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.
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. 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.
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.
- 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: blood pressure and heart rate at least every 5 min, ECG, pulse oximetry, capnography and temperature. Quantitative neuromuscular monitoring S10.
- Naloxone available in PACU. The label increment is 0.1–0.2 mg IV every 2–3 min S22. Prepare per institutional protocol.
- Lipid emulsion immediately available if surgeon infiltration is used 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 | Opioid-sparing foundation |
| Celecoxib | 400 mg once 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 | Additive respiratory depression S27 |
Antibiotics S6:
- Cefazolin 2 g, or 3 g if ≥120 kg, within 60 min; redose every 4 h S6.
- Clindamycin 900 mg (redose every 6 h) S6, or vancomycin 15 mg/kg started within 120 min; routine redosing not applicable S6.
PONV prophylaxis. Postoperative opioids count as one Apfel factor S9. Most patients in this population therefore have ≥3 factors: female, non-smoker, postoperative opioids. Estimated baseline risk with 3 factors is ~61% S9.
| Risk factors S9 | Prophylaxis (adults) |
|---|---|
| 1–2 | Two interventions S7, S8, e.g., dexamethasone 4–8 mg IV at induction + ondansetron 4 mg IV at end of surgery S7, S8 |
| ≥3 | Three to four interventions S7. Add, for example, propofol TIVA; transdermal scopolamine (evening before or 2 h before surgery S7; removed 24 h after surgery S30); amisulpride 5 mg at induction S31; or droperidol 0.625 mg at end of surgery S7 |
Also consider risk reduction: propofol TIVA, avoiding nitrous oxide, and minimizing opioid dose S7, 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 | 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 | Titrate to effect |
| 3 | Rocuronium | 0.6 mg/kg; RSI 0.6–1.2 mg/kg S17 | Succinylcholine for RSI: dose per its label (not verified in this session, so none is given) |
| — | IV lidocaine | Not with surgeon infiltration S1. Without any local-anesthetic intervention: ≤1.5 mg/kg IBW S1 | Consensus hourly ceiling 120 mg/h S1 |
Maintenance
- Hypnotic: propofol 100–200 mcg/kg/min (healthy <55 y) or 50–100 mcg/kg/min (elderly, debilitated, ASA III–IV) 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.
- 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.
- 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, S5, and IV lidocaine is not run concurrently S1.
- Optional adjuncts:
- Ventilation, hemodynamics, fluids, temperature: individualized. No numeric targets are given (no acceptable source).
- Hypotension:
Emergence and extubation
- PONV: ondansetron 4 mg IV at end of surgery if planned S7, S8.
- Reversal by quantitative monitoring S10:
- Extubate only when awake, ventilating adequately, and quantitative TOFR ≥0.9 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), 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 |
| 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 |
| Celecoxib | 200 mg twice daily after the day-1 regimen S25 |
| Ibuprofen | 400 mg every 4–6 h as needed 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. The label interval is every 2–3 h; PACU titration intervals follow institutional protocol S19. Hold for oversedation.
- Oral transition: oxycodone IR 5–15 mg every 4–6 h as needed (opioid-naïve start) S20.
Respiratory depression — naloxone (label values)
- Call for help. Stimulate, support the airway, and give bag-mask ventilation if needed.
- 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.
- Re-sedation can occur because some opioids outlast naloxone. Repeat doses may be needed at 1–2 h intervals 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.
PONV rescue
Use a different class from prophylaxis. Do not repeat a 5-HT3 antagonist within 6 h S7. Options:
- amisulpride 10 mg S31;
- droperidol 0.625 mg S7;
- promethazine 6.25 mg (boxed warning for tissue injury) S7;
- haloperidol 0.5 to <2 mg (off-label) S7.
Metoclopramide is not listed: its dose was not confirmed in the cited consensus in this session.
Discharge readiness
Modified Aldrete ≥9 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 and NSAID if appropriate S25, S26.
- Opioid, if needed: immediate-release, at the lowest effective dose S20, S21, and no more than needed for the expected duration of severe pain S21. Counsel on respiratory depression, avoiding alcohol and sedatives, safe storage and disposal S21.
- Long-term opioid therapy: continue the baseline regimen, coordinate with the prescriber, and do not abruptly discontinue S21.
- Opioid exposure estimate (oral only): MME/day = dose × CDC factor. Factors: morphine 1, oxycodone 1.5, hydromorphone 5 S21. Example arithmetic: oxycodone 5 mg four times a day = 20 mg × 1.5 = 30 MME/day S21. The factors are not for converting between opioids, for IV doses, or for buprenorphine or methadone S21.
- No fixed tablet quantities, durations or IV equianalgesic ratios are given. CDC 2022 does not set fixed limits S21, and no acceptable source for IV ratios was verified.
Special populations (qualitative modifiers)
- Older or frail patients:
- OSA:
- STOP-Bang 0–2 low risk, 3–4 intermediate, 5–8 high 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, Apfel score S9, baseline opioid regimen.
- Intra-op: each opioid dose and time, adjuncts, infiltration total mg S4, S5, PONV agents, reversal agent and dose, quantitative TOFR S10.
- Handoff: total opioid exposure and time of last dose, OSA or frailty flags, naloxone availability S22, expected rebound pain.
Example record (fictional, illustrative only; every dose shown lies within a cited label range):
- Induction: fentanyl, individualized S18; propofol 1–1.5 mg/kg (older patient) S16; rocuronium 0.6 mg/kg S17
- PONV: dexamethasone 8 mg at induction and ondansetron 4 mg at end of surgery S7, S8; TIVA
- Analgesia: hydromorphone 0.2 mg IV slowly, repeated once after reassessment S19; surgeon infiltration bupivacaine total ___ mg, within label limits S5
- Reversal: sugammadex 2 mg/kg at T2 S11; quantitative TOFR ≥0.9 before extubation S10
Scores used (validation papers)
- Apfel S9: 0–4 factors → ~10%, 21%, 39%, 61%, 79%.
- STOP-Bang S32, S33: items as in 01 §5.3; categories 0–2 / 3–4 / 5–8 S33.
- Modified Aldrete S34: table in 05. The 1-point oxygen item is "needs O₂ to maintain SpO₂ >90%"; the circulation middle band is ±20–49 mmHg S34.
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.