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.

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. 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.

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). The 2026 ASA guideline addresses fascial plane blocks for mastectomy, not implant revision specifically 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 or Approach 3.

Contraindications and cautions

Local anesthetic: calculate the ceiling first

Sources: S4, S5. The U.S. labels give absolute doses, not mg/kg ceilings:

Worked arithmetic (education only).

• Bupivacaine 0.25%, 70 mL = 175 mg. That reaches the label's plain single-dose experience S5 before any surgeon infiltration is added.
• Ropivacaine 0.2%, 80 mL = 160 mg 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.
• 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.

Injection safety (qualitative, ASRA 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 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.
• If still unstable, repeat the bolus once or twice and/or double the infusion S3.
• Epinephrine in reduced doses (≤1 mcg/kg). Avoid vasopressin, calcium-channel blockers, beta-blockers and further local anesthetic. Benzodiazepine for seizures 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. This preserves rc2's stricter correction.

Preoperative medications (illustrative)

Antibiotic prophylaxis S6:

• Cefazolin 2 g IV, or 3 g if ≥120 kg, within 60 min before incision; redose every 4 h S6.
• Severe β-lactam allergy: clindamycin 900 mg (redose every 6 h) S6, or vancomycin 15 mg/kg started within 120 min before incision S6.

PONV prophylaxis (by Apfel risk factors S9):

Induction (example sequence; individualize)

Airway: ETT or supraglottic airway per anesthesiologist judgment and aspiration risk. Confirm with continuous waveform capnography 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. 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.
• Patients >65 y: loading 0.5 mcg/kg over 10 min and consider reduced maintenance. Hepatic impairment: consider dose reduction S14.
• Omitting the loading infusion is one way to limit bradycardia and hypotension; titrate within the label range 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.

Opioid: none planned. Small titrated rescue doses are acceptable (see Approach 3 for label values S18, 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.
   • Glycopyrrolate 0.1 mg IV, repeated every 2–3 min as needed S13; or
   • Ephedrine 5–10 mg IV bolus, not to exceed 50 mg 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.
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.

Emergence

• Stop infusions. Plan for dexmedetomidine's residual sedation S14.
• PONV: ondansetron 4 mg IV at end of surgery if planned S7, S8.
• Reversal guided by quantitative monitoring S10:
  • Sugammadex: 2 mg/kg at reappearance of T2; 4 mg/kg at 1–2 post-tetanic counts S11. Preferred over neostigmine for deep, moderate and shallow block S10.
  • Neostigmine only at minimal depth (TOFR 0.4 to <0.9) S10: 0.03–0.07 mg/kg, max 0.07 mg/kg or 5 mg, whichever is less S12, with glycopyrrolate 0.2 mg per 1 mg neostigmine S13.
• Extubate awake, with adequate ventilation, and with quantitative TOFR ≥0.9 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;
  • 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.
• If pain persists:
  1. Assess block function and exclude surgical causes such as hematoma.
  2. Rescue options: ketamine bolus ≤0.35 mg/kg S15 (off-label), or hydromorphone 0.2–1 mg IV slowly, starting at 0.2 mg in elderly or debilitated patients S19.
  3. Titration intervals follow PACU protocol. The label interval is every 2–3 h S19.
  4. Consider a rescue block or surgeon infiltration within the remaining local-anesthetic budget S4, S5.
• Opioid-tolerant patients may need doses above the opioid-naïve start; individualize.
• PONV rescue: a different class from prophylaxis S7. See 05.
• Discharge readiness: modified Aldrete ≥9 S34 plus institutional criteria. The score is necessary, not sufficient.

Home analgesia (illustrative)

• Scheduled acetaminophen S24 and an NSAID if appropriate S25, S26.
• Opioid only if needed: oxycodone IR, opioid-naïve start 5–15 mg every 4–6 h as needed S20. Prescribe the lowest effective dose and no more than the expected duration of severe pain S21. Counsel on storage and disposal S21.

Special populations (qualitative modifiers)

• Elderly or frail: propofol at the label's reduced ranges S16; dexmedetomidine age reduction S14; minimize benzodiazepines S27; no routine gabapentinoid.
• Obesity / OSA (STOP-Bang S33):
  • Use the drug-specific weight scalar: IBW for IV lidocaine S1 (not used in this approach); actual body weight for sugammadex 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.
  • 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 and STOP-Bang 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.
• Handoff: block function, local-anesthetic total, last opioid dose, risk flags.

Evidence base

• Citations and certainty judgments: 06 — References & Evidence.
• Dose sources: DOSING_SOURCES.md.
• Change history: RELEASE_NOTES.md and CHANGELOG.

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