By Maggie Jeffries, MD

One of the challenges that high volume cataract surgery centers face is how to balance efficiency with cost control both for the center and the anesthesia group. 
Our high-volume surgeons will perform approximately 18-25 surgeries in two operating rooms during a 5-hour surgical block of time. This requires patients to arrive early so that they can be moved through the check-in and pre-surgical process as efficiently as possible so that 3-5 patients are in preoperative beds at any one time. Many times, this means patients will wait in the waiting room or in their preoperative beds for longer than they find acceptable especially if an unanticipated complication, such as a vitrectomy, occurs. This was indeed the problem when we took over a cataract center in 2013. Patients would be sitting in their beds constantly interrupting nurses and anesthesia providers about when was their turn, sometimes escalating into anger.  

As a group, we decided we could do better. We also had the challenge of staffing costs associated with “flip” rooms in a market of ever decreasing reimbursements. And thus, was the introduction of preoperative anxiolytic medications into our practice. 

We initially settled on use of diazepam 10mg PO given to patients by the preoperative nurse.  Exclusion criteria were patients who require assistance to ambulate, wheelchair bound, liver failure, and allergy to diazepam.  Patients of Asian descent received diazepam 5mg.  The preoperative nurse administers the medication per our standing orders after consents are signed, NPO is confirmed and an initial set of vital signs are taken.  They all receive in-services regarding exclusion criteria and dosing modification strategies.   When scheduled for an eye block, patients still received diazepam preoperatively.

Why diazepam?
Diazepam 5mg PO is commonly used by ophthalmologists for Lasik surgery with good results.  Most of our high-volume surgeons also use the femtosecond laser in conjunction with cataract surgery which requires the patient to be awake, relaxed and cooperative – similar to what they need during Lasik.  Diazepam also has mild muscle relaxant properties, helping our patients with arthritis and other orthopedic issues be more comfortably in the flat position. As with all benzodiazepines, there is often a beneficial element of amnesia.  Many patients fall into a light sleep but are easily arousable and their vital signs remain stable. 

As part of this process change, we tracked how much additional medications patients received in the OR and patient satisfaction.  The overall mood of our patients in the preoperative holding area went from anxious and frustrated to quiet and serene.  Our nurses and doctors also reported better satisfaction as the patients were not only more comfortable in the preoperative holding area but in the OR as well. 

Because patients were already somewhat relaxed, nurses could take a patient back to the OR and get them ready in anticipation of the surgeon/anesthesia team coming from finishing the prior OR. This enabled us to further increase our efficiency by staffing both ORs with the same CRNA (we work in a team model) – they would essentially follow the surgeon from room to room. Furthermore, many of our patients didn’t require additional medications in the OR after receiving diazepam which drove down the cost of anesthetic medications as diazepam is less expensive than midazolam and fentanyl. During drug shortages that involved both midazolam and fentanyl, we found our practice unaffected as our use of such medications is minimal. 

There are many other preoperative medications that we have added to our arsenal over time.
When given preoperatively, benzonatate (Tessalon) perles are fantastic in decreasing coughing and tramadol works to decrease postoperative pain when anticipated after particular surgeries (i.e. glaucoma procedures). There are also the standard medications used for the prevention of postoperative issues such as ketorolac, ondansetron, dexamethasone.

More recently, we have added the use of the MKO melt at two of our centers.  The MKO melt is a sublingual formulation of midazolam 3mg, ketamine 25mg and ondansetron 2mg.  Most patients typically require 1-2 melts and we have found that only about 15-20% of those patients will require additional IV medications in the OR.  This medication has a cost factor and at one of our centers we have specific criteria for its use such as young, high anxiety and co-existing psychiatric conditions.  At our other center, where the majority of patients are scheduled for the Lensx femtosecond laser, we use the MKO melt on all patients unless the medication is contraindicated.

In summary, we were able to greatly increase our efficiency and control staffing costs from the addition of preoperative anxiolytic medication before eye surgery.