AUTISM AND ANESTHESIAAMANDA WHIPPEY MD FRCPC

PEDIATRIC ANESTHESIOLOGIST

MCMASTER UNIVERSITY

OBJECTIVES

1. Review Autism Spectrum Disorder (ASD) its impact on the perioperative experience of patients

2. Discuss current research on Clinical Practice Guidelines that aim to decrease stress, anxiety and improve compliance in patients with ASD coming for surgery

DISCLOSURES

None

“ If you have met one person with autism, you’ve

met ONE person with autism”

- Dr. Stephen Shore

J Dev Behav Pediatr 2016 (37) 457-464

First identified in 1943 by Kanner

1980 - Autism a distinct disorder in DSM IV

2013 – ASD (Autism, Aspergers, PDD)

2017 – Less than 10% of anesthesia deptand 0% pediatric depts in Sweden have specific protocols to address needs of children with ASD

“a mental condition, present from early childhood, characterized by difficulty in communicating and forming relationships with other people and in using language and abstract concepts.”

Autism is Common

CDC Press Release March 2014

DIAGNOSIS Communication

Sensory

ProcessingBehaviour

40-80% ASD have

abnormal sensory

processing

1. Need for

routine

2. Stereotypic

movements

3. Intense special

interests

Visual > Verbal communication

Difficulty interpreting social

interaction

Pediatric Anesthesia 25 (2015)1076-184

*

THE OR IS A SCARY PLACE…

Abnormal responses to sensory stimuli

sound, touch, visual stimuli, pain, or the sensations of hot and cold

Preoperative anxiety = negative postoperative behaviors

sleep disturbances, nightmares, separation anxiety, apathy, general anxiety, withdrawal – up to 1 YR!

Routine dependence can lead to

extreme distress

Paediatr Anaesth. 2003;13(3):188-204

12 parents of patients describe their experience without and without perioperative dialogue

WITHOUT

HOPELESS STRUGGLE

UNSPEAKABLE

SUFFERING

DISGRACEFUL

SCENARIO

WITH

WARM HANDS

KNOWN FACES

INTERPLAY BETWEEN

PATIENT AND

CAREGIVER

Early literature focuses on combative or uncooperative children –NOT ROOT CAUSES

Behaviourally informed interventions are RARE

Individualized plans that minimize known stressors decreased noncompliance at induction from 50 17% WITHOUT premedication

Aim: to survey perioperative management practices for children with ASD

Arch Dis Child 2016 (101) 1090-1094

3 Main Themes:

1) Collaborating with caregiver to inform patient management

2) Developing a process for communicating information gathered from caregivers to perioperative staff

3) Modifying perioperative environment-based on patient-specific needs gathered from caregiver

** Importance of individualized care pervaded all themes**

retrospective chart review - preoperative sedation, stratified by autism spectrum disorder severity level, behavior at induction, caregiver satisfaction

246/251 patients had individual care plans carried out (98%)

45% patients were Aspergers/ Severity Level 1

Need for premedication increased (OR 5.5X) with increasing severity of ASD (level 3 vs level 1)

Cooperation at induction (overall 90%) did not differ between sedated and non sedated patients

Caregiver satisfaction 98%

DO YOU HAVE A PERIOPERATIVE PROGRAM FOR CHILDREN WITH ASD AT YOUR HOSPITAL?

A.Yes

B. No

C. I don’t know

Enhanced Perioperative Management of Children with Autism: a Pilot Study

AMANDA WHIPPEY MD FRCPC LEORA BERNSTEIN MD DESIGEN REDDY MD FRCPC

MCMASTER UNIVERSITY

Autism is increasing 1/68 children is diagnosed with ASD 1

Perioperative stress is high for the autistic child, their families and healthcare workers2

Can we introduce a perioperative care pathway that minimizes perioperative stress and anxiety for children with autism?

Introduction “Nolan would have been screaming, crying and terrified. It would have been a very different

and extremely stressful experience for both of us without the special accommodations.”

– Parent Feedback

1 CDC update Mar 27 20142 Scan J Car Sci 2012; 26 (4) 627-634

Methods

Special Accommodations Pathway:

Autism Severity Assessment3

Environment modification

Individual anxiolysis plans

Specialized SDS and PACU order sets

Child life support on day of surgery

“Wonderful to see there are extra and different types of care being given to children with special needs… best experience by far – Thank you!” – Parent Feedback

3 J Ped Health Car 28(5): 394-403

Methods Anxiety and sedation scores were recorded at: SDS, induction, PACU

Parental and Healthcare provider feedback used to modify protocol and establish feasiblity

Cases debriefed by sedation team (anesthesia, SDS nurses, CLS, AA) to improve process

“ Amazing program, I hope we learn more about it and it becomes part of our practice” - OR RN

Results 100% PARENTS, NURSES, ANESTHESTIOLOGISTS FELT PROGRAM SHOULD CONTINUE!

18 patients completed program No case cancellations

85% (17) Autism Severity 1 or 2 nonverbal/ minimally interactive

60% received both midazolam and ketamine presedation

-10 different medication plans

Drug Dose % (n)

None ---------- 5% (1)

Midazolam PO 0.5mg/kg0.25mg/kg

38% (7)38% (7)

Ketamine PO

IM

3mg/kg6mg/kg

2mg/kg

50% (9)16% (3)

16% (3)

“Absolutely helpful for patient, family and healthcare team to have preop sedation prior to OR. Very seamless transition” -Anesthesia Feedback

ResultsDemographics Descriptive Statistic (n=18)

Age (yr); mean(SD) 8.1(3.5)

Weight(kg); median (min,max) 28.8(11.1, 100.0)

Gender (male); n (%) 16(89)

Autism Severity Score; n(%)

1. Responds to name/ Aware of others

2. Interacts with toys, Beginning Language

3. Interacts with others, Controls behaviour

4. Maintains control, Verbalizes feelings

Missing

9(56)

6(38)

0

1(6)

2

Sensory Dislikes/ Triggers; n(%)

1. Smell

2. Loud Noises

3. Touch

4. Crowds

5. Bright Lights

6. Other

3 (16)

14 (78)

9 (50)

14 (78)

10 (56)

3 (17)

History of Aggressive/ Combative Behaviour n(%)

Missing

11(73)

3

Type of Surgery n(%)

Ent

Ortho

Dental

Urology

3(17)

1(6)

12(67)

2(11)

Time from admission to surgery (sedation time - 8am

surgery only); mean (SD) 38.6(15.7)

Duration of procedure; mean (min,max) 70 (15, 173)

Time from PACU to discharge; mean (min, max) 95.3(54,186)

• Most common triggers were loud noises and crowds

• 73% patients had a history of aggressive or combative behaviour

• Ave Sedation time was 40min

• Ave Recovery Time 95min

ResultsParental Feedback Exemplar Quote % (n)

Personalized Approach “(Staff) listened to suggestions which is what made this our

best experience ever!”

55% (10)

CLS (distraction, ipad) ”(CL) was encouraging and supportive – could not have

done it without her!”

44% (8)

Preoperative Sedation 33% (6)

Parental Presence ”playing a favourite show, letting him cuddle with mom

were great strategies”

33% (6)

Decreased Wait Times 27% (5)

Accommodating Staff ”Staff were professional and patient..took the time

necessary for our son to complete each step”

27% (5)

Quiet Room 27% (5)

“This program is absolutely necessary for patients and families with special needs!! Thank you so much for all the options!” – Parental Feedback

SLIDE 5 OF 5

ResultsHealthcare Provider Feedback Exemplar Quote

Program should continue “very worthwhile - particularly for family and patient” – PACU

Multidisciplinary Structure is Important

“Appreciated the structure, communication, and support from all services. Everyone had the same plan and expectations” –SDS RN

Preop Sedation can improve experience

“Absolutely helpful for patient, family and health care team to

have this preop sedation prior to the OR. Very seamless transition

into the OR with the child sedated and IV in place” – Anesthesia

Helpful for Families “I think this intervention is very beneficial to the patient as well as the family. It might delay OR time but it is less traumatic to the patient” – OR RN

Increased nursing ratio in PACU “1:1 nursing ratio for 60min … woke up very calm and had no issues” – PACU

PERIOPERATIVE MANAGEMENT GUIDELINES

Early identification is key!

Preoperative Interview Individualized plan

Autism Hx: communication, triggers, past experiences, flight risk, hx of aggression, po medication, previous sedation experience

Offer hospital and procedure preparation

social stories and videos

Early morning OR (minimize NPO time)

Proactive planning – premeds, personnel, order sets, communication

THE PREOP VISIT

Flexible admission process

Ie. Minimize transitions, wait times

Quiet room – privacy, dim lighting, iPad available, service animals

AVOID changing clothes, multiple health care providers, topical analgesic creams, routine vitals

Premedication on arrival – mix in favourite drink

IV placement if possible

PERIOPERATIVE MANAGEMENT GUIDELINES

Same Day Surgery

PREMEDICATION

Ketamine3-6mg/kg po

2mg/kg IM

0.5mg/kg IV

Dexmedetomidine2-5ug/kg nasal or po

2-4 ug/kg IM

1ug/kg IV load (10min)

Midazolam0.5mg/kg po

0.2mg/kg nasal

0.05mg/kg IV

DO YOU USE PREMEDICATION TO FACILITATE IV PLACEMENT OR INDUCTION?

A. Routinely

B. For compliance or anxiolysis

C. For compliance only

D. Rarely

E. Never

PREMEDICATION

Midazolam po (0.5mg/kg)

Paradoxical reactions

Tastes gross! – pH 3

Ketamine po (3-6 mg/kg)

emergence phenomenon, disorientation, sensory/ perceptual illusions, vivid dreams, nausea/ vomiting, nystagmus

S/E more common in females, IV administration, excessive stimulation

14% noncompliance with induction vs 30% with midazolam alone

No clear evidence for one

medication over another!

PREMEDICATION

Clonidine po

Prospective study 27 ASD children for EEG

2-7mcg/kg (mean dose 5mcg/kg)

95% completed test – 58min ave to achieve sedation!

Dexmedetomidine (po) [IM/intranasal/buccal]

13 patients (8 with ASD), age 4-14 for induction or IV placement (MRI/ EEG)

mean dose 2.6 +/- 0.83 mcg/kg po (Range 1-4.2 mcg/kg)

11/13 achieved sedation within 30-60min

Tasteless!

Dim lights in OR, minimize personnel, cover equipment/IV supplies

Parental presence/ iPads/ music

Do not delay induction – OR checklist before patient in room or after induction

IV or mask induction may be preferred

Adequate fluid administration, PONV prophylaxis and analgesia S/L IV before leaving OR

PERIOPERATIVE MANAGEMENT GUIDELINES

Anesthesia

ANESTHETIC EXPOSURE IN ASD

Subset of children with ASD have altered metabolic function

Decreased oxidative capacity

Impaired methylation

Growing body of evidence showing “regression” following anesthesia

Advocate use of: short acting medications (midazolam, fentanyl, remifentanil), B12 supplementation

AVOID N20 (deactivates methionine synthase), prolonged PPF infusions, deep anesthesia

Austin J Anesthesia and Analgesia 2014; 2(2):1015

S/L IV, remove IV early

Quiet recovery area (away from crying babies, loud TVs, turn down monitors)

Early parental presence

Communication boards

Discharge home direct from PACU when patient awake but sedated. Transfer admitted patients ASAP

PERIOPERATIVE MANAGEMENT GUIDELINES

PACU

Dexmedetomidine 5mcg/kg po + Midazolam 0.25mg/kg po (mixed with apple juice + sweetener)

Dexmedetomidine first (45min prior to IV placement) Midazolam 15min later or when showing signs of sedation

Quiet room, minimize personnel/ no vitals / have distraction available (iPad/ music of choice)/ Communication boards

Start early – may need time to administer medication

14 y/o (80 kg) ASD male for dental surgery. Nonverbal.

History of traumatic inductions/ noncompliance. Flight risk,

transitions poorly. Mother is primary source of comfort. Will

take po medication.

IV placed when sedated in SDS

Transport to OR on stretcher, lights dimmed, parental presence

IV induction, 10ml/kg RL bolus, PONV prophylaxis, deep extubation, PPF or dex to prevent emergence delirium

S/L IV at end of case

Quiet bay in recovery/ Expedited discharge from PACU

14 y/o (80 kg) ASD male for dental surgery. Nonverbal.

History of traumatic inductions/ noncompliance. Flight risk,

transitions poorly. Mother is primary source of comfort. Will

take po medication.

THE BOTTOM LINE

Autism is common

The perioperative experience can be traumatic and overwhelming

Individual Sedation plans based on the child’s specific needs improve compliance

Perioperative management has moved beyond just premedication

Important to create positive experiences to improve future interactions

Excellent resource for establishing clinical practice guidelines for ASD

Addresses ROOT causes and nonpharmacological approaches to improve compliance and minimize stress to the child and family

Advocates for the use of social stories, distraction (ipad), environment modification (quiet room/ dim lighting), premedication and early discharge.

PREMEDICATION Jannu et al 2016

Oral midazolam (0.75mg/kg) vs dexmedetomidine (4mcg/kg)

RCT 60 children 1-7 yrs

Onset significantly faster with midazolam (18min vs 30min) with equal mask acceptance. Dexmedetomidine produced less postop agitation

Kumari et al 2017 Oral midaz (0.5mg/kg) vs dexmedetomidine (4mcg/kg) vs clonidine (4mcg/kg)

RCT 90 children 4-12yrs

Oral midazolam has significantly faster onset, higher sedation score, lower anxiety and better parental separation and mask acceptance