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Literature Reviews

An audit of perioperative management of autistic children.
J H Van der Walt, C Moran Paediatric Anaesthesia 2001; 11:401-408

The aim of this project was to develop a management program for autistic children admitted to hospital for procedures requiring a general anesthetic. General anesthesia was administered on 87 occasions for 59 autistic children over a 4 year period. A positive diagnosis of autism required the presence of four criteria, all which must have manifested before three years of age, namely: (i) qualitative impairment in social interactions, (ii) impairment in verbal and nonverbal communication, (iii) restricted range of interests, and (iv) resistance to change.

Identification of autistic patients prior to surgery is by either notification through the local Autistic Association who requests that the patient's family to contact the hospital, or through the responsible surgeon. As soon as the hospital is notified, the patient's name is entered in the Pediatric Register of Anesthetic Problems. Then, when such a patient is booked for a procedure, the operating room computerized scheduling system generates an alert for the anesthesia department. The concerned anesthesiologist then contacts the family, a telephone interview is conducted, and an Autistic Anesthesia Questionnaire is completed, which elicits information to assist in admission and anesthetic management. The patient details include name, date of birth, unit record number, parents' names and telephone numbers, the intended procedure and date, surgeon's name, and admission plans (day surgery, day of surgery admission, or inpatient). A checklist section notes specific responses regarding the nature of the child's autistic disease. These include: autistic severity; special features; developmental level; likes fetishes, dislikes phobias for food, drink, activities, and objects; special needs; medication; medication; general health; social circumstances home and transport; and any other relevant information the parents consider important. The final section of the questionnaire contains management guidelines to formulate an anesthetic plan and to guide the anesthesiologist in implementing a standardized approach. The plan is discussed with the parents and written on the questionnaire. The plan includes special admission needs, premedication, type of induction, and postoperative strategy. The completed form is then given to the head nurse of the admission unit, who contacts the family a few days prior to surgery to streamline the admission. All elective admissions are through the day unit. As most of the admission details have already been obtained, most chidden are admitted to the holding area, or for the more severely affected children to a quiet room. Admission takes place about 45 minutes prior to surgery, and the children are scheduled to be first on the surgical list. The child's likes and dislikes are attended to and they receive premedication as indicated, oral midazolam 0.5 mg/kg and/or ketamine 7 mg/kg mixed with their favorite clear drink, as noted on the questionnaire. If the oral premedication is refused, the child is given ketamine 5 mg/kg im. Depending on the degree of sedation and cooperation, anesthesia is induced via a mask or iv route. All children receive tropisetron 0.1 mg/kg to maximum of 2 mg for antiemesis prophylaxis. For postoperative pain management, all children receive oral paracetamol together with their premedication, if they would accept it, otherwise as rectal suppository. The i.v. cannula is removed as soon as possible after surgery. Patients receive intraoperative opioids or local anesthetic block as indicated. All events are recorded on the questionnaire page and filed together with the anesthetic record in the anesthesia department database. The patient is discharged as soon as possible. Parents are contacted later to inquire about the child's physical and emotional condition.

Comments: The authors have shown that this potentially uncooperative group of patients can be anesthetized with a minimum of emotional trauma, both to the child and the parents. The most important features of the program are that the anesthesiologist is forewarned and that the parents have been enlisted prior to admission to the hospital. The parents know a lot about their child's idiosyncrasies, and the parent - anesthesiologist dialogues have assured them that the child is in good hands, more so if previous episodes with hospitals have been traumatic. It is also very noteworthy that cooperation of the administrative staff in the admission unit and the nursing team, which was phenomenal (wish all hospitals were so blessed). Participation of the surgeon by informing the anesthesiologist in a timely fashion, and the willingness of the other surgeons in allowing the child be done as the first patient is also very important. All these children should receive premedication, even if they appear reasonably calm, because they are known to suffer panic attacks on arrival in the operating room. Attention to detail and gaining the parents' confidence were most rewarding, as noted from the unsolicited letters of appreciation that the anesthesiologists received from the parents, even in cases where some restraint was required during induction.

Reviewed by Hoshang J. Khambatta, MD #include ./footer_include.iphtml