Perioperative Management and Outcomes in Patients With Autism Spectrum Disorder
Myron Yaster MD and Francis Veyckemans MD
I’ve got to admit that some of the worst and least satisfying experiences I ever had as a clinical pediatric anesthesiologist involved the perioperative management of children with severe autism spectrum disorder (ASD). So, when I saw today’s PAAD by O’Brien et al.1 on perioperative management and outcomes in patients with ASD it jumped to the top of my reading list. Unfortunately, today’s PAAD, a retrospective cohort study of pediatric patients (ages 3–18 years old) with ASD at a single institution (the Children’s Hospital of Philadelphia (CHOP)) raises as many questions as answers and highlights the urgent need for future, multi-institutional prospective studies to guide evidence-based practices for the care of these children. Hopefully Dr Paul Stricker, one of the authors of today’s paper and who has extensive experience in leading these kinds of studies2,3 will pick up the ball and run with it. Or maybe one of you will!
Before our deep dive into today’s article, I’ve got to raise a question that has troubled me for years that I’d like to share with you. O’Brien et al. looked at patients with ASD undergoing 4 types of ambulatory surgery using patient data from a single-center (CHOP) electronic health record (EHR) between 2016 and 2021. “The 4 types of ambulatory procedures included: tonsillectomy/adenoidectomy, ophthalmological surgery, minor general surgery (i.e., inguinal or umbilical hernia repair), and urologic procedures (i.e., hypospadias repair, circumcision, and hydrocelectomy).”1 Amongst the outpatient procedures NOT included were diagnostic imaging studies. In my clinical practice, I found these studies, particularly MRIs requiring general anesthesia, really troublesome because I wasn’t convinced that most, or really almost any, were necessary or would change medical management in any way. Have any of you had similar doubts? I’ll discuss this issue at the end of today’s PAAD and am wondering if any of you share my concerns? Myron Yaster MD
Original article
O'Brien EM, Stricker PA, Harris KA, Liu H, Griffis H, Muhly WT. Perioperative Management and Outcomes in Patients With Autism Spectrum Disorder: A Retrospective Cohort Study. Anesth Analg. 2024 Feb 1;138(2):438-446. doi: 10.1213/ANE.0000000000006426. Epub 2023 Apr 3. PMID: 37010953.
“Autism spectrum disorder (ASD) is a neurocognitive disorder characterized by impairments in communication and socialization and is associated with higher rates of concomitant mood disorders, epilepsy, and cerebral palsy.”1 The prevalence is increasing and “it is currently estimated that 1 in 40 to 44 children in the United States (or approximately 1.5 million children) has ASD. As a result, anesthesiologists are increasingly involved in the care of pediatric patients with ASD presenting for surgical or procedural care and medical imaging.”1,4 “The objective of this study was to compare postoperative pain scores and perioperative management in a cohort of pediatric patients with and without ASD undergoing ambulatory surgery while controlling for confounding. We hypothesized that children with ASD would have higher maximum PACU pain scores compared to non-ASD patients.”
A key to understanding today’s article is the author’s evaluation of confounders including: “procedure category, patient age at index surgery, sex, race and ethnicity, American Society of Anesthesiologists (ASA) physical status, duration of surgery, anesthetizing location, intraoperative opioid dose in milligram morphine equivalents per kilogram (MME/kg), and intraoperative dexmedetomidine dose. MMEs were calculated using a previously published conversion table for pediatric patients. They also considered that premedication may be a potential confounding variable. An additional sensitivity analysis completed ad hoc excluded patients that received any alternative premedications other than midazolam (ketamine and dexmedetomidine).”1
OK, what did they find? “Children with ASD did not have significantly higher maximum PACU pain scores compared to non-ASD controls following ambulatory surgery. Outside of postoperative pain scores, our analysis revealed subtle differences in premedication strategies and conditions at the time of induction but postoperative opioid administration, PACU ED, emesis, and length of stay were similar between the cohorts.”1 Pain is difficult to assess in children with ASD because many cannot express themselves verbally or express pain with an unusual behavior such as self-mutilation or aggression.5 Finally, one of the key road blocks in interpreting this data is that the severity of ASD was unknown. And, as the authors conclude “developing a severity scale for children with ASD entering the perioperative arena is a natural next step in advancing evidence-based care for this vulnerable population.”1
Such a scale and an accordingly individualized perioperative plan have already been proposed and evaluated retrospectively by Swartz et al in Winnipeg.6 The presentation and severity of ASD is indeed highly variable, from severe mental retardation to mild symptoms easily coped with or Asperger’s syndrome. Moreover, the presence of autistic traits is also described in patients with pathologies such as fragile X, Bourneville’ sclerosis or trisomy 21. Another issue which was not evaluable in this retrospective study was the behavioral preparation of these children before coming to the OR: many teams use preoperative rehearsals, pictograms or even special applications on iPads or iPhones to facilitate communication and help these children cope with the stress of unusual faces, places and situations. Last, the team caring for a child with ASD should know what can trigger a panic crisis: coming too close, touching their skin, too much noise or light, or looking into their eyes. Simply avoiding the triggering gesture can make a large difference (FV).
Not surprisingly, induction of anesthesia was more stormy in patients with ASD despite more premedication. At the study institution, CHOP, virtually all patients with or without ASD are premedicated with oral midazolam. The ASD patients received nasal dexmedetomidine a bit more often than the controls and were more likely to have parental or child life specialist presence at the induction of anesthesia. Thus, they were all premedicated. In my (MY) own experience, even with premedication, many of these patients require an IM ketamine induction (“dart”), sometimes just to get the child into the operating room.
Expanding this research to inpatients and to patients undergoing diagnostic imaging studies are necessary next steps. I (MY) would urge investigators to even going further particularly for patients undergoing diagnostic (really MRI) imaging studies to evaluate the disease process. Are these MRIs necessary? Do the results change medical management?
Send your thoughts to Myron (myasterster@gmail.com) who will post in a Friday reader response.
References
1. O'Brien EM, Stricker PA, Harris KA, Liu H, Griffis H, Muhly WT. Perioperative Management and Outcomes in Patients With Autism Spectrum Disorder: A Retrospective Cohort Study. Anesthesia and analgesia 2024;138(2):438-446. (In eng). DOI: 10.1213/ane.0000000000006426.
2. King MR, Staffa SJ, Stricker PA, et al. Safety of antifibrinolytics in 6583 pediatric patients having craniosynostosis surgery: A decade of data reported from the multicenter Pediatric Craniofacial Collaborative Group. Pediatric Anesthesia 2022;32(12):1339-1346. DOI: https://doi.org/10.1111/pan.14540.
3. Stricker PA, Goobie SM, Cladis FP, et al. Perioperative Outcomes and Management in Pediatric Complex Cranial Vault Reconstruction: A Multicenter Study from the Pediatric Craniofacial Collaborative Group. Anesthesiology 2017;126(2):276-287. (In eng). DOI: 10.1097/aln.0000000000001481.
4. Kogan MD, Vladutiu CJ, Schieve LA, et al. The Prevalence of Parent-Reported Autism Spectrum Disorder Among US Children. Pediatrics 2018;142(6) (In eng). DOI: 10.1542/peds.2017-4161.
5. Kopecky K, Broder-Fingert S, Iannuzzi D, Connors S. The needs of hospitalized patients with autism spectrum disorders: a parent survey. Clinical pediatrics 2013;52(7):652-60. (In eng). DOI: 10.1177/0009922813485974.
6. Swartz JS, Amos KE, Brindas M, Girling LG, Ruth Graham M. Benefits of an individualized perioperative plan for children with autism spectrum disorder. Paediatric anaesthesia 2017;27(8):856-862. (In eng). DOI: 10.1111/pan.13189.