Should You Go IV-Free?

Anesthesia

By: Daniel Cook

Published: 7/23/2019

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Oral sedation promises to improve efficiencies and increase patient satisfaction in busy eye centers.


GOOD BEGINNING Patients appreciate avoiding IV starts, perhaps the most stress-inducing part of surgery.   |  Michael Greenwood, MD

The refractive eye procedure was scheduled to begin in about 20 minutes, just enough time for the sedative effects of the sublingual tablets to take effect. Michael Greenwood, MD, looked on as a nurse opened a two-pack of tablets. Things got a little hazy after that. “I vaguely recall someone in the OR telling a joke and another person in the room saying the procedure went perfectly,” remembers Dr. Greenwood, an ophthalmic surgeon at Vance Thompson Vision in Fargo, N.D.

Dr. Greenwood was the one sitting in the stretcher chair, not standing next to it, when the nurse slid 2 tablets under his tongue. The tablets slowly dissolved, sending a steady stream of the sedative midazolam, the analgesic ketamine and the antiemetic ondansetron into his bloodstream. The worry of surgery slipped away in minutes, and he soon become blissfully unaware of his surroundings.

“The entire experience was very pleasant,” he says. So pleasant, in fact, that he chose oral sedation for subsequent surgeries performed on his wife and mother-in-law.

Proponents of IV-free eye surgery tout its potential to please patients and improve clinical workflows, while others point to cost and safety concerns as reasons to stick with intravenous sedation. Here’s a look at both sides.

Plenty of positives

Dr. Greenwood says IV-free cataract surgery is an efficient sedation option in ophthalmology, a specialty where every minute counts, including those minutes spent trying to start IVs when first-stick success is never a guarantee.

His patients receive 1 to 2 tablets based primarily on age: 2 for those under 65 years; 1.5 for those 65 to 75 and 1 for those over 75. (You can order the tablets in bulk from a 503B outsourcing pharmacy and administer them to patients without needing individual prescriptions.)

Dr. Greenwood says the tablets provide a consistent sedation, adding to his confidence as he performs surgery. In addition, he says, patients experience a euphoric high from the ketamine, which softens the discomforting sensations of surgery, including staring into the bright light of the surgical microscope.

William Wiley, MD, medical director of the Cleveland (Ohio) Eye Clinic, says inconsistencies in the timing of sedating cataract patients can occur when nurses start IVs and wait for anesthesia to administer midazolam, with doses varying from provider to provider. He points out that nurses, without waiting for anesthesia, can time the administration of sublingual sedation in pre-op, so patients are feeling its calming effects before they’re wheeled back to the OR and are fully sedated when surgery starts.

Dr. Wiley says liquid valium placed under the patient’s tongue has a long onset, making it less than ideal for relatively fast outpatient procedures, while liquid midazolam has a brief onset, but can have variable effect due to how much of the drug is administered and how much patients actually swallow.

Administering midazolam in a sublingual tablet ensures the administration of a full, accurate dose, according to Dr. Wiley, leading to a more consistent and predictable sedative effect. The total length of action is about an hour, he says, so patients are typically fully recovered after spending about 15 minutes in post-op.

Nurses, too, appreciate not having to fret about sticking older patients multiple times to find usable veins. “I’ll occasionally joke with my nurses by telling them we’re out of the tablets,” says Dr. Greenwood. “You can see their shoulders slump.”

Nurses can time the administration of sublingual sedation so patients feel calm before heading to the OR.

Jay Horowitz, CRNA, president of Quality Anesthesia Corp. in Sarasota, Fla., isn’t completely sold on the time-saving potential of oral sedation. He recognizes its appeal, but says he can’t count on the variability of its onset in individual patients, especially when sedating patients in high-volume practices.

Mr. Horowitz is often in the OR with ophthalmic surgeon T. Hunter Newsom, MD, owner of Newsom Eye in Tampa, Fla. “He’s a world-class surgeon and he’s fast — he can safely perform excellent cataract surgery in about 4 minutes,” says Mr. Horowitz. “I need to keep pace, and the onset of action of any oral sedative is variable. I don’t think it can match the predictability of popping in an IV.”

Sublingual sedation eliminates the need to start IVs, perhaps the most stress-inducing part of a relatively painless procedure. “Many patients are more anxious about getting the IV than they are about undergoing surgery,” says Dr. Wiley. “Administering drugs sublingually eliminates that anxiety altogether.”

But at what cost?

Sublingual sedation saves patients from getting stuck, but some providers argue against IV-free surgery by pointing to the clinical importance of starting lines in older patients who present for cataract surgery, many of whom have several comorbidities.

Plus, the use of IV midazolam is highly predictable and safe, says Mr. Horowitz. “Although some patients will be unhappy about having an IV started, there are plenty of ways to make the stick less painful. Most patients I deal with are overwhelmingly in favor of being sedated and extremely satisfied with the results,” he says.

Mr. Horowitz can count on one hand the number of patients who’ve refused IV sedation for cataract surgery. He’s cared for some 50,000 cataract patients, according to this unofficial count, and claims he has never needed to resuscitate any of them during surgery. He has, however, cared for patients with previously undiagnosed clinical issues, generally cardiac-related, that required cancelling cases or transferring patients to ERs.

He acknowledges that complications in cataract surgery are rare, but also points out that it can be difficult to place a line under the pressure of a true emergency in a patient who has suffered vascular collapse.

Dr. Greenwood recognizes the safety concerns of IV-free surgery. He’s a big believer in the benefits of oral sedation, but also understands some clinical scenarios demand the use of IVs. For example, he typically has lines started in patients set to undergo more invasive, longer cases such as full thickness corneal transplants or implantation of complex IOLs and glaucoma tube shunts, and supplements their sedation with tablets as needed.

SATISFACTION GUARANTEED Oral sedation could increase the number of patients who refer their family and friends to your facility.   |  Pamela Bevelhymer, RN, BSN, CNOR

Facilities interested in going IV-free should ease into the practice by building confidence among the clinical team, according to Dr. Greenwood.

“Start IVs in patients and saline-lock the lines without administering medications,” he suggests. “Try that for a couple weeks or until your providers and surgeons gain confidence with the practice, and see for themselves how well patients do.”

Administering sedation tablets adds to the expense of cataract surgery. Whereas the supplies needed to start an IV are only about $2, a pack containing 2 sublingual tablets costs about $25.

“Some might wonder where they can make up the additional $23,” says Dr. Greenwood. “Well, I think that can be made up in reducing the staff time needed to start IVs and avoiding delays caused by failed IV sticks. On the front end it looks like the tabs add to case costs, but you make that up in convenience and also in improved patient experience, which is difficult to quantify.”

Using sedation tablets to improve efficiencies by eliminating the time it takes to start IVs is a break-even proposition, according to Dr. Wiley. But, he says, you can’t discount the improved patient experience that will increase the likelihood that patients will return to have their second eye done and refer friends and family to your facility. “In those ways, oral sedation pays for itself,” says Dr. Wiley. OSM

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