive sleep apnea, airway history, sex, body mass index, and American Society of Anesthesiologists (ASA) class, were comparable across cohorts (P>0.05). MAP upon awakening differed significantly across cohorts, with the lowest value in the both-protocol cohort. Median and maximum postoperative day 0 pain scores were also significantly lower in both-protocol patients compared with controls. In the control cohort, TXA was associated with significantly lower intraoperative MAP. CONCLUSIONS: Standardized emergence-based anesthetic protocols were associated with improved early postoperative hemodynamic control and reduced acute pain after orthognathic surgery. TXA may independently reduce intraoperative MAP, although prospective studies are needed to validate these findings.