What is the recommended pre‑operative intravenous nalbuphine dose (mg per kilogram) for an adult patient undergoing surgery?

Preoperative Nalbuphine Dosing for Adults

For adult patients undergoing surgery, administer nalbuphine 0.3 mg/kg intravenously as a preoperative dose, given 10-15 minutes before induction, to attenuate the hemodynamic response to intubation and provide perioperative analgesia. 1, 2

Dosing Algorithm

Standard Preoperative Dose

• 0.3 mg/kg IV is the evidence-based preoperative dose for adults 2
• Administer slowly over 10-15 minutes before induction 1
• This dose effectively attenuates pressor response to tracheal intubation while providing good perioperative analgesia 2

Context-Specific Adjustments

For supplement to general anesthesia (induction doses):

• Induction range: 0.3-3 mg/kg IV over 10-15 minutes 1
• Maintenance: 0.25-0.5 mg/kg IV as single boluses as required 1

For postoperative breakthrough pain (PACU/ward):

• Adults: 0.1-0.2 mg/kg IV, titrated to effect 3
• Repeat every 3-4 hours as needed 3
• Standard adult dose: 10 mg for 70 kg patient (approximately 0.14 mg/kg) 1

Critical Safety Parameters

Maximum dosing limits:

• Single maximum dose: 20 mg in opioid-naïve patients 1
• Maximum total daily dose: 160 mg 1
• Repeat dosing interval: every 3-6 hours 1

Essential monitoring requirements:

• Have naloxone, resuscitative equipment, intubation equipment, and oxygen immediately available 1
• Monitor for respiratory depression, especially within first 24-72 hours 1
• Continuous observation required when used as anesthesia supplement 1

Evidence-Based Advantages

Hemodynamic stability:

• Nalbuphine 0.3 mg/kg produces significantly less tachycardia and hypertension during intubation compared to pentazocine 0.6 mg/kg 2
• Provides cardiovascular stability without significant hemodynamic changes 4

Superior postoperative analgesia:

• Only 16.6% of patients receiving preoperative nalbuphine 0.3 mg/kg required rescue analgesia within 30 minutes postoperatively, compared to 60% with pentazocine 2
• Provides effective analgesia without ceiling effect concerns at appropriate doses 4

Common Pitfalls to Avoid

Do not use high-dose nalbuphine (>0.3 mg/kg) to reverse respiratory depression from large-dose fentanyl:

• Doses of 0.3 mg/kg, 0.1 mg/kg, or 0.05 mg/kg used to reverse fentanyl 50-75 mcg/kg caused hypertension, tachycardia, severe pain, agitation, nausea, vomiting, and dysrhythmias 5
• This antagonist effect negates the intended preoperative analgesic benefit 5

Avoid abrupt discontinuation in physically dependent patients:

• Taper by 25-50% every 2-4 days if discontinuing after regular use 1
• Monitor for withdrawal symptoms and adjust taper accordingly 1

Do not combine with benzodiazepines or CNS depressants without careful monitoring:

• Increased risk of profound sedation and respiratory depression 1
• Requires dose adjustment and enhanced monitoring 1

Multimodal Integration

Combine nalbuphine with:

• Dexamethasone 8 mg IV at induction to reduce pain and PONV 3, 6
• IV lidocaine 1-2 mg/kg bolus followed by 1-2 mg/kg/h for major surgery without regional analgesia 3
• Ketamine 0.5 mg/kg for high-risk pain patients or those on chronic opioids 3, 6