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.
Post-mastectomy breast implant revision — educational dosing reference, November 2026
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How to read this document
Every numeric value is a label, guideline or consensus value tagged to 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.
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.
- 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. 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), COPD, CO₂ retention | Avoid sedative stacking; minimize benzodiazepines S27; enhanced monitoring |
| Bradycardia, conduction disease | Caution with dexmedetomidine S14 |
| Uncontrolled hypertension, tachyarrhythmia, psychosis | Avoid ketamine S15 |
| Hepatic impairment | Dexmedetomidine dose reduction S14; acetaminophen caution, contraindicated if severe S24 |
| Severe renal impairment | Avoid ketorolac S23; NSAID caution S26 |
Surgeon infiltration — one local-anesthetic budget
- Before incision, confirm the agent, concentration, planned volume and total mg against the label maximum S4, S5. Ropivacaine field block/infiltration is up to 200 mg S4. Bupivacaine: individualize; single-dose experience up to 175 mg plain or 225 mg with epinephrine; ≤400 mg/24 h S5.
- Use the lowest effective dose and incremental infiltration 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 | |
| Celecoxib | 400 mg once 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 | Needle-anxiety support: non-drug measures first |
Antibiotics: as in Approach 1 S6.
PONV prophylaxis: two interventions for 1–2 risk factors S7, S8; three to four for ≥3 S7. Doses: dexamethasone 4–8 mg S7, S8, ondansetron 4 mg S7, 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 | Selective, phenotype-matched |
| Propofol | ~2–2.5 mg/kg (healthy <55 y); ~1–1.5 mg/kg (elderly, debilitated, ASA III–IV) S16 | Titrate to effect |
| Rocuronium | 0.6 mg/kg; RSI 0.6–1.2 mg/kg S17 | |
| IV lidocaine | Not combined with infiltration 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 |
Maintenance
- Propofol TIVA: 100–200 mcg/kg/min (healthy <55 y) or 50–100 mcg/kg/min (elderly, debilitated, ASA III–IV) 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. 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.
- Escalation when nociception persists at adequate depth:
- Confirm depth.
- Ask the surgeon for more infiltration within the remaining budget S4, S5.
- Then prefer small titrated opioid doses (see Approach 3 S18, 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 S13, S28, S29.
Emergence
- Ondansetron 4 mg at end of surgery if planned S7, S8.
- Reversal guided by quantitative monitoring S10:
- Extubate at TOFR ≥0.9 S10.
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; ketorolac by the label tiers (30 mg or 15 mg every 6 h; max 120 or 60 mg/day; ≤5 days) S23; or oral NSAID S25, S26.
- Rescue:
- 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; agents and doses in 05.
- Discharge readiness: modified Aldrete ≥9 S34 plus institutional criteria.
Special populations and delirium risk (qualitative)
- Older or frail patients:
- propofol at the label's reduced ranges S16;
- dexmedetomidine age reduction S14;
- avoid or minimize benzodiazepines S27;
- no routine gabapentinoid;
- normothermia;
- adequate analgesia (pain itself precipitates delirium);
- early reorientation.
- Ketamine, if used, stays within the consensus bolus limit 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. Dose sources: DOSING_SOURCES.md. Author: Collin B. George, pre-medical student. License: CC BY 4.0. Educational framework; not clinically validated; not for patient care.