Enhanced Perioperative Management of Children with Autism: a prospective cohort Pilot Study

Transcription

1 Enhanced Perioperative Management of Children with Autism: a prospective cohort Pilot Study Leora Bernstein PGY4 Department of Anesthesia McMaster University Dr. Desi Reddy, Dr. Jason Busse, Dr. Amanda Whippey, Debbie O'Rourke, Toni Tidy

2 Outline Conflict of interest Background Literature Review PICO: intervention, outcome Obstacles Future Directions

3 Why Autism

4

5 Change is hard.

6 Background

7

8

9

10 Who lands up hurt?

11 The OR is a scary place... For everyone but especially if you are afraid of...

12 New smells

13 New people

14 New routines

15 All while NPO

16

17 Literature review

18

19 Autism spectrum disorder and the preoperative experience Arnold et al November 2015

20 retrospective study 121 patients w ASD and 881 non ASD patients over 5 years older and heavier with shorter procedures more likely to receive a non standard premedication (IM ketamne) 43% standard premedication 15% no premedication (8.2% of non ASD population) 50% less likely to complain of pain shorter time to discharge (not statistically significant)

21 The experience of parents of children with severe autism in connection with their children's anesthetic, in the presence and absence of the peri operative dialogue: a hermeneutic study Lindbergh et al 2012

22 A hopeless struggle

23 Unspeakable suffering

24 A disgraceful scenario

25 post intervention

26 Key components Early recognition Quiet room Pre-op sedation Minimize transition periods Flexibility Learning curve

27 A pilot study

28 Never test the water with both feet. African proverb Ghana

29 PICO Test feasibility prior to starting a larger study Population: children ages 3-18 booked for elective surgery at McMaster Children's Hospital with a diagnosis of Autism Spectrum Disorder Intervention: specific care bundle Comparison: previous experience as rated by caregiver Outcome: feasibility

30 Exclusion criteria Caregiver declines to consent Healthcare provider and or caregiver do not think the protocol is necessary

31 Intervention: early identification Child identified by dental office Child booked for early am pre operative clinic appointment and 0800 OR booking Alert sent to autism team Consent obtained via telephone Child life worker fills out autism awareness green sheet over the telephone 2 days prior to appointment Pre operative clinic visit is expedited to less than half hour child is booked as special accommodations

32

33

34 Intervention: day of OR Patient met by sedation team (AA, child life, and same day nurse) direct to PACU "isolation area" Autism awareness green sheet on front of chart Pre op sedation administered ( PO, IV, IM) OR checklist done in PACU Sign on OR " Special accommodations"

35

36 Intervention: PACU Early saline lock IV Early presence of caregiver Direct discharge from PACU

37 Intervention: debrief Multidisciplinary approach Debrief with whole team: 2 child life workers Attending anesthesiologist Same day nurse Anesthesia Assistant Research assistant

38 Results so far

39 7 patients since August 2015 age Dental (1 combined dental + optho) 2 ENT 2 ophthalmology

40 Sedation 1 case cancelled 2 no sedation given 1 required IM ketamine (in addition to PO ketamine/midazolam) 1 midazolam only 2 midazolam and ketamine combination and intraoperative

41 Did you find these interventions disruptive to your usual routine? yes no unsure

42 Did you find these interventions beneficial to your usual routine? yes no unsure

43 Would you continue this intervention? yes no unsure

44 Feasibility 1 case cancelled 1 case sedation ordered not given 1 parent lost to follow up 5 cases all forms completed

45 Obstacles Early recognition Quiet room Pre-op sedation Minimize transition periods Flexibility and change in routine Coordination of multiple specialities Funding and limited resources

46

47 Future directions Retrospective chart review Expanded prospective study

48 References Van der Walt, J.H., Moran, C. (2001). An Audit of Perioperative Management of Autistic Children. Pediatric Anesthesia 2001 ; Thompson, D.G., Tielsch-Goddard, A. (2014) Improving Management of Patients with Autism Spectrum Disorder Having Scheduled surgery: Optimizing Practice. Journal of Pediatric Health Care 2014; 28 (5): Bagshaw,M. Aneasthesia and the autistic child.journal of Perioperative Practice ; 21 (90) Lindberg,S., von Post, I., Eriksson,K. The experience of parents of children with severe autism in connection with their children s anesthetics, in the presence and absence of the perioperative dialogue: a hermeneutic study. Scandinavian Journal of Caring Sciences 2012; 26 (4): Souders, M.C., et al. Caring for Children and Adolescents with autism who require challenging procedures. Pediatric Nursing (6); Delli K, Reichart PA, Bornstein, MM, Livas, C. Management of children with autism spectrum disorder in the dental setting: Concerns, behavioural approaches and recommendations. Med Oral Patol Oral Cir Bucal Nov 1; 18(6) Gutstein,H., Johnson,K., Heard,M., Gregory,G.Oral Ketamine Preanesthetic Medication in Children.Anesthesiology. 1992; 76 (1): Benedikt,T, Rzepecki,A., Sauer,K., Hobbhahn,J. A comparison of two different doses of ketamine with midazolam and midazolam alone as oral preanesthetic medication on recovery after sevoflurane anesthesia Pediatric Anesthesia. 2002; 12: Warner DL, Cabaet J, Velling D. Ketamine plus midazolam a most effective paediatric premedicant. Pael Aneasth 1995; 5: Feld, L.H., Negus J.B., White P.F. Oral midazolam preanesthetic medication in pediatric outpatients Anesthesiology , Moore P, Cuddy M, Magera J, Caputo, A, Chen A, Wilkinson L. Oral transmucosal fentanyl pretreatment for outpatient general anesthesia Anesth Prog :29-34 Nishina K, Mikawa K. Clonidine in Pediatria Anesthsia Curr Opin aneathesiol 15: Arnold, B., Elliott, A., Laohamroonvorapongse, D., Hanna, J., Norvell, D., & Koh, J. (2015). Autistic children and anesthesia: Is their perioperative experience different? Pediatric Anesthesia Paediatr Anaesth, 25(11), doi: /pan Snow, S. L., Smith, I. M., Bird, S. J., Wright, A. S., & Chorney, J. (2016). A call to solve the puzzle together by building an evidence base for perioperative management of children with autism spectrum disorder. Pediatric Anesthesia Paediatr Anaesth, 26(7), doi: /pan Taghizadeh, N., Davidson, A., Williams, K., & Story, D. (2015). Autism spectrum disorder (ASD) and its perioperative management. Pediatric Anesthesia Paediatr Anaesth, 25(11), doi: /pan