The older I get, the less opiate I administer. My goal is simple, I want wide awake patients in PACU who are free of pain and nausea. I listen to the PACU nurses who have a clue, and I'm convinced the #1 cause of PONV, and PACU sedation, is unnecessarily excessive opiate administration. For truly painful cases, there are local anesthetics, for everything else 100mcg of fentanyl is almost always more than enough. Ex-Laps get epidurals or TAP blocks. Orthopedic surgeries get blocks. I use more than 100 mcg of fentanyl, or add in hydromorphone, maybe once or twice per month.
I never use opiates for GI scopes.
I titrate based on EtCO2 at the end of the case. 40 for PSV, 50 for SV. Keep it simple.
Intraoperatively, judicious use of beta blockers is pretty effective.
I am just finishing up a bilateral knee replacement case. The isobaric spinal was sufficient, although I did add 25 mg of ketamine to my propofol for the last hour just in case. The patient is snoring comfortably as her exparel blocks set up.
My patients are happy, my PACU nurses are happy, my life is good. For the life of me, I can't figure out why I used to feel like I had to use higher fentanyl doses, and hydromorphone, so frequently.