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Archive Anesthesia 2020

Should You Add Oral Sedation?

The benefits of IV-free options are well-documented, but do they outweigh provider concerns?

Jared Bilski

BIO

PAIN FREE
PAIN FREE Cataract patients often say the needle stick during IV administration is the most painful part of the entire surgery.

For many patients undergoing minor outpatient procedures like cataract surgery, the needlestick that's used to administer IV sedation is often the most painful part of the process. So why not eliminate this patient satisfaction-killer whenever you have an opportunity to do so?

Needle aversion is one of the primary reasons John Berdahl, MD, an ophthalmologist at Vance Thompson Vision in Sioux Falls, S.D., gives most of his patients sublingual sedation tablets consisting of midazolam (3 mg), ketamine HCI (25 mg) and ondansetron (2 mg). The "melts" are placed under the patient's tongue before surgery and take effect within minutes.

"Every facility has some form of oral sedation available for patients who refuse to have IVs started," says T. Hunter Newsom, MD, a cataract and refractive surgeon and the founder of the Newsom Eye & Laser Center in Sebring and Tampa, Fla.

Not having to place an IV is only one of the reasons to use oral sedation for cataract patients. "Anesthesia approaches vary so widely, and sublingual sedation brings a greater consistency to the process because we can avoid first pass metabolism. It also has rapid onset," says Dr. Berdahl.

The "sublingual troche" Dr. Berdahl uses generally is given in one-, one-and-a-half or two-tablet dosages. He estimates 40% of his cataract patients get one tablet, 30% get one and a half and the other 30% get two tablets before surgery. The dosage is driven primarily by age. "The older the patient, the less sedation they receive," says Dr. Berdahl.

The final and, according to Dr. Berdahl, potentially greatest big-picture benefit of oral sedation options is that they're opioid-free. "The ability to avoid fentanyl in cataract procedures is important," says Dr. Berdahl. "The literature shows patients who receive opioids only once can face problems of dependency."

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