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 sublin-
gually 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 sedat-
ed 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, how-
ever, cared for patients with previously undiagnosed clinical issues,
generally cardiac-related, that required cancelling cases or transfer-
ring 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 under-
stands some clinical scenarios demand the use of IVs. For example,
6 2 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • J U L Y 2 0 1 9
