# Approach 3 — Opioid-Inclusive Balanced General Anesthesia (No 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. The numbering does not imply preference.*

## How to read this document
Every numeric value is a label, guideline, consensus or score-paper 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.

*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
- Opioid-inclusive balanced anesthesia with multimodal adjuncts is a mainstream, guideline-concordant technique.
- Using it is **not** evidence that another strategy failed. Avoiding intraoperative opioids does not by itself establish greater safety; POFA found more hypoxemia and bradycardia with dexmedetomidine-based opioid-free anesthesia.
- Typical reasons to choose it:
  - patient preference after discussion;
  - contraindications to the opioid-sparing adjuncts;
  - no block feasible;
  - a prior inadequate response.
- **Long-term opioid therapy** is not by itself a reason to choose this approach. A block plus multimodal care with the baseline opioid continued is also reasonable. Do not abruptly discontinue long-term therapy [S21](../DOSING_SOURCES.md#s21).
- **Opioid use disorder:** continue the medication for OUD (buprenorphine, methadone or naltrexone plan) in coordination with the prescriber. Do not withhold indicated opioids.
- Opioid-related risks: respiratory depression, oversedation, PONV and persistent use. Patient factors (OSA, age, frailty), co-administered sedatives and the recovery environment all matter.

---

## Preparation
- **Monitoring:** ASA basic standards [S35](../DOSING_SOURCES.md#s35): blood pressure and heart rate at least every 5 min, ECG, pulse oximetry, capnography and temperature. Quantitative neuromuscular monitoring [S10](../DOSING_SOURCES.md#s10).
- **Naloxone** available in PACU. The label increment is 0.1–0.2 mg IV every 2–3 min [S22](../DOSING_SOURCES.md#s22). Prepare per institutional protocol.
- **Lipid emulsion** immediately available if surgeon infiltration is used [S3](../DOSING_SOURCES.md#s3).
- **Airway:** ETT or supraglottic airway per anesthesiologist judgment and aspiration risk.

---

## Preoperative medications (illustrative)

| Medication | Label / guideline value | Notes |
|---|---|---|
| Acetaminophen | 1000 mg (≥50 kg); max 4000 mg/day all routes [S24](../DOSING_SOURCES.md#s24) | Opioid-sparing foundation |
| Celecoxib | 400 mg once [S25](../DOSING_SOURCES.md#s25) | Renal, GI and CV cautions |
| Gabapentinoid | **Not routine; no dose given** | Off-label |
| Midazolam | Initial IV as little as 1 mg, ≤2.5 mg in a healthy adult; reduce in older or debilitated patients and **with opioids** [S27](../DOSING_SOURCES.md#s27) | Additive respiratory depression [S27](../DOSING_SOURCES.md#s27) |

**Antibiotics [S6](../DOSING_SOURCES.md#s6):**
- Cefazolin 2 g, or 3 g if ≥120 kg, within 60 min; redose every 4 h [S6](../DOSING_SOURCES.md#s6).
- Clindamycin 900 mg (redose every 6 h) [S6](../DOSING_SOURCES.md#s6), or vancomycin 15 mg/kg started within 120 min; routine redosing not applicable [S6](../DOSING_SOURCES.md#s6).

**PONV prophylaxis.** Postoperative opioids count as one Apfel factor [S9](../DOSING_SOURCES.md#s9). Most patients in this population therefore have ≥3 factors: female, non-smoker, postoperative opioids. Estimated baseline risk with 3 factors is ~61% [S9](../DOSING_SOURCES.md#s9).

| Risk factors [S9](../DOSING_SOURCES.md#s9) | 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 + 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 TIVA; transdermal scopolamine (evening before or 2 h before surgery [S7](../DOSING_SOURCES.md#s7); removed 24 h after surgery [S30](../DOSING_SOURCES.md#s30)); amisulpride 5 mg at induction [S31](../DOSING_SOURCES.md#s31); or droperidol 0.625 mg at end of surgery [S7](../DOSING_SOURCES.md#s7) |

Also consider risk reduction: propofol TIVA, avoiding nitrous oxide, and minimizing opioid dose [S7](../DOSING_SOURCES.md#s7), [S8](../DOSING_SOURCES.md#s8).

---

## Induction (example; individualize)

| Step | Agent | Label / guideline value | Notes |
|---|---|---|---|
| 1 | Fentanyl | Individualize by age, weight, physical status, other drugs and procedure. The label's "low-dose" general-anesthesia tier is 2 mcg/kg. Reduce the initial dose in elderly and debilitated patients and base later increments on the response [S18](../DOSING_SOURCES.md#s18) | No phenotype-specific mcg/kg values are given |
| 2 | 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 |
| 3 | Rocuronium | 0.6 mg/kg; RSI 0.6–1.2 mg/kg [S17](../DOSING_SOURCES.md#s17) | Succinylcholine for RSI: dose per its label (not verified in this session, so none is given) |
| — | IV lidocaine | Not with surgeon infiltration [S1](../DOSING_SOURCES.md#s1). Without any local-anesthetic intervention: ≤1.5 mg/kg IBW [S1](../DOSING_SOURCES.md#s1) | Consensus hourly ceiling 120 mg/h [S1](../DOSING_SOURCES.md#s1) |

---

## Maintenance
- **Hypnotic:** propofol 100–200 mcg/kg/min (healthy <55 y) or 50–100 mcg/kg/min (elderly, debilitated, ASA III–IV) [S16](../DOSING_SOURCES.md#s16); or a volatile agent titrated to age-adjusted MAC.
- **Opioid strategy: lowest effective dose; avoid late-case stacking.**
  - Fentanyl increments are titrated to stimulus and individualized [S18](../DOSING_SOURCES.md#s18).
  - Hydromorphone for longer-acting analgesia: 0.2–1 mg IV slowly over 2–3 min. Lower start (0.2 mg) in elderly or debilitated patients; ¼–½ of the usual starting dose in hepatic or renal impairment [S19](../DOSING_SOURCES.md#s19).
  - Time doses so the respiratory effect can be assessed before extubation.
  - No fixed fentanyl infusion rate, bolus size, typical total or stop time is given (no acceptable source).
- **Surgeon infiltration** reduces opioid needs. It shares the local-anesthetic budget [S4](../DOSING_SOURCES.md#s4), [S5](../DOSING_SOURCES.md#s5), and IV lidocaine is not run concurrently [S1](../DOSING_SOURCES.md#s1).
- **Optional adjuncts:**
  - dexmedetomidine (off-label as a GA adjunct; label maintenance range 0.2–1 mcg/kg/h procedural, with age and hepatic reductions) [S14](../DOSING_SOURCES.md#s14);
  - ketamine bolus ≤0.35 mg/kg [S15](../DOSING_SOURCES.md#s15).
  - IV lidocaine is not combined with infiltration [S1](../DOSING_SOURCES.md#s1).
- **Ventilation, hemodynamics, fluids, temperature:** individualized. No numeric targets are given (no acceptable source).
- **Hypotension:**
  - phenylephrine 40–100 mcg IV bolus (repeat every 1–2 min, ≤200 mcg each; infusion 10–35 mcg/min, ≤200 mcg/min) [S28](../DOSING_SOURCES.md#s28);
  - if bradycardic, ephedrine 5–10 mg IV, ≤50 mg total [S29](../DOSING_SOURCES.md#s29).

---

## Emergence and extubation
- **PONV:** ondansetron 4 mg IV at end of surgery if planned [S7](../DOSING_SOURCES.md#s7), [S8](../DOSING_SOURCES.md#s8).
- **Reversal by quantitative monitoring** [S10](../DOSING_SOURCES.md#s10):
  - Sugammadex: 2 mg/kg at T2 reappearance; 4 mg/kg at 1–2 post-tetanic counts [S11](../DOSING_SOURCES.md#s11).
  - 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 [S12](../DOSING_SOURCES.md#s12), with glycopyrrolate 0.2 mg per 1 mg neostigmine [S13](../DOSING_SOURCES.md#s13).
- **Extubate** only when awake, ventilating adequately, and quantitative TOFR ≥0.9 [S10](../DOSING_SOURCES.md#s10). Opioid-related respiratory depression can occur after extubation.
- No numeric extubation thresholds beyond TOFR are given (no acceptable source).

---

## PACU

### Monitoring
- Continuous pulse oximetry, with ventilation assessed directly. SpO₂ on supplemental oxygen can look reassuring during hypoventilation.
- Consider capnography for OSA (e.g., STOP-Bang ≥3, which is sensitive for moderate-to-severe OSA [S33](../DOSING_SOURCES.md#s33)), older age, combined sedatives or high opioid exposure.
- Reassess sedation before every opioid dose.
- No fixed monitoring intervals, durations or numeric triggers are given (no acceptable source). **A reader should not wait for a number before getting help.**

### Scheduled non-opioid foundation
| Medication | Label value |
|---|---|
| Acetaminophen | 1000 mg every 6 h (≥50 kg); max 4000 mg/day all routes [S24](../DOSING_SOURCES.md#s24) |
| Ketorolac IV | <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) |
| Celecoxib | 200 mg twice daily after the day-1 regimen [S25](../DOSING_SOURCES.md#s25) |
| Ibuprofen | 400 mg every 4–6 h as needed [S26](../DOSING_SOURCES.md#s26) |


### Opioid rescue (label values)
- **Hydromorphone:** 0.2–1 mg IV slowly. Lower start (0.2 mg) in elderly or debilitated patients; ¼–½ of the usual start in hepatic or renal impairment [S19](../DOSING_SOURCES.md#s19). The label interval is every 2–3 h; PACU titration intervals follow institutional protocol [S19](../DOSING_SOURCES.md#s19). Hold for oversedation.
- **Oral transition:** oxycodone IR 5–15 mg every 4–6 h as needed (opioid-naïve start) [S20](../DOSING_SOURCES.md#s20).

### Respiratory depression — naloxone (label values)
1. Call for help. Stimulate, support the airway, and give bag-mask ventilation if needed.
2. **Naloxone 0.1–0.2 mg IV every 2–3 min** to adequate ventilation and alertness. Avoid full reversal: larger doses reverse analgesia and raise blood pressure [S22](../DOSING_SOURCES.md#s22).
3. Re-sedation can occur because some opioids outlast naloxone. Repeat doses may be needed at 1–2 h intervals [S22](../DOSING_SOURCES.md#s22). Monitor for an extended period and discuss monitored care.

*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).*

### PONV rescue
Use a different class from prophylaxis. Do not repeat a 5-HT3 antagonist within 6 h [S7](../DOSING_SOURCES.md#s7). Options:
- amisulpride 10 mg [S31](../DOSING_SOURCES.md#s31);
- droperidol 0.625 mg [S7](../DOSING_SOURCES.md#s7);
- promethazine 6.25 mg (boxed warning for tissue injury) [S7](../DOSING_SOURCES.md#s7);
- haloperidol 0.5 to <2 mg (off-label) [S7](../DOSING_SOURCES.md#s7).

Metoclopramide is not listed: its dose was not confirmed in the cited consensus in this session.

### Discharge readiness
Modified Aldrete ≥9 [S34](../DOSING_SOURCES.md#s34) is necessary, not sufficient. Also required: sedation resolved, ventilation adequate without stimulation, pain and nausea controlled with a plan, and institutional criteria met. A lower threshold for extended observation applies after any naloxone, and with OSA plus ongoing opioid needs.

---

## Home analgesia (illustrative)
- Scheduled acetaminophen [S24](../DOSING_SOURCES.md#s24) and NSAID if appropriate [S25](../DOSING_SOURCES.md#s25), [S26](../DOSING_SOURCES.md#s26).
- **Opioid, if needed:** immediate-release, at the lowest effective dose [S20](../DOSING_SOURCES.md#s20), [S21](../DOSING_SOURCES.md#s21), and no more than needed for the expected duration of severe pain [S21](../DOSING_SOURCES.md#s21). Counsel on respiratory depression, avoiding alcohol and sedatives, safe storage and disposal [S21](../DOSING_SOURCES.md#s21).
- **Long-term opioid therapy:** continue the baseline regimen, coordinate with the prescriber, and do not abruptly discontinue [S21](../DOSING_SOURCES.md#s21).
- **Opioid exposure estimate (oral only):** MME/day = dose × CDC factor. Factors: morphine 1, oxycodone 1.5, hydromorphone 5 [S21](../DOSING_SOURCES.md#s21). Example arithmetic: oxycodone 5 mg four times a day = 20 mg × 1.5 = 30 MME/day [S21](../DOSING_SOURCES.md#s21). The factors are **not** for converting between opioids, for IV doses, or for buprenorphine or methadone [S21](../DOSING_SOURCES.md#s21).
- No fixed tablet quantities, durations or IV equianalgesic ratios are given. CDC 2022 does not set fixed limits [S21](../DOSING_SOURCES.md#s21), and no acceptable source for IV ratios was verified.

---

## Special populations (qualitative modifiers)
- **Older or frail patients:**
  - propofol at the label's reduced ranges [S16](../DOSING_SOURCES.md#s16);
  - reduced initial fentanyl dose [S18](../DOSING_SOURCES.md#s18);
  - hydromorphone low start [S19](../DOSING_SOURCES.md#s19);
  - benzodiazepines minimized [S27](../DOSING_SOURCES.md#s27);
  - no routine gabapentinoid;
  - delirium prevention;
  - enhanced PACU observation.
- **OSA:**
  - STOP-Bang 0–2 low risk, 3–4 intermediate, 5–8 high [S33](../DOSING_SOURCES.md#s33);
  - minimize opioids and sedatives;
  - extubate fully awake;
  - head-up positioning;
  - continuous monitoring, with capnography considered;
  - home CPAP use per the treating team.
- **Long-term opioid therapy and OUD:** see "Where this approach fits". Expect higher requirements in tolerant patients; tolerance is physiologic, not "drug-seeking". Use non-stigmatizing language and never withhold indicated analgesia.

---

## Documentation (educational template)
- **Pre-op:** rationale, OSA screen [S33](../DOSING_SOURCES.md#s33), Apfel score [S9](../DOSING_SOURCES.md#s9), baseline opioid regimen.
- **Intra-op:** each opioid dose and time, adjuncts, infiltration total mg [S4](../DOSING_SOURCES.md#s4), [S5](../DOSING_SOURCES.md#s5), PONV agents, reversal agent and dose, quantitative TOFR [S10](../DOSING_SOURCES.md#s10).
- **Handoff:** total opioid exposure and **time of last dose**, OSA or frailty flags, naloxone availability [S22](../DOSING_SOURCES.md#s22), expected rebound pain.

**Example record (fictional, illustrative only; every dose shown lies within a cited label range):**
- Induction: fentanyl, individualized [S18](../DOSING_SOURCES.md#s18); propofol 1–1.5 mg/kg (older patient) [S16](../DOSING_SOURCES.md#s16); rocuronium 0.6 mg/kg [S17](../DOSING_SOURCES.md#s17)
- PONV: dexamethasone 8 mg at induction and ondansetron 4 mg at end of surgery [S7](../DOSING_SOURCES.md#s7), [S8](../DOSING_SOURCES.md#s8); TIVA
- Analgesia: hydromorphone 0.2 mg IV slowly, repeated once after reassessment [S19](../DOSING_SOURCES.md#s19); surgeon infiltration bupivacaine total ___ mg, within label limits [S5](../DOSING_SOURCES.md#s5)
- Reversal: sugammadex 2 mg/kg at T2 [S11](../DOSING_SOURCES.md#s11); quantitative TOFR ≥0.9 before extubation [S10](../DOSING_SOURCES.md#s10)

---

## Scores used (validation papers)
- **Apfel** [S9](../DOSING_SOURCES.md#s9): 0–4 factors → ~10%, 21%, 39%, 61%, 79%.
- **STOP-Bang** [S32](../DOSING_SOURCES.md#s32), [S33](../DOSING_SOURCES.md#s33): items as in [01 §5.3](../01_PreOp_Assessment_and_Checklist.md#53-osa-screen-stop-bang); categories 0–2 / 3–4 / 5–8 [S33](../DOSING_SOURCES.md#s33).
- **Modified Aldrete** [S34](../DOSING_SOURCES.md#s34): table in [05](../05_PACU_and_Discharge_Instructions.md#discharge-readiness). The 1-point oxygen item is "needs O₂ to maintain SpO₂ >90%"; the circulation middle band is ±20–49 mmHg [S34](../DOSING_SOURCES.md#s34).

---

*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.*