2026.10-rc2 - educational review candidate

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.

Revised 27 October 2026 after the rc1 PRs were merged.

This pass corrects newly identified source and software defects and deliberately narrows unsupported clinical/methodological content. Earlier versions remain recoverable in Git history. See PUBLICATION_REVIEW.md for the precise scope and limitations, PROVENANCE.md for author statements, and RELEASE_MANIFEST.json for current-file hashes.

The candidate is not a clinical protocol, validated controller, systematic/scoping review certification, or legal opinion. No repository visibility change is included.

Applied example set — 28 October 2026

Added 7 topic-specific male/female case pairs, a local copy of the shared anesthesia-options set, two levels of source mapping and an explicit verification standard. The profiles are entirely synthetic; the source checks are scoped and do not certify clinical validity. Existing clinical/manuscript text and PDF exports are preserved.

29 October 2026 — Portfolio presentation and reading path

Added a concise reader’s guide, explicit AI-assistance/authorship scope and review-status notes. Linked the portfolio home and corrected navigation wording. This presentation pass preserves substantive manuscripts, casebooks, code and existing exports. Repository visibility is unchanged.

November 2026 — accuracy and governance review

Dated 5 November 2026. Author: Collin B. George, pre-medical student. AI-assisted editing is disclosed in AUTHORSHIP_AND_REVIEW.md.

What changed

The educational dosing reference was restored. The rc2 discussion stubs were replaced with operational content from a citation-audited v2.0 draft (kept locally, not previously published). The live filenames were kept so external links keep working:
- v2.0 06_References_and_Evidence.md → 06_References_Evidence_Breast_Augmentation.md, titled "References & Evidence".
- v2.0 07_OR_Readiness_Checklist.md → OR_Checklist_Pre-Induction.md.
- v2.0's docs/index.html was not restored.
- Every live-only file was kept (cases, shared guide, audits, manifests, governance files).
DOSING_SOURCES.md was added, with entries S1–S39.
- Every numeric dose, rate, maximum, interval, conversion factor, threshold or timing in the restored documents carries an inline tag linking to an entry.
- Each entry gives the full citation or FDA label, the exact values it supports, and how it was verified.
- Only these source types are accepted: guidelines and consensus statements, FDA labels, and score-validation papers.
rc2 corrections that are stricter than v2.0 were preserved:
- IV lidocaine is never combined with blocks or infiltration (Foo 2021). v2.0 had allowed it "if the attending elects", or as an alternative to infiltration with a shared budget.
- POFA is framed as showing important adverse outcomes.
- There is no first/second/third-line order and no "preferred / fallback / lowest PONV / superior analgesia" language. v2.0's "Preferred" and "Fallback" labels, its "Bottom line: start with Protocol 1" statement, its "best for" columns, and the comparison table's "choose / avoid" summary were removed or reframed as considerations.
- No numeric respiratory triggers before seeking help.
- No fixed home instructions.
Citation currency:
- The fifth PONV consensus (Gan 2025, doi:10.1213/ANE.0000000000007816) was added. Its PMID is unverified: PMID 41237407, cited by the sibling review repository, could not be confirmed in this session.
- The fourth consensus (Gan 2020) is kept and labeled historical, because its dose table is the one that could be checked.
- The ASRA antithrombotic guideline is now Kopp 2025 (fifth edition).
- The 2026 ASA local/regional analgesia guideline (Joshi, Anesthesiology 2026;144:19-43, PMID 41363869) was added.
- Also added: the ASRA/AAPM/ASA ketamine consensus (Schwenk 2018), the CDC 2022 opioid guideline, the STOP-Bang papers (Chung 2008, 2016), Aldrete 1995, and the ASA basic monitoring standard (amended 2025).

Dose values changed to match the source (v2.0 → now)

Anesthetic agents and reversal

Propofol induction 1.5–2 mg/kg → about 2–2.5 mg/kg (<55 y) / 1–1.5 mg/kg (elderly, debilitated, ASA III–IV). Diprivan label, S16.
Propofol maintenance 75–150 mcg/kg/min → 100–200 / 50–100 mcg/kg/min. S16.
Rocuronium 0.6–1 mg/kg → 0.6 mg/kg, and RSI 0.6–1.2 mg/kg. S17.
Neostigmine 0.03–0.05 mg/kg (max 5 mg) → 0.03–0.07 mg/kg, max 0.07 mg/kg or 5 mg, whichever is less. S12.
Sugammadex "TOF 2–4 → 2 mg/kg; TOF 0–1 → 4 mg/kg" → label wording: 2 mg/kg at T2 reappearance; 4 mg/kg at 1–2 post-tetanic counts. S11.
Phenylephrine 50–100 mcg → 40–100 mcg bolus, with the label's repeat-bolus and infusion limits. S28.
Glycopyrrolate for bradycardia 0.2–0.4 mg → 0.1 mg, repeated every 2–3 min. S13.
IV lidocaine "max 100 mg" cap → consensus limits: ≤1.5 mg/kg IBW, ≤1.5 mg/kg/h, ≤120 mg/h, ≤24 h, not under 40 kg. S1.

Adjuncts

Dexmedetomidine: v2.0's 0.2–0.5 mcg/kg/h falls within the label range and was kept. The label's loading dose, procedural maintenance range (0.2–1 mcg/kg/h), >65 y reduction and hepatic reduction were added, and the use was marked off-label. S14.
Ketamine fixed 10–20 mg microboluses → expressed as the consensus limit, bolus ≤0.35 mg/kg (infusion up to about 1 mg/kg/h). v2.0's 0.2–0.3 mg/kg and 0.1–0.2 mg/kg/h fall within it. S15.

Opioids and naloxone

Hydromorphone PACU rescue "0.2–0.4 mg q15–20 min / 0.4–0.8 mg (tolerant) / q20–30 min (elderly, OSA)" → label 0.2–1 mg IV slowly, every 2–3 h. Lower start (0.2 mg) in elderly or debilitated patients; ¼–½ dose in hepatic or renal impairment; PACU titration interval per institutional protocol. S19.
Fentanyl induction phenotype table (0.5–2 mcg/kg by group) → label statements: individualize; low-dose general-anesthesia tier 2 mcg/kg; reduce in elderly and debilitated patients. S18.
Naloxone 0.04–0.08 mg every 2–3 min → label 0.1–0.2 mg every 2–3 min, with repeat doses possible at 1–2 h intervals. S22.

Non-opioid analgesics

Ketorolac "15 mg IV q6h" → label tiers. <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.
Ibuprofen 600 mg q6h / 400–600 mg q6h → 400 mg every 4–6 h. S26.
Celecoxib premedication 200–400 mg → label acute-pain regimen, 400 mg then 200 mg if needed on day 1. S25.

Antiemetics and PONV

Promethazine 6.25–12.5 mg → 6.25 mg. S7.
Scopolamine patch "continue ×72 h" → removed 24 h after surgery, per label. S30.
Apfel risk ~10/20/40/60/80% → 10/21/39/61/79%. S9.
PONV rescue gained amisulpride 10 mg (label). Prophylaxis options gained amisulpride 5 mg. S31.

Antibiotics

Cefazolin timing "30–60 min before incision" → "within 60 min". S6.
Vancomycin redosing "q12h" → not applicable. S6.

Scores

Aldrete oxygen item "SpO₂ >90% with O₂ = 1" → "needs O₂ to maintain SpO₂ >90%". The circulation middle band is stated as ±20–49 mmHg. S34.

Values deleted (no acceptable, verifiable source)

Local anesthetics and blocks (Protocol 1, Protocol 2)

PECS I/II and serratus per-plane volumes.
"Typical" bilateral volumes.
Infiltration example volumes and concentrations.
mg/kg ceilings (about 3 mg/kg ropivacaine; 2–2.5 mg/kg bupivacaine). The U.S. labels give absolute doses instead (S4, S5).
Minimum-weight column.
"Aspirate every 3–5 mL".
Perineural dexamethasone 2–4 mg.
Epinephrine 1:400,000.
Ultrasound frequency and needle size.
Block-assessment timing and dermatomes.

Premedication and adjuncts

Gabapentin 100–300 mg and "300 mg maximum" (perioperative use is off-label; no acceptable dose source).
Midazolam elderly "≤0.5–1 mg".
Elderly-specific dexmedetomidine and ketamine numbers. Replaced by label reductions.
"Stop dexmedetomidine 10–15 min before end".
"Stop ketamine 5–10 min before end".

Intraoperative targets and airway

Preoxygenation duration and EtO₂ target.
BIS ranges.
MAC fractions; sevoflurane and desflurane percentages.
Ventilation targets: tidal volume, PEEP, respiratory rate, EtCO₂, FiO₂, SpO₂.
MAP, HR and temperature targets.
Fluid rate, "<1500 mL", "LR 500–1000 mL".
HR triggers for bradycardia treatment.
ETT sizes and cuff pressure.
Extubation thresholds (RR, SpO₂, BIS 70–80, 5-s head lift).
RASS cut-offs.
Succinylcholine 1–1.5 mg/kg (label not verified this session).

Opioid technique and PACU monitoring (Protocol 3)

Fentanyl infusion 0.5–1 mcg/kg/h and 1–1.5 mcg/kg/h (tolerant).
Fentanyl 25–50 / 50–100 mcg increments; "typical total 100–200 mcg".
"Stop fentanyl 20–30 min before end".
"Hydromorphone ≥20–30 min before extubation"; "provides 3–4 h".
"Hydromorphone 0.8–1.2 mg total".
Fixed PACU vital-sign, SpO₂ and RASS intervals and durations.
Exposure triggers (">150/200 mcg fentanyl equivalent").
Capnography alarm values; RR/SpO₂/RASS severity tables for naloxone.
Naloxone 0.04 mg/mL dilution instruction, infusion 0.04–0.08 mg/h, "usually 0.4 mg total", half-life figure, "4–6 h minimum" monitoring.
Respiratory-depression incidence "1–5%".
Monitored-bed numeric triggers.
OSA discharge minute rules, AHI and exposure thresholds.
"Reduce 33–50%" and "reduce all agents 25–33%".
Chronic-opioid ">50 MME/day" threshold.

PONV

Metoclopramide 10 mg (dose not confirmed in the cited consensus this session).
Ondansetron infusion 1 mg/h.
Propofol 10–20 mg rescue.
Repeat dexamethasone 4 mg.
Home ondansetron #10–15.

Opioid conversion and home prescribing

IV equianalgesic table: hydromorphone 1.5 mg IV ≈ fentanyl 100 mcg ≈ morphine 10 mg IV, with its worked IV example. Only the CDC oral MME factors are given (S21).
Oxycodone prescription quantities (#5–20) and durations (3–5 days; taper 1–3 days).
"ER 40 mg + IR 10 mg #20" example.
Expected home pain-score course.

Antibiotics and irrigation

Vancomycin "max 2 g".
Triple-antibiotic irrigation recipe (cefazolin 1 g + gentamicin 80 mg + bacitracin 50,000 U per 500 mL). Its sources are primary studies, and bacitracin injection was withdrawn (S38).
Pulse lavage "≥3 L".

Surgical workflow (04)

All clock times (T-60 … T+100 min) and "typical OR time 90–130 min".
Upright angle 45–80°.
Arm abduction "<90°" (replaced by "avoid hyperabduction").
Suture sizes.

PACU, discharge and home (05, 02, 04)

O₂ 2–4 L/min and SpO₂ ≥94%.
Vitals q15 min.
Pain ≤4/10 targets.
"Stable vitals ×1–2 h".
Drain emptying every 8–12 h; removal "<30 mL/24 h ×2 days".
Lifting 5–10 lb; activity week bands.
Showering 48 h; Steri-Strips 7–14 days.
Alcohol 48–72 h; driving 24 h.
Fever >101°F; drain output >100 mL/shift.
Follow-up schedule.
Counseling-script recovery timings and "2–4 injections".

OR checklist

E-cylinder "≥1800–2200 psi".
Push-dose epinephrine 10 mcg/mL.

Quality metrics

QI trigger percentages (>30%, >15%, >5%).

Review findings applied (reviewer A, November 2026)

#3 — APPLIED_CASES.md registry: guideline N now attributed to Thilen SR et al., with volume and pages; B given 2026;144:19-43. The same correction was made in EXAMPLE_SOURCE_AUDIT.json.
#7 — BR-06's awareness point now cites T (Nimmo 2019 TIVA/pEEG) instead of N (in the Markdown and the JSON case map).
#8 — Duplicate DOI links removed from the APPLIED_CASES.md registry. Markdown links stripped from JSON title strings.
#9 — Circular "See ANESTHESIA_OPTIONS_AND_CASES.md" checked fields replaced with a check statement that cross-references SHARED_SOURCE_AUDIT.json.
#10, #11 — The boilerplate three-source "Sources and limits" blocks and the fragile POFA PDF link were removed with the replaced modules. Module-specific tags and DOI links are used instead.
#12 — A retained-filename note was added to 06.
#13 — The README disclaimer blockquote now sits directly under the H1.
Not applied (outside scope or done elsewhere):
- #1 (capnography wording) was already fixed in the shared guide.
- #2, #4, #5 and #6 concern ANESTHESIA_OPTIONS_AND_CASES.md and SHARED_SOURCE_AUDIT.json, which were left unchanged as instructed.
- #14 is informational.

Verification limits

DailyMed, Drugs@FDA, PubMed and doi.org could not be opened from the build environment. Labels and identifiers were checked through web-search records of FDA-hosted label PDFs, manufacturer pages, label mirrors and indexing services. Each DOSING_SOURCES entry states what was confirmed.
Unverified identifiers:
- the fifth PONV consensus PMID;
- the CDC 2022 PMID;
- the Bratzler and Chung DOIs;
- the ASRA 2020 checklist DOI (recorded from the repository's audit, not re-resolved).
Partly verified content:
- The CDC MME factor values were taken from the guideline's table as read by the author; the search record did not display them.
- The promethazine and scopolamine consensus details came from secondary summaries.
- The ASRA LAST checklist dosing panel was confirmed only in secondary reproductions.

Folded in: v2.0 review notes and changelog (November 2026, previously unpublished)

v2.0 summary judgment. v1.0 had a sound structure. Its safety framing was careful in many places: LAST, opioid stacking, the naloxone protocol and delirium mitigation. Three problems would have undermined it with any physician reader:

Citation integrity. 14 of 24 references matched no published article, and 9 more had the wrong year, journal, title or edition.
Outcome figures with no source. Examples: "PONV 3–8% vs 15–25%", "respiratory events <2% vs 5–10%" and "PACU 60–90 vs 120–180 min". These ran opposite to the best RCT on dexmedetomidine-based OFA (POFA 2021).
Arithmetic and consistency errors:
- local-anesthetic volumes exceeding mg/kg ceilings in small patients;
- IV lidocaine stacked on bilateral blocks;
- lipid emulsion marked "not needed" for pathways using infiltration;
- single-agent PONV prophylaxis at Apfel 2;
- an incorrect oxycodone conversion (15 → 20 mg PO per 10 mg IV morphine);
- a per-liter triple-antibiotic recipe that should have been per 500 mL.

v2.0 changes.

Citations. 14 unmatched entries were removed and 9 corrected. Verified sources were added: POFA, Foo 2021, Verret 2020, Kharasch 2020, Grape 2020, Hussain 2019, Thilen 2023, Neal 2018/2021, Kopp 2025, Bratzler 2013, Jewell 2021, the FDA 2020 bacitracin withdrawal, and the FDA 2020/2021 implant labeling. "Strong (A)" labels were replaced with author-judged certainty levels.
Clinical safety corrections:
- a calculate-ceiling-first instruction for local anesthetic;
- IV lidocaine omitted with blocks and infiltration;
- lipid emulsion available in all pathways;
- two-agent PONV prophylaxis at Apfel 1–2;
- PACU PONV rescue from a different drug class;
- neostigmine limited to minimal-depth block, with quantitative TOFR ≥0.9;
- removal of sedative escalation in Protocol 2;
- chronic opioid use routed to block + multimodal care with the baseline continued;
- MOUD continued, with indicated opioids not withheld;
- lymphedema-side BP cuff and IV guidance;
- separate cefazolin and vancomycin timing;
- gabapentinoids removed from routine premedication;
- anticoagulation recast as relative and block-depth-dependent per ASRA.
Analytic integrity.
- All unsourced numeric outcome benchmarks were removed.
- The pathway hierarchy was reframed around block evidence and opioid stewardship.
- Promotional language was removed from the counseling script, and implant-specific risks (BIA-ALCL) and block risks were added.
- "Validated, Clinically Accurate" was removed from the OR checklist.
Hygiene. Broken README links fixed. Scope unified as post-mastectomy implant revision, not cosmetic augmentation.

Open items carried forward from v2.0 (still open):

Fill remaining PMIDs and DOIs from PubMed when it is reachable.
Review PROSPECT 2026 for oncological breast surgery (Desai et al., Anaesthesia, doi:10.1111/anae.70313) and reconcile it with the three approaches, especially gabapentinoids and block choice.
Read the full fifth PONV consensus dose table and update S7/S8.
Re-check each label entry directly on DailyMed or Drugs@FDA.
Capsulectomy and drain criteria remain expert-opinion level.
An anesthesiologist's review would strengthen the portfolio. Do not describe the work as "attending-reviewed" unless that review actually happens.