AUTISM AND ANESTHESIA AMANDA WHIPPEY MD FRCPC PEDIATRIC ANESTHESIOLOGIST MCMASTER UNIVERSITY

Transcription

1 AUTISM AND ANESTHESIA AMANDA WHIPPEY MD FRCPC PEDIATRIC ANESTHESIOLOGIST MCMASTER UNIVERSITY

2 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

3 DISCLOSURES None If you have met one person with autism, you ve met ONE person with autism - Dr. Stephen Shore

4 First identified in 1943 by Kanner Autism a distinct disorder in DSM IV 2013 ASD (Autism, Aspergers, PDD) 2017 Less than 10% of anesthesia dept and 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. J Dev Behav Pediatr 2016 (37)

5 Autism is Common CDC Press Release March 2014

6 DIAGNOSIS Communication Visual > Verbal communication Difficulty interpreting social interaction 40-80% ASD have abnormal sensory processing Sensory Processing * Behaviour 1. Need for routine 2. Stereotypic movements 3. Intense special interests Pediatric Anesthesia 25 (2015)

7 THE OR IS A SCARY PLACE Routine dependence can lead to extreme distress 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! Paediatr Anaesth. 2003;13(3):

8 12 parents of patients describe their experience without and without perioperative dialogue

9 WITHOUT WITH HOPELESS STRUGGLE UNSPEAKABLE SUFFERING DISGRACEFUL SCENARIO WARM HANDS KNOWN FACES INTERPLAY BETWEEN PATIENT AND CAREGIVER

10 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)

11 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 patientspecific needs gathered from caregiver ** Importance of individualized care pervaded all themes**

12 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%

13 DO YOU HAVE A PERIOPERATIVE PROGRAM FOR CHILDREN WITH ASD AT YOUR HOSPITAL? A.Yes B. No C. I don t know

14 Enhanced Perioperative Management of Children with Autism: a Pilot Study AMANDA WHIPPEY MD FRCPC LEORA BERNSTEIN MD DESIGEN REDDY MD FRCPC MCMASTER UNIVERSITY Introduction Autism is increasing 1/68 children is diagnosed with ASD 1 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 Perioperative stress is high for the autistic child, their families and healthcare workers 2 Can we introduce a perioperative care pathway that minimizes perioperative stress and anxiety for children with autism? 1 CDC update Mar Scan J Car Sci 2012; 26 (4)

15 Methods Special Accommodations Pathway: Autism Severity Assessment 3 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):

16 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

17 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 % (1) Midazolam PO 0.5mg/kg 0.25mg/kg Ketamine PO IM 3mg/kg 6mg/kg 2mg/kg 38% (7) 38% (7) 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

18 Results 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 Demographics 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 Sensory Dislikes/ Triggers; n(%) 1. Smell 2. Loud Noises 3. Touch 4. Crowds 5. Bright Lights 6. Other Missing 9(56) 6(38) 0 1(6) 2 3 (16) 14 (78) 9 (50) 14 (78) 10 (56) 3 (17) History of Aggressive/ Combative Behaviour n(%) 11(73) Missing 3 Type of Surgery n(%) Ent 3(17) Ortho 1(6) Dental 12(67) Urology 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)

19 Results Parental Feedback Exemplar Quote % (n) Personalized Approach (Staff) listened to suggestions which is what made this our CLS (distraction, ipad) best experience ever! (CL) was encouraging and supportive could not have done it without her! 55% (10) 44% (8) Preoperative Sedation 33% (6) Parental Presence 33% (6) playing a favourite show, letting him cuddle with mom were great strategies Decreased Wait Times 27% (5) Accommodating Staff 27% (5) Staff were professional and patient..took the time necessary for our son to complete each step 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

20 Results Healthcare Provider Feedback Program should continue Multidisciplinary Structure is Important Preop Sedation can improve experience Helpful for Families Increased nursing ratio in PACU Exemplar Quote very worthwhile - particularly for family and patient PACU Appreciated the structure, communication, and support from all services. Everyone had the same plan and expectations SDS RN 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 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 1:1 nursing ratio for 60min woke up very calm and had no issues PACU

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22 PERIOPERATIVE MANAGEMENT GUIDELINES Early identification is key! THE PREOP VISIT 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

23 PERIOPERATIVE MANAGEMENT GUIDELINES 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 Same Day Surgery

24 PREMEDICATION Midazolam 0.5mg/kg po 0.2mg/kg nasal 0.05mg/kg IV Ketamine 3-6mg/kg po 2mg/kg IM 0.5mg/kg IV Dexmedetomidine 2-5ug/kg nasal or po 2-4 ug/kg IM 1ug/kg IV load (10min)

25 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

26 PREMEDICATION Midazolam po (0.5mg/kg) Paradoxical reactions Tastes gross! ph 3 No clear evidence for one medication over another! 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

27 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! Tasteless! Dexmedetomidine (po) [IM/intranasal/buccal] 13 patients (8 with ASD), age 4-14 for induction or IV placement (MRI/ EEG) mean dose 2.6 +/ mcg/kg po (Range mcg/kg) 11/13 achieved sedation within 30-60min

28 PERIOPERATIVE MANAGEMENT GUIDELINES Anesthesia 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

29 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

30 PERIOPERATIVE MANAGEMENT GUIDELINES PACU 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

31 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. 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

32 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

33 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

34 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.

35 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