Polypharmacy – Be aware of medication interactions. Polypharmacy is common in these patients.

Pre-anesthetic eval – If at all possible, meet with the patient and family PRIOR to the day of surgery. The family can help to identify baseline behavior, stressors, previous anesthetic experiences, and preferences of the patient. All are important avoid behavioral outbursts and additional stress on the patient. Patient-provider relationships may also be developed, but not always possible.

Use visuals – Visual information is better processed than spoken information. Using pain scales that do not rely on verbal communication is recommended when assessing ASD patients.

Early case – Schedule cases early in the day and minimize wait time.

Reduce stimulation – Provide a quiet/non-stimulating environment and minimize the number of contacts. During induction, it is recommended to limit the number of personnel in the operating room. Make the environment as calm and comfortable as possible. If possible, provide a quiet, low-lit environment, and family members in the post-operative period.

Distractions – Provide distractions such as the patient’s favorite toy, video games, etc. Electronic media has been shown to reduce perioperative stress and difficult behaviors

Preanesthetic drugs – Oral premedication can be problematic for some ASD patients. Recommended to administer premedication in the patients favorite drink (be conscious of NPO guidelines). Intranasal premedication MAY require restraint depending on the disposition of the patient.

Benzodiazepines are recommended as premedication for mild ASD:
Midazolam:
PO: 0.25 – 1.0 mg/kg (max 20 mg)
Intranasal: 0.2 mg/kg
IM: 0.1-0.2 mg/kg
IV: 0.01 – 0.1 mg/kg
Diazepam:
PO 0.1-0.5 mg/kg

Ketamine is recommended as premedication for more severe cases of ASD
PO and IM: 3-6 mg/kg
Intranasal: 3 mg/kg

Alpha-2 adrenergic agonists are recommended as adjuvants to the above:
Clonadine
Dexmedetomidine:
PO: 0.004 mg/kg
Intranasal: 0.001 mg/kg

Team effort – Discuss the workflow and plan with the surgical team and PACU.

BIS monitor – has been shown to be useful in guiding pharmaceutical support and improving patient safety

Reduce emergence agitation – Towards the end of the case, it is recommended to administer sedative medications to reduce the risk of emergence agitation. Dexmedetomadine, ketamine, clonadine, and propofol have been shown to reduce emergence agitation.

Prevent/Treat pain early – Communication difficulties will be exacerbated by pain.

Heterogenous neurodevelopmental disorder. The “heterogenous” portion of the disorder profile is suggestive that each patient will be uniquely different.

the fastest growing neurodevelopmental disorder in the world.

Unknown etiology.

Prevalence is thought to be approximately 1% of the total population. This is 30% higher than the 2008 reports which is thought to be affected by both recognition and development of broader diagnostic criteria. However, the prevalence of the condition consistently increased over the past two decades using consistent criteria.

Boys are affected 5 times more often than girls.

This disorder is characterized by disabilities in social communication, nonverbal social cues, social relationships, perceptions of the surrounding environment, ability to cope with stress, and atypical cognition. Preoccupation with specific objects and/or behaviors may also be seen.

55% of patients will have an intellectual diability (defined as an IQ less than 70), and 16% will have a severe intellectual disability. Echolalia and repetitive movements are common and exacerbated by stress.

Multiple GI problems such as malabsorption, maldigestion, irritable bowel syndrome, celiac disease, food intolerance and allergies. All of these contribute to nutritional deficiencies.

70% of these patients will have AT LEAST one concurrent psychiatric disorder.

30% of these patients will be diagnosed with epilepsy by adolescence

Very common problem is dental caries. Food intolerance has some contribution to this, but the primary etiology is behavioral problems which interfere with dental hygiene habits.

Mitochondrial dysfunction is one of the most common metabolic abnormalities found in these patients.

The May, 2013 Diagnostic and Statistical Manual of Mental Disorders (DSM) V now classifies Asperger syndrome and pervasive developmental disorder as a part of one condition – autism spectrum disorder (ASD). Asperger syndrome, however, is considered a ‘high functioning autism’ or ‘social autism’.

The focus of the medical community is to provide prompt diagnosis (which is multidisciplinary) in order to institute behavioral interventions.

These patients are often on multiple medications needed for comorbidities. The most common medications are treating insomnia, hyperactivity/inattention, aggression and behavioral disorders.

There is a strong association (with possibilities of causation) between autism and immune inflammation/disregulation, oxidative stress, mitochondrial abnormalities, and exposure to toxins