# Approach 1 — Regional Block (PECS/Serratus) + Multimodal General Anesthesia

> **Educational work by a pre-medical student — not medical advice.** Not a clinical protocol, prescription, or patient handout, and not for patient care. See [DISCLAIMER](../DISCLAIMER.md).

### Post-mastectomy breast implant revision — educational dosing reference, November 2026

*Filename retained for link compatibility ("Protocol_1_OFIA…"). The numbering does not imply preference.*

## How to read this document
This document lays out one approach as a structured educational example. Every numeric value is a label, guideline or consensus value tagged to [DOSING_SOURCES.md](../DOSING_SOURCES.md). The values are **illustrative**. They are not validated for implant revision and are not orders. Real doses are individualized by the treating anesthesiologist under institutional policy, formulary and pharmacy review. Several uses below are off-label (marked).

*Values changed from v2.0, and v2.0 values removed for lack of an acceptable source, are listed in [RELEASE_NOTES.md](../RELEASE_NOTES.md).*

---

## Where this approach fits
- PECS I/II and serratus plane blocks reduce early pain and opioid use after breast surgery compared with no block. The evidence is moderate-certainty and heterogeneous, and the benefit is concentrated early (see [06](../06_References_Evidence_Breast_Augmentation.md)). The 2026 ASA guideline addresses fascial plane blocks for mastectomy, not implant revision specifically [S37](../DOSING_SOURCES.md#s37).
- **No universal superiority.** Most of the analgesic benefit comes from the **block**, not from an opioid-free general anesthetic. In the POFA RCT, dexmedetomidine-based opioid-free anesthesia had **more** of the composite adverse outcome (driven by hypoxemia) and more severe bradycardia, with less PONV and opioid use. Opioid-free GA is an option with its own risk profile. It is not a safer standard.
- "Opioid-sparing" is the aim. Small titrated opioid doses remain acceptable and are not a failure.

**Alternatives:** if a block is contraindicated, declined or unsuccessful, see [Approach 2](Protocol_2_OFIA_BlockFree.md) or [Approach 3](Protocol_3_OpioidBased_NoBlocks.md).

---

## Contraindications and cautions

| Item | Practical approach |
|---|---|
| Infection at block site | Do not perform the block |
| True amide local-anesthetic allergy | No block; consider alternatives |
| Patient refusal | Respect; discuss alternatives |
| Antithrombotic therapy / coagulopathy | **Relative** for superficial, compressible plane blocks. Apply the ASRA guideline by agent, dose, timing and block depth [S36](../DOSING_SOURCES.md#s36) |
| Baseline bradycardia, conduction disease, chronic beta-blockade | Caution with dexmedetomidine (bradycardia/hypotension) [S14](../DOSING_SOURCES.md#s14) |
| Hepatic impairment | Dexmedetomidine dose reduction should be considered [S14](../DOSING_SOURCES.md#s14). IV lidocaine is not used in this approach [S1](../DOSING_SOURCES.md#s1) |
| Severe renal impairment | Avoid ketorolac (contraindicated in advanced renal impairment) [S23](../DOSING_SOURCES.md#s23); NSAID caution [S26](../DOSING_SOURCES.md#s26) |
| Prior chest-wall radiation, obesity | Plane identification may be harder; serratus plane is an alternative |

---

## Local anesthetic: calculate the ceiling first

Sources: [S4](../DOSING_SOURCES.md#s4), [S5](../DOSING_SOURCES.md#s5). The U.S. labels give **absolute** doses, not mg/kg ceilings:

| Agent | Concentration → mg/mL | Label dose information |
|---|---|---|
| Ropivacaine | 0.2% = 2 mg/mL; 0.5% = 5 mg/mL | Field block / infiltration up to 200 mg. Major nerve block 175–250 mg (0.5%, 35–50 mL). Adjust to site and patient status [S4](../DOSING_SOURCES.md#s4) |
| Bupivacaine | 0.25% = 2.5 mg/mL | Individualize the maximum. Most single-dose experience is up to 175 mg plain or 225 mg with epinephrine 1:200,000. ≤400 mg per 24 h [S5](../DOSING_SOURCES.md#s5) |

**Worked arithmetic (education only).**
- Bupivacaine 0.25%, 70 mL = 175 mg. That reaches the label's plain single-dose experience [S5](../DOSING_SOURCES.md#s5) before any surgeon infiltration is added.
- Ropivacaine 0.2%, 80 mL = 160 mg [S4](../DOSING_SOURCES.md#s4).
- Each block volume is chosen by the anesthesiologist. The **total** across both sides and any infiltration shares one budget, and lower is preferred: the LAST advisory emphasizes the lowest effective dose [S2](../DOSING_SOURCES.md#s2).
- In a small or frail patient, institutional weight-based limits apply.

*Not given here:* per-plane "typical volumes" and mg/kg ceilings (v2.0 values removed; no acceptable source verified them). The v2.0 warning that typical volumes can exceed safe totals in smaller patients is kept, in qualitative form.
- Perineural dexamethasone (an off-label use) has no dose given.
- Epinephrine is mentioned only as the labeled 1:200,000 bupivacaine formulation [S5](../DOSING_SOURCES.md#s5).

**Injection safety (qualitative, ASRA [S2](../DOSING_SOURCES.md#s2)):**
- ultrasound guidance;
- incremental injection with aspiration and continuous monitoring;
- stop at any sign of intravascular injection or toxicity.

**LAST preparedness:**
- 20% lipid emulsion immediately available [S3](../DOSING_SOURCES.md#s3).
- Dosing for >70 kg: 100 mL bolus over 2–3 min, then 200–250 mL over 15–20 min. Dosing for ≤70 kg: 1.5 mL/kg bolus over 2–3 min, then ~0.25 mL/kg/min. Upper limit ~12 mL/kg [S3](../DOSING_SOURCES.md#s3).
- If still unstable, repeat the bolus once or twice and/or double the infusion [S3](../DOSING_SOURCES.md#s3).
- Epinephrine in reduced doses (≤1 mcg/kg). Avoid vasopressin, calcium-channel blockers, beta-blockers and further local anesthetic. Benzodiazepine for seizures [S3](../DOSING_SOURCES.md#s3).

**IV lidocaine is not used in this approach.** The consensus advises against IV lidocaine concurrently with blocks or infiltration or while their effect is active, with about 4 h separation [S1](../DOSING_SOURCES.md#s1). This preserves rc2's stricter correction.

---

## Preoperative medications (illustrative)

| Medication | Label / guideline value | Notes |
|---|---|---|
| Acetaminophen | 1000 mg (≥50 kg); max 4000 mg/day all routes [S24](../DOSING_SOURCES.md#s24) | Contraindicated in severe hepatic impairment [S24](../DOSING_SOURCES.md#s24) |
| Celecoxib | 400 mg once (acute-pain regimen) [S25](../DOSING_SOURCES.md#s25) | Renal, GI and CV cautions [S25](../DOSING_SOURCES.md#s25) |
| Gabapentinoid | **Not routine; no dose given** | Verret 2020; off-label |
| Midazolam (anxiolysis) | Titrate slowly; initial IV dose as little as 1 mg and ≤2.5 mg in a healthy adult; reduce in older or debilitated patients and with opioids [S27](../DOSING_SOURCES.md#s27) | Minimize with OSA or delirium risk |

**Antibiotic prophylaxis [S6](../DOSING_SOURCES.md#s6):**
- Cefazolin 2 g IV, or 3 g if ≥120 kg, within 60 min before incision; redose every 4 h [S6](../DOSING_SOURCES.md#s6).
- Severe β-lactam allergy: clindamycin 900 mg (redose every 6 h) [S6](../DOSING_SOURCES.md#s6), or vancomycin 15 mg/kg started within 120 min before incision [S6](../DOSING_SOURCES.md#s6).

**PONV prophylaxis (by Apfel risk factors [S9](../DOSING_SOURCES.md#s9)):**

| Risk factors | Prophylaxis (adults) |
|---:|---|
| 1–2 | **Two interventions** [S7](../DOSING_SOURCES.md#s7), [S8](../DOSING_SOURCES.md#s8): e.g., dexamethasone 4–8 mg IV at induction [S7](../DOSING_SOURCES.md#s7), [S8](../DOSING_SOURCES.md#s8) + ondansetron 4 mg IV at end of surgery [S7](../DOSING_SOURCES.md#s7), [S8](../DOSING_SOURCES.md#s8) |
| ≥3 | **Three to four interventions** [S7](../DOSING_SOURCES.md#s7). Add, for example: propofol-based TIVA; transdermal scopolamine (evening before or 2 h before surgery [S7](../DOSING_SOURCES.md#s7); removed 24 h after surgery per label [S30](../DOSING_SOURCES.md#s30)); or amisulpride 5 mg IV at induction [S31](../DOSING_SOURCES.md#s31) / droperidol 0.625 mg IV at end of surgery [S7](../DOSING_SOURCES.md#s7) (QT warnings) |

---

## Induction (example sequence; individualize)

| Step | Agent | Label / guideline value | Notes |
|---|---|---|---|
| 1 | Ketamine (optional, analgesic adjunct; off-label use) | Bolus ≤0.35 mg/kg [S15](../DOSING_SOURCES.md#s15) | Avoid in active psychosis or poorly controlled cardiovascular disease [S15](../DOSING_SOURCES.md#s15) |
| 2 | Propofol | Healthy <55 y: ~2–2.5 mg/kg. Elderly, debilitated or ASA III–IV: ~1–1.5 mg/kg; titrate (40 mg or 20 mg every 10 s) [S16](../DOSING_SOURCES.md#s16) | Adjuncts reduce requirement; titrate to effect |
| 3 | Rocuronium | 0.6 mg/kg; RSI 0.6–1.2 mg/kg [S17](../DOSING_SOURCES.md#s17) | |
| — | IV lidocaine for airway reflexes | **Not used** with a block (overlap) [S1](../DOSING_SOURCES.md#s1) | No induction lidocaine dose given in this approach |

**Airway:** ETT or supraglottic airway per anesthesiologist judgment and aspiration risk. Confirm with continuous waveform capnography [S35](../DOSING_SOURCES.md#s35).

---

## Maintenance

**Hypnosis**
- *Propofol TIVA:* label maintenance 100–200 mcg/kg/min (healthy <55 y); 50–100 mcg/kg/min (elderly, debilitated or ASA III–IV) [S16](../DOSING_SOURCES.md#s16). The label rates assume co-administered nitrous oxide or opioid. Titrate to depth (processed EEG where used).
- *Volatile:* titrated to age-adjusted MAC (no numeric fraction given).

**Dexmedetomidine (off-label as a GA adjunct)**
- Label procedural-sedation reference: loading 1 mcg/kg over 10 min; maintenance started at 0.6 mcg/kg/h and titrated within 0.2–1 mcg/kg/h [S14](../DOSING_SOURCES.md#s14).
- Patients >65 y: loading 0.5 mcg/kg over 10 min and consider reduced maintenance. Hepatic impairment: consider dose reduction [S14](../DOSING_SOURCES.md#s14).
- Omitting the loading infusion is one way to limit bradycardia and hypotension; titrate within the label range [S14](../DOSING_SOURCES.md#s14). Plan for context-sensitive sedation at emergence.

**Ketamine (optional; off-label analgesic use)**
- Boluses ≤0.35 mg/kg; infusion up to ~1 mg/kg/h [S15](../DOSING_SOURCES.md#s15).

**Opioid:** none planned. Small titrated rescue doses are acceptable (see [Approach 3](Protocol_3_OpioidBased_NoBlocks.md) for label values [S18](../DOSING_SOURCES.md#s18), [S19](../DOSING_SOURCES.md#s19)).

**Ventilation, hemodynamics, temperature:** lung-protective ventilation, patient-specific blood-pressure goals and normothermia per the anesthesiologist. No numeric targets are given (no acceptable source was verified in this pass).

### Hypotension and bradycardia (label values)
1. Assess depth, vasodilation, volume, bleeding and ventilation.
2. Hypotension with bradycardia (dexmedetomidine pattern likely): reduce or stop dexmedetomidine [S14](../DOSING_SOURCES.md#s14).
   - Glycopyrrolate 0.1 mg IV, repeated every 2–3 min as needed [S13](../DOSING_SOURCES.md#s13); or
   - Ephedrine 5–10 mg IV bolus, not to exceed 50 mg [S29](../DOSING_SOURCES.md#s29).
3. Hypotension without bradycardia: phenylephrine 40–100 mcg IV bolus; further boluses every 1–2 min, ≤200 mcg each; infusion 10–35 mcg/min, ≤200 mcg/min [S28](../DOSING_SOURCES.md#s28).
4. Severe bradycardia: atropine per ACLS and the anesthesiologist.

*Values changed from v2.0, and v2.0 values removed for lack of an acceptable source, are listed in [RELEASE_NOTES.md](../RELEASE_NOTES.md).*

---

## Emergence

- Stop infusions. Plan for dexmedetomidine's residual sedation [S14](../DOSING_SOURCES.md#s14).
- PONV: ondansetron 4 mg IV at end of surgery if planned [S7](../DOSING_SOURCES.md#s7), [S8](../DOSING_SOURCES.md#s8).
- **Reversal guided by quantitative monitoring** [S10](../DOSING_SOURCES.md#s10):
  - Sugammadex: 2 mg/kg at reappearance of T2; 4 mg/kg at 1–2 post-tetanic counts [S11](../DOSING_SOURCES.md#s11). Preferred over neostigmine for deep, moderate and shallow block [S10](../DOSING_SOURCES.md#s10).
  - Neostigmine only at minimal depth (TOFR 0.4 to <0.9) [S10](../DOSING_SOURCES.md#s10): 0.03–0.07 mg/kg, max 0.07 mg/kg or 5 mg, whichever is less [S12](../DOSING_SOURCES.md#s12), with glycopyrrolate 0.2 mg per 1 mg neostigmine [S13](../DOSING_SOURCES.md#s13).
- **Extubate** awake, with adequate ventilation, and with quantitative TOFR ≥0.9 [S10](../DOSING_SOURCES.md#s10).

---

## PACU

- **Expected:** often lower early pain while the block works; plan for block regression.
- **Monitoring:** ventilation as well as oxygenation. SpO₂ on supplemental oxygen can mask hypoventilation.
- **Scheduled non-opioid analgesia:**
  - acetaminophen per [S24](../DOSING_SOURCES.md#s24);
  - ketorolac <65 y: 30 mg every 6 h, max 120 mg/day; ≥65 y, renal impairment or <50 kg: 15 mg every 6 h, max 60 mg/day; ≤5 days [S23](../DOSING_SOURCES.md#s23).
- **If pain persists:**
  1. Assess block function and exclude surgical causes such as hematoma.
  2. Rescue options: ketamine bolus ≤0.35 mg/kg [S15](../DOSING_SOURCES.md#s15) (off-label), or hydromorphone 0.2–1 mg IV slowly, starting at 0.2 mg in elderly or debilitated patients [S19](../DOSING_SOURCES.md#s19).
  3. Titration intervals follow PACU protocol. The label interval is every 2–3 h [S19](../DOSING_SOURCES.md#s19).
  4. Consider a rescue block or surgeon infiltration within the remaining local-anesthetic budget [S4](../DOSING_SOURCES.md#s4), [S5](../DOSING_SOURCES.md#s5).
- Opioid-tolerant patients may need doses above the opioid-naïve start; individualize.
- **PONV rescue:** a different class from prophylaxis [S7](../DOSING_SOURCES.md#s7). See [05](../05_PACU_and_Discharge_Instructions.md).
- **Discharge readiness:** modified Aldrete ≥9 [S34](../DOSING_SOURCES.md#s34) plus institutional criteria. The score is necessary, not sufficient.

## Home analgesia (illustrative)
- Scheduled acetaminophen [S24](../DOSING_SOURCES.md#s24) and an NSAID if appropriate [S25](../DOSING_SOURCES.md#s25), [S26](../DOSING_SOURCES.md#s26).
- Opioid only if needed: oxycodone IR, opioid-naïve start 5–15 mg every 4–6 h as needed [S20](../DOSING_SOURCES.md#s20). Prescribe the lowest effective dose and no more than the expected duration of severe pain [S21](../DOSING_SOURCES.md#s21). Counsel on storage and disposal [S21](../DOSING_SOURCES.md#s21).

---

## Special populations (qualitative modifiers)
- **Elderly or frail:** propofol at the label's reduced ranges [S16](../DOSING_SOURCES.md#s16); dexmedetomidine age reduction [S14](../DOSING_SOURCES.md#s14); minimize benzodiazepines [S27](../DOSING_SOURCES.md#s27); no routine gabapentinoid.
- **Obesity / OSA (STOP-Bang [S33](../DOSING_SOURCES.md#s33)):**
  - Use the drug-specific weight scalar: IBW for IV lidocaine [S1](../DOSING_SOURCES.md#s1) (not used in this approach); actual body weight for sugammadex [S11](../DOSING_SOURCES.md#s11).
  - Minimize sedative stacking.
  - Use enhanced monitoring per policy.
- **Long-term opioid therapy:**
  - A block plus multimodal care is reasonable.
  - Continue the baseline regimen and do not abruptly discontinue [S21](../DOSING_SOURCES.md#s21).
  - Expect higher rescue needs.
- **Opioid use disorder:** continue the medication for OUD in coordination with the prescriber. Do not withhold indicated opioids.

---

## Documentation (educational template)
- **Pre-op:** consent for GA and block; ASA class; Apfel [S9](../DOSING_SOURCES.md#s9) and STOP-Bang [S33](../DOSING_SOURCES.md#s33); rationale and contingency.
- **Block:** side, agent, concentration, volume, **total mg**, additives, assessment, complications.
- **Intra-op:** technique, infusion rates, opioid totals, antiemetics, reversal agent and dose, quantitative TOFR [S10](../DOSING_SOURCES.md#s10).
- **Handoff:** block function, local-anesthetic total, last opioid dose, risk flags.

---

## Evidence base
- Citations and certainty judgments: [06 — References & Evidence](../06_References_Evidence_Breast_Augmentation.md).
- Dose sources: [DOSING_SOURCES.md](../DOSING_SOURCES.md).
- Change history: [RELEASE_NOTES.md](../RELEASE_NOTES.md) and [CHANGELOG](../CHANGELOG).

*Author: Collin B. George, pre-medical student ([ORCID 0009-0007-8162-6839](https://orcid.org/0009-0007-8162-6839)). License: CC BY 4.0. Educational framework; not clinically validated; not for patient care.*