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Anesthetizing uncooperative patients is difficult. The combination of autism and anesthesia requires careful planning.
Children or adults with psychological, developmental, or behavioral disorders such as autism may be combative or aggressive, and may require extra measures of preanesthetic sedation or restraint. The parents/guardians and the anesthesia team need to be actively involved with forming the preoperative plan for uncooperative patients.
The incidence of autism in the United States is high—the Autism and Developmental Disabilities Monitoring (ADDM) Network of the Center for Disease Control estimates about 1 in 59 children has autism spectrum disorder (ASD).
Characteristics of autism include developmental delays of behavioral and social skills, and an inability to communicate. The symptoms of ASD stretch across a broad range from mild to incapacitating.
It’s not infrequent that autistic patients need surgery and anesthesia. Patients with autism commonly need to be sedated for routine procedures that a normal child or adult would cooperate with. Dental cases are common, and are frequently referred to a hospital because the typical care systems at an outpatient surgery center or a dental office are inadequate to complete a successful anesthetic.
The most common anesthesia induction technique in children and toddlers is an inhalation induction with sevoflurane. The routine practice of performing an inhalational sevoflurane induction on a child with autism may be impossible.
The most common anesthesia induction technique in adults involves the intravenous injection of propofol. The routine practice of starting a preoperative IV to begin anesthesia care on an adolescent or adult with autism may also be impossible.
Let’s look at an example case of an uncooperative adolescent who is adult-sized and who requires an anesthetic:
A 16-year-old, 70-kilogram male with Autistic Spectrum Disorder is scheduled for dental surgery and teeth cleaning. He is verbal with his mother, but refuses to interact with the anesthesia or nursing personnel. He refuses to change into a hospital gown, or to remove his long-sleeved sweater. He refuses to drink or swallow any premedication, he refuses an IV, and he refuses inhalation induction. The mother, who is the patient’s legal guardian, consents to surgery and anesthesia, but she is unable to convince her son to cooperate with the medical team.
What do you do?
The surgical and anesthetic team spent significant time explaining, reassuring, and coddling the patient, to no avail. They told the mother she had the choice of going home without any surgical procedure or anesthesia at all. The mother was adamant that the procedure needed to be performed. To this end, all parties agreed to the following plan:
- Two hospital security guards were called to the bedside in the preoperative area.
- The two hospital guards and the mother donned white operating room coveralls.
- At the mother’s consent, the guards laid the patient down on the hospital gurney, held him there, and the surgical team and the guards pushed the gurney down the hallway to the operating room (a significant distance of approximately 100 yards).
- Upon arrival in the operating room, one of the security guards uncovered the sweater from the patient’s arm, and the anesthesiologist injected an intramuscular mixture of 2 mg/kg ketamine, 0.2 mg/kg midazolam, and .02 mg/kg atropine into the patient’s deltoid muscle. The patient protested, and the mother reassured him.
- The oximeter and routine monitors were placed.
- Once the patient became sedated (2-4 minutes later), the mother was escorted from the room and the anesthesiologist started an IV in the patient’s arm. The patient was then preoxygenated via mask in the standard fashion, propofol 1 mg/kg and rocuronium 0.5 mg/kg were injected IV, and the trachea was intubated.
- The surgery proceeded as scheduled, with sevoflurane as maintenance anesthesia.
- At the conclusion of surgery, the patient was extubated awake and taken to the Post Anesthesia Care Unit (PACU) in stable condition. The mother was reunited with the patient there. The patient was sedate, calm, comfortable, and tolerated the PACU care well.
- The patient was discharged home without complications after 90 minutes in the PACU. The mother was happy with the perioperative care.
Perhaps this practice of intramuscular induction of anesthesia sounds brutal to you.
The intramuscular (IM) ketamine/midazolam/atropine induction of anesthesia as described in the case study above is effective. In our practice, the recipe is the combination of 2 mg/kg of ketamine, 0.2 mg of midazolam, and .02 mg/kg of atropine.
The ketamine concentration is 100 mg/ml. The midazolam concentration is 5 mg/ml. The total volume of the intramuscular injection in our case study patient was 140 mg ketamine (1.4 ml), 14 gm midazolam (2.8 ml), and 1.4 mg atropine (1.4 ml), for a total injectate volume of 5.6 ml. More dilute concentrations of these three drugs will necessitate too large a volume for intramuscular injection. This IM induction technique is effective in safely inducing general anesthesia without an IV within 2-4 minutes, and has been described in a previous article on dental office anesthesia.
There are more gentle approaches to an uncooperative patient—approaches which this patient would not agree to. The literature lists these options for premedication or induction of anesthesia in uncooperative patients:
- Intranasal premedication sedation with either 0.5 mg/kg of midazolam, or 1 microgram/kg of dexmedetomidine were found to be equally effective in sedating 20 uncooperativechildren aged 2-6 years for dental treatment visits. 0.25 mg/kg of atropine, in combination with 0.5 mg/kg of midazolam, and 1-2
- Oral premedication sedation with 5 mg/kg oral midazolam. Oral sedation is considered as the oldest, easiest way of administrating sedative drugs to pediatric patients. Midazolam is a well-known sedative, and we use this often in our practice if the patient will accept it. The effect initiates within 20–30 minutes of oral administration.
- Oral premedication with dexmedetomidine 5 mcg/kg.
- Oral midazolam, ibuprofen, and 6 mg/kg of ketamine. Oral ketamine of up to 8 mg/kg has shown to effective in improving compliance during induction of anesthesia. Compared with oral midazolam, oral ketamine causes less respiratory depression. Ketamine does cause nystagmus, increased salivation, hallucinations and emergence delirium. When used alone as a premedicant ketamine has not been found to be effective. There is no significant difference between oral ketamine and oral midazolam in the postoperative recovery or hospital discharge.
Uncooperative children or adults with ASD will each have individualized needs. Patients with significant ASD may have severe objections to the doctor-patient relationship, and it can take a prolonged time to gain their trust. It’s important to discuss the perioperative anesthetic issues and the preoperative plan with a parent or guardian well in advance of the surgical date if possible. The anesthesia team can determine the simplest means of preoperative sedation/anesthesia to complete the case successfully, and the family can give input regarding previous anesthesia successes or failures. It’s optimal if the family and the MDs can agree to an appropriate approach to the anesthetic, days prior to the actual surgery.
Parents often ask about the risk of general anesthesia to the brain of their child. At present there is no documented connection between exposures to general anesthesia and the development or worsening of autistic symptoms. In a study of a birth cohort of 114,435 children from Taiwan from 2001 to 2010, 5197 children under the age of 2 years were exposed to general anesthesia and surgery. The 1 : 4 matched control group comprised 20,788 children. The results showed that neither exposure to general anesthesia and surgery before the age of 2 years age, nor the number of exposures, were associated with the development of autistic disorder.
Do autistic patients suffer more complications from anesthesia and surgery than non-autistic patients? In a review by Arnold published in Pediatric Anesthesia in 2015, other than a significant difference in the premedication type and route (per the discussion above), children with ASD had similar perioperative experiences as non‐ASD subjects.
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Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:
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