I think this is an interesting topic. I had a few attendings in residency that, because of literature at the time suggesting that intraop narcotics just might exacerbate long-term metastases, would completely avoid intraop narcotics during abdominal and breast cancer whacks. (First Google hit on this topic-
http://www.uchospitals.edu/news/2012/20120321-opioid.html).
They'd get through the case with esmolol and nitro. At the end, during closure, would reverse and then titrate in narcs to respiratory rate.
I thought they were nuts at first. What about preemptive analgesia? Stress of surgery? Spinal cord wind-up? Surely they'd wake up miserable?
Nah. These patients all did just fine postop. Indistinguishable from pts having "usual" management with intraop narcs. I was pretty impressed. So I needed convincing, but I am in the camp that you don't
need intraop narcotics. The patient doesn't have a functioning cortex, there is no "pain," which is a conscious experience. That said, it's usually easier to just give the narcs.
For the elderly or those with ADRs (i.e. nausea), I try to limit as much as possible, which is sometimes to zero. In fact just did a narc-free lap chole- pt with severe nausea to all narcs (but apparently not volatile). Induced with ketafol, made sure surgeons gave adequate local, IV tylenol and toradol at the end. Comfortable in PACU, no nausea.
I almost never give more than a total of 500mcg total fentanyl to my hearts, which is how much they would have had on board by skin incision during training. They (mostly) all get ketamine and magnesium, the elderly also get IV tylenol.
For elderly patients getting procedures that a block covers, I don't use narcs either.
I think at the end of the day, it behooves us to limit them to whatever amount is reasonable for that patient having that surgery. Every patient will be different.