# Approach 2 — Systemic Multimodal General Anesthesia Without a Block

> **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_2_OFIA…"). The numbering does not imply preference.*

## How to read this document
Every numeric value is a label, guideline or consensus value tagged to [DOSING_SOURCES.md](../DOSING_SOURCES.md). The values are **illustrative**, not validated for implant revision, and not orders. Individualize under institutional policy. Off-label uses are 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
- This approach is used when a block is contraindicated, declined, time-limited or not technically feasible. It aims to spare opioids. Opioid rescue remains available and is not a failure.
- **"Block-free" is not "local-anesthetic-free."** Surgeon infiltration is usually the analgesic foundation, so local-anesthetic toxicity remains a concern. Lipid emulsion stays immediately available [S3](../DOSING_SOURCES.md#s3).
- **IV lidocaine and infiltration are not automatically compatible.** The consensus advises against IV lidocaine concurrently with other local-anesthetic interventions or while their effect is active [S1](../DOSING_SOURCES.md#s1). Because infiltration is central here, IV lidocaine is generally **not** combined with it. This preserves rc2's stricter correction.
- Multimodal combinations have their own harms. Dexmedetomidine, ketamine, acetaminophen, NSAIDs and opioids are not interchangeable, and a "non-opioid" label is not evidence of safety. The POFA trial found more hypoxemia and bradycardia with dexmedetomidine-based opioid-free anesthesia.

---

## Contraindications and cautions

| Consideration | Approach |
|---|---|
| Surgeon infiltration not planned or not feasible | Analgesic foundation is weak; reconsider the approach |
| OSA (STOP-Bang [S33](../DOSING_SOURCES.md#s33)), COPD, CO₂ retention | Avoid sedative stacking; minimize benzodiazepines [S27](../DOSING_SOURCES.md#s27); enhanced monitoring |
| Bradycardia, conduction disease | Caution with dexmedetomidine [S14](../DOSING_SOURCES.md#s14) |
| Uncontrolled hypertension, tachyarrhythmia, psychosis | Avoid ketamine [S15](../DOSING_SOURCES.md#s15) |
| Hepatic impairment | Dexmedetomidine dose reduction [S14](../DOSING_SOURCES.md#s14); acetaminophen caution, contraindicated if severe [S24](../DOSING_SOURCES.md#s24) |
| Severe renal impairment | Avoid ketorolac [S23](../DOSING_SOURCES.md#s23); NSAID caution [S26](../DOSING_SOURCES.md#s26) |

---

## Surgeon infiltration — one local-anesthetic budget
- Before incision, confirm the agent, concentration, planned volume and **total mg** against the label maximum [S4](../DOSING_SOURCES.md#s4), [S5](../DOSING_SOURCES.md#s5). Ropivacaine field block/infiltration is up to 200 mg [S4](../DOSING_SOURCES.md#s4). Bupivacaine: individualize; single-dose experience up to 175 mg plain or 225 mg with epinephrine; ≤400 mg/24 h [S5](../DOSING_SOURCES.md#s5).
- Use the lowest effective dose and incremental infiltration [S2](../DOSING_SOURCES.md#s2). Document what was given.
- No example volumes are given; the surgeon chooses the volume within the calculated budget.

---

## Preoperative medications (illustrative)

| Medication | Label / guideline value | Notes |
|---|---|---|
| Acetaminophen | 1000 mg (≥50 kg); max 4000 mg/day all routes [S24](../DOSING_SOURCES.md#s24) | |
| Celecoxib | 400 mg once [S25](../DOSING_SOURCES.md#s25) | Renal, GI and CV cautions |
| Gabapentinoid | **Not routine; no dose given** | Off-label |
| Midazolam | Titrate; initial IV as little as 1 mg, ≤2.5 mg in a healthy adult; reduce in older or debilitated patients [S27](../DOSING_SOURCES.md#s27) | Needle-anxiety support: non-drug measures first |

**Antibiotics:** as in [Approach 1](Protocol_1_OFIA_With_PECS_Block.md#preoperative-medications-illustrative) [S6](../DOSING_SOURCES.md#s6).

**PONV prophylaxis:** two interventions for 1–2 risk factors [S7](../DOSING_SOURCES.md#s7), [S8](../DOSING_SOURCES.md#s8); three to four for ≥3 [S7](../DOSING_SOURCES.md#s7). Doses: dexamethasone 4–8 mg [S7](../DOSING_SOURCES.md#s7), [S8](../DOSING_SOURCES.md#s8), ondansetron 4 mg [S7](../DOSING_SOURCES.md#s7), [S8](../DOSING_SOURCES.md#s8), others as in Approach 1.

---

## Induction (example; individualize)

| Agent | Label / guideline value | Notes |
|---|---|---|
| Ketamine (optional; off-label analgesic use) | Bolus ≤0.35 mg/kg [S15](../DOSING_SOURCES.md#s15) | Selective, phenotype-matched |
| Propofol | ~2–2.5 mg/kg (healthy <55 y); ~1–1.5 mg/kg (elderly, debilitated, ASA III–IV) [S16](../DOSING_SOURCES.md#s16) | Titrate to effect |
| Rocuronium | 0.6 mg/kg; RSI 0.6–1.2 mg/kg [S17](../DOSING_SOURCES.md#s17) | |
| IV lidocaine | Not combined with infiltration [S1](../DOSING_SOURCES.md#s1) | If a clinician uses it with **no** infiltration: ≤1.5 mg/kg IBW over ~10 min, infusion ≤1.5 mg/kg/h IBW, ≤120 mg/h, ≤24 h; not under 40 kg [S1](../DOSING_SOURCES.md#s1) |

---

## Maintenance
- **Propofol TIVA:** 100–200 mcg/kg/min (healthy <55 y) or 50–100 mcg/kg/min (elderly, debilitated, ASA III–IV) [S16](../DOSING_SOURCES.md#s16); titrate to depth.
- **Dexmedetomidine (optional; off-label GA adjunct):** label procedural-sedation maintenance is 0.2–1 mcg/kg/h after a 1 mcg/kg / 10 min load. For >65 y the load is 0.5 mcg/kg and maintenance should be reduced; consider reduction in hepatic impairment [S14](../DOSING_SOURCES.md#s14). Omitting the load is one way to limit bradycardia and hypotension.
- **Ketamine (optional):** boluses ≤0.35 mg/kg; infusion up to ~1 mg/kg/h [S15](../DOSING_SOURCES.md#s15).
- **Escalation when nociception persists at adequate depth:**
  1. Confirm depth.
  2. Ask the surgeon for more infiltration within the remaining budget [S4](../DOSING_SOURCES.md#s4), [S5](../DOSING_SOURCES.md#s5).
  3. Then prefer **small titrated opioid doses** (see Approach 3 [S18](../DOSING_SOURCES.md#s18), [S19](../DOSING_SOURCES.md#s19)) over escalating sedatives.
  - Escalating sedative adjuncts to control nociception is avoided (sedative "stacking").
- **Ventilation, hemodynamics, temperature:** individualized; no numeric targets are given (no acceptable source).
- **Hypotension and bradycardia:** label vasopressor and anticholinergic values as in [Approach 1](Protocol_1_OFIA_With_PECS_Block.md#hypotension-and-bradycardia-label-values) [S13](../DOSING_SOURCES.md#s13), [S28](../DOSING_SOURCES.md#s28), [S29](../DOSING_SOURCES.md#s29).

## Emergence
- Ondansetron 4 mg 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 or 4 mg/kg by depth [S11](../DOSING_SOURCES.md#s11);
  - neostigmine only at minimal depth [S10](../DOSING_SOURCES.md#s10): 0.03–0.07 mg/kg, max 0.07 mg/kg or 5 mg [S12](../DOSING_SOURCES.md#s12), with glycopyrrolate 0.2 mg per 1 mg neostigmine [S13](../DOSING_SOURCES.md#s13).
- Extubate at TOFR ≥0.9 [S10](../DOSING_SOURCES.md#s10).

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## PACU
- **Expected:** pain is more variable than with a block and depends on infiltration. Sedation from systemic adjuncts is more likely.
- **Scheduled analgesia:** acetaminophen [S24](../DOSING_SOURCES.md#s24); ketorolac by the label tiers (30 mg or 15 mg every 6 h; max 120 or 60 mg/day; ≤5 days) [S23](../DOSING_SOURCES.md#s23); or oral NSAID [S25](../DOSING_SOURCES.md#s25), [S26](../DOSING_SOURCES.md#s26).
- **Rescue:**
  1. Exclude surgical causes.
  2. Then give small titrated hydromorphone (0.2–1 mg IV slowly, 0.2 mg start in elderly or debilitated patients) [S19](../DOSING_SOURCES.md#s19). Intervals per PACU protocol; the label interval is every 2–3 h [S19](../DOSING_SOURCES.md#s19). Alternatively, a ketamine bolus ≤0.35 mg/kg (off-label) [S15](../DOSING_SOURCES.md#s15).
- **Excess sedation** (more likely here):
  - support airway and oxygenation, and assess ventilation, not SpO₂ alone;
  - review the total sedative exposure;
  - give flumazenil only for a suspected benzodiazepine effect after a risk–benefit assessment;
  - get prompt clinical help.
  - No fixed sedation-score cut-off or escalation time is given (no acceptable source).
- **PONV rescue:** a different class from prophylaxis [S7](../DOSING_SOURCES.md#s7); agents and doses in [05](../05_PACU_and_Discharge_Instructions.md#ponv-rescue).
- **Discharge readiness:** modified Aldrete ≥9 [S34](../DOSING_SOURCES.md#s34) plus institutional criteria.

---

## Special populations and delirium risk (qualitative)
- **Older or frail patients:**
  - propofol at the label's reduced ranges [S16](../DOSING_SOURCES.md#s16);
  - dexmedetomidine age reduction [S14](../DOSING_SOURCES.md#s14);
  - avoid or minimize benzodiazepines [S27](../DOSING_SOURCES.md#s27);
  - no routine gabapentinoid;
  - normothermia;
  - adequate analgesia (pain itself precipitates delirium);
  - early reorientation.
  - Ketamine, if used, stays within the consensus bolus limit [S15](../DOSING_SOURCES.md#s15), at the low end of the range.
- **OSA/COPD:**
  - avoid stacking dexmedetomidine, benzodiazepines and gabapentinoids;
  - extubate fully awake;
  - continuous SpO₂, with capnography considered;
  - lower-dose opioid rescue with closer reassessment.

## Documentation
- Reason a block was not used.
- Infiltration agent, concentration, volume and **total mg**.
- Adjunct doses and stop times.
- Opioid exposure, antiemetics and reversal.
- Sedative totals and delirium-risk status at handoff.

---

*Evidence: [06](../06_References_Evidence_Breast_Augmentation.md). Dose sources: [DOSING_SOURCES.md](../DOSING_SOURCES.md). Author: Collin B. George, pre-medical student. License: CC BY 4.0. Educational framework; not clinically validated; not for patient care.*