IVs should be painless

The study by Mathew et al.¹ regarding patients' pain experiences during cataract surgery is a bit disturbing because intravenous (IV) cannulation should not cause any pain. An effective dilute local anesthetic agent can be made by mixing 1 part lidocaine 1% with 9 parts sterile saline 0.9% with benzyl alcohol preservative. Creating a skin wheal by injecting this solution through a 30-gauge, ½-inch needle is virtually painless and renders IV cannululation painless as well. In my opinion, IV cannulation should never be attempted on an awake patient without making this wheal. In 35 years of practice, I have never encountered a complication with this technique, and my patients have been uniformly grateful. If one prefers, EMLA® cream (lidocaine 2.5%–prilocaine 2.5%) is also an option.

If the authors would not attempt sub-Tenon's cannulation without first applying a topical anesthetic agent to the conjunctiva, they should not be starting IVs without first using local anesthesia. Had they taken this simple step, the only important conclusion from their data would be that surgery under topical anesthesia is more painful than under sub-Tenon's anesthesia. The need to start an IV before sub-Tenon's or topical anesthesia remains debatable, but the duty to start every patient's IV painlessly should not be.

Gary L Fanning MD

Sycamore, IL, USA