Reader response
Myron Yaster MD
From Sean P Antosh, MD, Chief Medical Wellness and Engagement Officer, Pediatric Anesthesiologist, Dayton Children's Hospital
I am excited about the recent attention given to caring for neurodiverse patients and how pediatric anesthesiologists can ensure a safe, compassionate, and equitable experience for them. Research indicates that patients with autism spectrum disorders (ASD) are at higher risk of adverse events during hospitalizations, particularly when their routines, special interests, sensory sensitivities, and understanding levels are not considered. Preparation, understanding, and knowledge among patients, parents, and care staff are crucial for a smooth transition and positive outcomes.
I am particularly intrigued by the concept of desensitizing patients with ASD to nasal medications. While this approach requires significant preparation and resources in collaboration with Child Life specialists, it has proven effective. At Dayton Children’s Hospital, we have developed adaptive sensory environments (Dayton Children's Hospital Adaptive Sensory Environments) in our preoperative and procedural units to minimize sensory stimulation. Through our quality improvement efforts, we have reduced the necessity for premedications to approximately 20% of our ASD patients, compared to over 90% previously, without compromising induction compliance.
Ultimately, I advocate for looking beyond traditional medication approaches and embracing a team-based strategy involving Child Life specialists, nurses, and families to ensure safe and compassionate care. For those interested in advancing our efforts in caring for neurodiverse patients, I encourage joining the SPA special interest group on Perioperative Care of Children with Special Developmental and/or Behavioral Health Needs!
From Jemma Kang ,Assistant Professor, Director of Residents and Rotators,Associate Director of the Procedure Center, Department of Anesthesiology, Cincinnati Children's Hospital Medical Center
Thank you very much for the article "Improving Induction Experiences for Children with Autism Spectrum Disorder and/or Developmental Delay". Taking care of neurodiverse patients is a niche of mine and every day I strive to help improve their experience in the perioperative area. What I have found that has mostly improved the experience for neurodiverse patients from both the guardian side and the medical side has been collaboration.
Our collaboration includes the guardians, proceduralists, Child Life specialists (CL), Behavior Safety Team (BST), the anesthesia nurse practitioners (NPs), perioperative nursing staff and our anesthesia staff for the procedure.
The process starts with the Identification of the patient. With flags on our EMR they are found by the proceduralist, CL or BST. Once identified, our anesthesia NPs collaborate with the guardians for the most desirable preop anesthesia plan. This is different from an Adaptive Care Plan, that is also made by CL for certain patients to help with healthcare encounters. Our preop plan may include an anxiolytic prior to arrival, which is wonderful but sometimes needs the buy in of their PCP or psychiatrist. After that it includes minimizing registration and minimizing prolonged NPO times and finally an induction plan. The guardian input is integral to devising this induction plan, to find out what has worked and what has not worked for the patient. For those that tolerate PO, I have emptied soda cans and juice boxes and replaced it with midazolam/ketamine to successfully achieve oral intake. For those who have oral aversion, there is a discussion if intranasal dexmedetomidine and/or intranasal versed would be enough or if we should proceed with an IM ketamine injection. Sometimes with large teenagers (80+kg), we may need to hold them for any intranasal medications and if since the dose may not be enough, it may be simpler to have a behavior safety team trained in de-escalation to quickly hold the patient and for us to administer the ketamine safely. I find that when the everyone involves has a heads up about the plan, the more successful the plan is for the patient and safe for medical personnel.
One last note, we also have a moderate sedation protocol where beyond a certain dose of sedation medications, nursing is required to monitor the patient with airway equipment, monitors and anesthesia personnel are required to be immediately available in case the patient goes into the realm of deep sedation and needs extra support, typically of the airway. This also requires training and comfort of the perioperative team, which takes time. Once you start seeing success stories however from both the guardian side and the medical staff side, it fuels the whole team, and it has been wonderful to see that we have improved one of the barriers for these patient’s access to medical care.