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    IV-free sedation may help anxious cataract patients

    Sublingual approach sees other benefits in reduced ASC time, better experience

    Dr. WileyCleveland—Cataract surgery has evolved from the original striking of an opaque lens with a blunt object to the modern era of phacoemulsification and onward. The procedure continues to be refined and, as one of the safest procedures in medicine, has moved from a hospital to an outpatient setting.

    In spite of its safety, most cataract surgeons still routinely use intravenous (IV) sedation and as insurance in case of any other medical emergency that may arise. However, clinical experience with oral anesthesia delivery is showing it may be more effective than IV delivery, and patient pushback may force us to get rid of the “just-in-case IV.”

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    Most cataract surgeries employ the following medications singularly or in some combination: midazolam, fentanyl, ketamine, and propofol.

    Ten years ago, our surgical center preferred midazolam and fentanyl. Though these worked well, the opioid also produced some hard-to-predict side effects, such as nausea, that heavily influenced patients’ impression of surgery. Thus we switched to midazolam and ketamine.

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    Ketamine is known as a dissociative anesthesia that produces an analgesic and sedative effect. Ketamine is commonly used for short surgical procedures as it has rapid induction, analgesia, and amnesia with a short recovery period. Ketamine was found to change patients’ perspective of cataract surgery from something scary to something positive.

    Midazolam is commonly utilized for conscious sedation/anxiolysis/amnesia and when used for anesthesia, can reduce the unpleasant emergence reactions caused be ketamine.1, 2 Studies have demonstrated that midazolam and ketamine have additive effects on conscious sedation, but not on anesthesia.3

    Getting ahead of surgical anxiety

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