17.7 Autism Spectrum Disorder

Question 1

A 5-year-old boy with autistic spectrum disorder (ASD) is listed for dental extractions as a day case.
a) What constitutes ASD (1 mark)
and what are the key clinical features? (6 marks)

Answer 1

ASD is a lifelong condition affecting brain development.

It impacts on communication,
social interaction and abstract thought.

It may be associated with reduced
IQ in approximately half of all cases.

Key clinical features:
» Communication problems:
language delay,
avoidance of conversation,
failure to understand nuance,
literal interpretation.

> > Interaction:
lack of eye contact,
reduced interaction,
low understanding of the usual
rules of social interaction.
Intolerance of people entering their
personal space,
minimal use of gestures.

> > Abstract thought:
inability to generalise information,
unable to appreciate that different people
have different thoughts,
knowledge and beliefs.
Inability to understand metaphorical explanations.

> > Behaviours:
routine (and distress if routines broken),
repetitive behaviours,
rigid food preferences,
highly specific interest for particular
subjects or activities.

Question 2

b) List the important issues when providing anaesthesia for dental extractions in children. (6 marks)

Answer 2

Organisational:
» Proper hospital setting required
offering the same standard of care as for
other cases requiring general anaesthesia.

> > Availability of paediatric anaesthetic equipment.

> > Staff trained in care of paediatric
patients including resuscitation.

> > Facility for preoperative assessment
in advance in selected cases.

Preoperative:
» Preoperative assessment will usually `
be done on day of admission
so careful questioning to ensure fitness
for procedure and good
explanations for consent are required.

> > Premedication including
topical local anaesthesia for cannulation,
consideration of antisialagogue.

> > Play specialist/psychologist especially
for children with special needs or specific fears.

> > Well-managed induction to maximise
cooperation of patient.

> > Strategies for uncooperative child,
parental presence.

Intraoperative:
» Shared (small) airway.

> > Blood from extractions may
result in blood inhalation or laryngospasm.

> > Throat pack.

> > Risk of dislodgement of airway with surgery/gag.

> > Head-up positioning risks reduced cardiac output and cerebral perfusion pressure

Postoperative:
» Management of pain –
NSAIDs and paracetamol (which may be given
preoperatively) usually sufficient.

> > Some children resist taking oral medication, especially if there is oral pain following dental work.

> > Management of nausea and swelling (dexamethasone plus ondansetron).

> > Day-case procedure so antiemesis
and analgesia must be sufficiently well
managed to facilitate early postoperative eating and drinking and then discharge.

> > Risk of laryngospasm in recovery due to blood in airway.

Question 3

c) Give the specific problems of providing anaesthesia for children with ASD and outline possible
solutions. (7 marks)

Answer 3

1. Distress due to unfamiliar hospital setting may
   make it difficult to perform preoperative
   assessment on day of admission.
   =
   May be necessary to do this in the
   community, including weight measurement.
   Quiet, separate waiting area.
2. Language issues may make it difficult for the
   child to comprehend what is to happen.
   =
   Use of appropriate visual information, play
   specialist or psychologist to enhance
   comprehension. Information provision in
   advance.
3. Lack of familiarity with environment, out of
   routine, may cause distress.
   =
   Maximise the familiarity of the environment,
   minimise the disruption to routine by allowing
   e.g. own clothes, familiar objects, parent/
   carer, minimise waiting time. Give clear
   timetable of day ahead and stick to it.

4.
Preoperative starvation may be poorly
tolerated as it breaks routine.
=
First on list, clear fluids until one hour before
surgery.

5. # May dislike physical contact.Keep to a minimum, warn first.
6. # Topical local anaesthetic may not be tolerated.Consider inhalational induction, consider
   staffing requirements for this.
7. # Lack of cooperation.Discussion regarding physical restraint in
   advance. Consideration of cancelling and
   bringing back after premedication
8. Dysphoric response to midazolam is possible
   in ASD.
   =
   Consider whether premedication is necessary.
   Consider combining midazolam and ketamine
9. Inability of child to communicate likes and
   dislikes.
   =
   Utilise parents’ knowledge of child to
   anticipate problems, communication passport.