Anesthesiology/IV Problems

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QUESTION: Dear Dr Shah

I go out of my mind with pain with any sort or duration of venipuncture, and terminate the procedure immediately--even for a simple blood draw.  EMLA and iontophoretic patches do not help, since they provide only dermal anesthesia.  

I need surgery for an inguinal hernia, but cannot find a surgeon in Washington State who will use local anesthetic only with no IV canulation.  I would like to find one, but above all I would like the IV problem taken care of for future emergencies.

ANSWER: While there are still a small proportion of surgeons that are comfortable, qualified, and competent to repair an inguinal hernia under local anesthesia, I would be surprised if there is even one legitimate surgeon that would do so without the patient having an IV.  The amount of local required to perform the surgery is substantial; therefore, the theoretical risk of local anesthetic toxicity is also high, and the only effective way to treat toxicity is with an IV already in place.  Good surgeons and anesthesiologists understand this risk, and would be doing patients a disservice by not having an IV.  

You're certainly not the first patient to be nervous about having an IV, but have you also considered that compared to the injections required to anesthetize the inguinal area, the IV is insignificant?  I typically insert patients' IVs after injecting a small amount of subcutaneous lidocaine to numb the insertion site..most patients say it makes the IV much more tolerable.

The bottom line is that for your safety, it is mandatory to have an IV before surgery.  Consider discussing with your anesthesiologist taking a preoperative oral medication like Valium.  In order for it to be effective, it is best to take Valium about 45-60 minutes before you have your IV inserted.

---------- FOLLOW-UP ----------

QUESTION: Dear Dr Shah

Thanks for the clear and informative discussion.  You have certainly convinced me on the need for IV.  Thanks also for the suggestion on numbing the insertion site; however, the problem is not the pain of insertion, but the pain caused by the needle's presence in the vein.  I tried a blood draw on Monday (with an iontophoretic patch), and was not able to last more than a few seconds. Perhaps my local lab would be willing to try the subQ lidocaine, but I remain doubtful, as there would be no local anesthetic inside the vein.

Do you think that the infusion of conscious sedation drugs into my system would block the needle-in-vein pain before I pull away from the pain source?

I tried valium several times before some massive dental surgery, and it had the effect of making me weak while doing nothing for pain sensitivity.

Regards,

Michael Mates

Answer
An IV that is already in place has no needle in it.  The needle is used to insert the IV under the skin, but all that remains is a very thin plastic tube.  While you may be aware that there is something under your skin, it is not sharp and typically not painful inside the blood vessel.  While the administration of IV anesthetic/sedative medications may produce a stinging sensation at the IV site for a few seconds, the medications frequently start working within 15-20 seconds.  

Valium is not intended to affect pain sensation.  It is only meant to lessen preoperative anxiety.  

Anesthesiology

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Arjav Shah, M.D.

Expertise

I have a broad anesthetic experience in my Dallas practice, so I can answer most questions about anesthesia, but defer to other's expertise in chronic pain management

Experience

Board-certified in Anesthesiology and Critical Care Medicine, in practice since 1999. I have been in private practice in Dallas since 2001, and am a strong supporter of physician-only anesthesia.

Education/Credentials
Residency in Surgery and Anesthesiology at University of Texas Medical Branch at Galveston, Fellowship in Critical Care Medicine at Wake Forest University

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