FRCA Notes

Autistic Spectrum Disorder

This topic falls under the rather large umbrella of 'recalls/explains the implications of paediatric medical problems for anaesthesia'.

Resources

  • ASD is a lifelong developmental disability characterised by difficulties in interaction with other people

  • Affects 1 in 100 children
  • Males are 4 - 9x more affected

  • There is a 'biological plausibility' for a potential mechanism by which antenatal/neonatal opioid exposure can contribute to development of autism… in a rodent model
  • Difficulty with:
    • Social communication
    • Social integration
    • Emotional engagement
    • Distinguishing fiction from reality

  • Repetitive interests
  • Repetitive movements
  • Hyper- or hypo-activity to sensory stimulation
  • Abnormal fixation on certain issues
  • Inflexible and distressed by changes to routine/new experiences
  • May have low, normal or increased intelligence

Perioperative management of the child with autistic spectrum disorder


  • There may be a high degree of fear, associated with:
    • Entering the hospital environment
    • Losing control
    • Taking pre-medication
    • Needles
    • Face masks / gas induction
  • Put first on list to limit distress caused by fasting and unfamiliar environment
  • Pre-medication if possible e.g. midazolam 0.5mg/kg, clonidine 1 - 4μg/kg
  • Local anaesthetic cream if tolerated

  • Have parent/care present during induction
  • Use of toys or comfort objects familiar to the patient
  • Use play therapists
  • Use alternative communication tools and distraction e.g. presence of parents, music, lights
    • Some patients may have a "communication passport" which will inform use of these methods

  • Patients may be taking behaviour-modifying medication:
    • Anti-psychotics
    • Stimulants
    • Nocturnal melatonin
  • Patients may be taking drugs which induce hepatic enzymes e.g. anti-epileptics, thus influencing anaesthetic requirements

  • Administer medications intra-operatively to help reduce the risk of common post-operative issues:
    • Pain: multi-modal analgesia including use of nerve blocks where appropriate
    • PONV: intra-operative hydration and multi-modal anti-emesis
    • Emergence delirium: propofol (either as TIVA or a bolus towards the end of the case), ketamine, ɑ2-antagonists

    • Consider parent/carer present during emergence
    • Remove cannula (and as much superfluous medical plastic) as soon as possible, or secure very well
    • Use observational pain scales e.g. FLACC, knowledge of individual pain behaviours
    • Day case surgery is beneficial to minimise disruption in routine
    • Rigid post-operative protocol (e.g. must eat and drink prior to discharge) may be counter-productive