# 05 — PACU & Discharge

> **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

## Purpose
This is an illustrative recovery-phase reference: handoff, monitoring, multimodal analgesia, PONV rescue and discharge readiness. Doses are label or guideline values tagged to [DOSING_SOURCES.md](DOSING_SOURCES.md). They are not orders and must be individualized. Home instructions come only from the treating team. This file is not a patient handout.

*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).*

---

## PACU handoff checklist (anesthesia → PACU nurse)

| Item | Details to report |
|---|---|
| Analgesic approach | 1 / 2 / 3 (see [03](03_Anesthesia_Protocols/README.md)) |
| Regional block | Yes (type ______) / No |
| Local anesthetic | Agent, concentration, **total mg** from block + infiltration [S4](DOSING_SOURCES.md#s4), [S5](DOSING_SOURCES.md#s5); time given |
| IV lidocaine | Given? (should not overlap with block or infiltration [S1](DOSING_SOURCES.md#s1)) |
| Airway | SGA / ETT |
| Infusions used | Dexmedetomidine / ketamine / other — stop times |
| Opioids | Agent, total dose, time of last dose |
| Reversal | Agent and dose; quantitative TOFR ≥0.9 documented [S10](DOSING_SOURCES.md#s10) |
| PONV prophylaxis | Agents and times (rescue should use a different class [S7](DOSING_SOURCES.md#s7)) |
| Drains | None / number and location |
| Risk flags | OSA (STOP-Bang [S33](DOSING_SOURCES.md#s33)), frailty, long-term opioid therapy, lymphedema-side arm |

---

## Monitoring priorities

- **Ventilation and oxygenation together.** Supplemental oxygen can keep SpO₂ reassuring while a patient hypoventilates, so SpO₂ alone is not a ventilation assessment. Use institutional criteria for capnography, especially with OSA, opioids or combined sedatives.
- **Circulation.** Blood pressure and heart rate per PACU policy. Watch for dexmedetomidine-related bradycardia and hypotension [S14](DOSING_SOURCES.md#s14).
- **Sedation.** Assess before every opioid dose.
- **Pain, nausea, temperature and the surgical site** (hematoma).

*v2.0 listed fixed oxygen flows, SpO₂ targets and vital-sign intervals without a source. They were removed. Persistent sedation or respiratory compromise needs **prompt clinical help**. This document does not tell a reader to wait for a particular respiratory rate or saturation.*

**Expected pattern (qualitative):** approach 1 — often lowest pain while the block works; plan for block regression. Approach 2 — more variable; depends on infiltration. Approach 3 — may be comfortable on arrival, with rebound as intraoperative opioids wane.

---

## Multimodal analgesia (illustrative label values)

| Tier | Medication | Label / guideline value | Notes |
|---|---|---|---|
| Foundation | **Acetaminophen** | ≥50 kg: 1000 mg every 6 h (or 650 mg every 4 h); max 4000 mg/day from all routes and products [S24](DOSING_SOURCES.md#s24). <50 kg: 15 mg/kg every 6 h, max 75 mg/kg/day [S24](DOSING_SOURCES.md#s24) | Contraindicated in severe hepatic impairment [S24](DOSING_SOURCES.md#s24) |
| Foundation | **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 total including oral [S23](DOSING_SOURCES.md#s23) | Boxed warnings: bleeding, GI, renal, CV [S23](DOSING_SOURCES.md#s23) |
| Foundation (oral) | **Ibuprofen** | 400 mg every 4–6 h as needed; higher single doses were no more effective in analgesic trials [S26](DOSING_SOURCES.md#s26) | NSAID warnings [S26](DOSING_SOURCES.md#s26) |
| Foundation (oral) | **Celecoxib** | 400 mg once, then 200 mg if needed on day 1; then 200 mg twice daily as needed [S25](DOSING_SOURCES.md#s25) | CV and GI boxed warnings [S25](DOSING_SOURCES.md#s25) |
| Non-drug | Cold therapy, positioning | — | Per surgeon |
| Rescue | **Hydromorphone** IV | 0.2–1 mg slowly over 2–3 min; labeled every 2–3 h as needed. Start low (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) | PACU titration intervals follow institutional protocol; reassess sedation and ventilation before each dose |
| Rescue (oral) | **Oxycodone** IR | Opioid-naïve start: 5–15 mg every 4–6 h as needed; lowest effective dose [S20](DOSING_SOURCES.md#s20) | Long-term opioid therapy: continue baseline regimen [S21](DOSING_SOURCES.md#s21) |

*Gabapentin was removed from this table: perioperative use is off-label and there is no acceptable dose source. 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).*

---

## Opioid-induced respiratory depression — reversal (label values)

1. Call for help. Stimulate, support the airway, and ventilate if needed.
2. **Naloxone** 0.1–0.2 mg IV every 2–3 min, titrated to adequate ventilation and alertness. Do not aim for full reversal: larger doses reverse analgesia and raise blood pressure [S22](DOSING_SOURCES.md#s22).
3. Opioid effects may outlast naloxone, so repeat doses may be needed at 1–2 h intervals [S22](DOSING_SOURCES.md#s22). Extended monitoring and a monitored-care discussion follow any naloxone use.

*v2.0's smaller naloxone increments and infusion rate were changed to the labeled increment; no acceptable source for the smaller increments was verified.*

---

## PONV rescue
Source: [S7](DOSING_SOURCES.md#s7), unless another tag is shown.

| Step | Intervention |
|---|---|
| Principle | Use an antiemetic from a class **not** used for prophylaxis. Repeating a 5-HT3 antagonist within 6 h of the prophylactic dose adds little [S7](DOSING_SOURCES.md#s7). |
| Option | **Amisulpride** 10 mg IV over 1–2 min (labeled for treatment, including after failed prophylaxis with another class) [S31](DOSING_SOURCES.md#s31) |
| Option | **Droperidol** 0.625 mg IV [S7](DOSING_SOURCES.md#s7) — QT boxed warning; ECG considerations |
| Option | **Promethazine** 6.25 mg [S7](DOSING_SOURCES.md#s7) — IV promethazine carries a boxed warning for severe tissue injury; avoid where alternatives exist |
| Option | **Haloperidol** 0.5 to <2 mg IV (off-label) [S7](DOSING_SOURCES.md#s7) |
| Scopolamine patch | If used for prophylaxis, the label removes it 24 h after surgery [S30](DOSING_SOURCES.md#s30) |

*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).*

---

## PACU documentation template (educational)

```text
PACU arrival time: ______   Pain on arrival: ___/10
Approach: [ ] 1 block + GA   [ ] 2 GA, no block   [ ] 3 opioid-inclusive GA
Regional block: [ ] Yes (type ______)  [ ] No   Local anesthetic total: ___ mg (agent ____)
Airway: [ ] SGA  [ ] ETT     Quantitative TOFR before extubation: ____
Drains: [ ] None  [ ] ___ (location ______)
PONV prophylaxis given: ____________________
PACU analgesics: acetaminophen ___ mg  NSAID ___ mg  other ________
Rescue opioid: [ ] None  [ ] agent/dose/time ________
Naloxone given: [ ] No  [ ] Yes (dose/time ________) → extended monitoring
PONV rescue: [ ] None  [ ] agent/class ________
Modified Aldrete score at discharge from phase I: ___/10
Discharge destination: [ ] Home  [ ] Extended observation  [ ] Admission
Instructions reviewed by treating team: [ ] Yes   Responsible adult escort: [ ] Yes
```

---

## Discharge readiness

- **Modified Aldrete score ≥9** [S34](DOSING_SOURCES.md#s34) is a common phase I threshold. It is **necessary, not sufficient**, and does not authorize home discharge by itself.

| Item | 2 | 1 | 0 |
|---|---|---|---|
| Activity | Moves 4 extremities | Moves 2 extremities | Moves 0 |
| Respiration | Breathes deeply, coughs freely | Dyspnea or limited breathing | Apneic |
| Circulation [S34](DOSING_SOURCES.md#s34) | BP ±20 mmHg of pre-anesthetic | BP ±20–49 mmHg | BP ±50 mmHg or more |
| Consciousness | Fully awake | Arousable on calling | Not responding |
| O₂ saturation [S34](DOSING_SOURCES.md#s34) | >92% on room air | Needs O₂ to keep >90% | <90% even with O₂ |

Source: [S34](DOSING_SOURCES.md#s34).

- Discharge also needs, per the responsible team: ventilation adequate without stimulation; sedation resolved; pain and nausea controlled with a plan; surgical site stable; drain teaching (if drains); responsible adult escort; and written and verbal instructions from the treating team.
- Patients who received naloxone, or who have OSA with ongoing opioid needs, merit a lower threshold for extended monitoring under institutional policy.

---

## Home-phase topics (content supplied by the treating team)

v2.0 listed fixed numbers for drain emptying, drain removal, lifting limits, showering, Steri-Strip duration, alcohol avoidance, driving, fever and drain-output thresholds, and follow-up timing. **All were removed.** None had an acceptable source, and these instructions are surgeon- and patient-specific. Topics the treating team typically covers:

- drain care and the criteria for removal;
- arm movement, lifting and garment use;
- wound care and showering;
- medication schedule, including the acetaminophen daily maximum [S24](DOSING_SOURCES.md#s24) and safe opioid storage and disposal [S21](DOSING_SOURCES.md#s21);
- driving, and avoiding alcohol and sedatives while taking opioids;
- warning signs: fever, rapidly increasing swelling or bruising, bright-red drain output, foul or cloudy drainage, spreading redness, severe one-sided pain, shortness of breath or chest pain;
- the follow-up schedule and a 24/7 contact number; emergency services if severe symptoms occur and the surgeon cannot be reached.

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*Educational resource only. Doses are illustrative and must be individualized; see [DOSING_SOURCES.md](DOSING_SOURCES.md). Author: Collin B. George, pre-medical student.*