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.

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. 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.

PACU handoff checklist (anesthesia → PACU nurse)

Item	Details to report
Analgesic approach	1 / 2 / 3 (see 03)
Regional block	Yes (type ______) / No
Local anesthetic	Agent, concentration, total mg from block + infiltration S4, S5; time given
IV lidocaine	Given? (should not overlap with block or infiltration 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
PONV prophylaxis	Agents and times (rescue should use a different class S7)
Drains	None / number and location
Risk flags	OSA (STOP-Bang 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.
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. <50 kg: 15 mg/kg every 6 h, max 75 mg/kg/day S24	Contraindicated in severe hepatic impairment 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	Boxed warnings: bleeding, GI, renal, CV S23
Foundation (oral)	Ibuprofen	400 mg every 4–6 h as needed; higher single doses were no more effective in analgesic trials S26	NSAID warnings S26
Foundation (oral)	Celecoxib	400 mg once, then 200 mg if needed on day 1; then 200 mg twice daily as needed S25	CV and GI boxed warnings 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	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	Long-term opioid therapy: continue baseline regimen 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.

Opioid-induced respiratory depression — reversal (label values)

Call for help. Stimulate, support the airway, and ventilate if needed.
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.
Opioid effects may outlast naloxone, so repeat doses may be needed at 1–2 h intervals 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, 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.
Option	Amisulpride 10 mg IV over 1–2 min (labeled for treatment, including after failed prophylaxis with another class) S31
Option	Droperidol 0.625 mg IV S7 — QT boxed warning; ECG considerations
Option	Promethazine 6.25 mg 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
Scopolamine patch	If used for prophylaxis, the label removes it 24 h after surgery S30

Values changed from v2.0, and v2.0 values removed for lack of an acceptable source, are listed in RELEASE_NOTES.md.

PACU documentation template (educational)

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 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	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	>92% on room air	Needs O₂ to keep >90%	<90% even with O₂

Source: 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 and safe opioid storage and disposal 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.

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