Autism spectrum disorder (ASD) and its perioperative management

Continuous Infusion of Dexmedetomidine for Maintenance of Sedation in an Aggressive Adolescent with Autism Spectrum Disorder in the Emergency Department

BACKGROUND

The treatment of aggressive behavior and agitation in pediatric patients with autism spectrum disorder (ASD) in the emergency department is topical and challenging.

CASE PRESENTATION

We described an adolescent with autism spectrum disorder treated ten times in the pediatric emergency department for severe episodes of aggressiveness and agitation. After resolving the acute phase of these behavioural crises, sedation was maintained with a continuous infusion of dexmedetomidine to prevent the resurgence of agitation and to organize discharge properly, considering the family's needs. The continuous infusion of dexmedetomidine allowed the patient to remain asleep most of the time during his stay at the emergency department. No adverse events were recorded.

CONCLUSIONS

The continuous infusion of dexmedetomidine could represent a safe and valuable tool to facilitate the permanence of the patient in the PED.

Management of Procedural Pain and Anxiety in Youth With Autism Spectrum Disorder: A Scoping Review

BACKGROUND

Although there is a body of literature on the implementation of interventions to manage procedural pain and anxiety in youth with autism spectrum disorders (ASD), we found no literature presenting the current state of knowledge on this topic.

OBJECTIVES

To review the state of knowledge on interventions for the management of procedural pain and anxiety in children and adolescents with ASD.

METHOD

A scoping review using PRISMA-ScR was conducted.

DATA SOURCES

PubMed, MEDLINE, all EBM reviews, Embase, APA PsychInfo, EBSCO CINAHL, and ProQuest Dissertations and Theses Global databases were searched. Gray literature was also searched.

ANALYSIS METHOD

Braun and Clarke's (2006) model for thematic analysis in psychology was used to synthesize the search results.

RESULTS

Thirty articles were selected. Analysis of the extracted data revealed four elements of intervention for better management of procedural pain and anxiety in the study population: 1) characteristics of the procedure and the immediate environment; 2) parent-child interactions; 3) health care provider-child interactions; and 4) direct pharmacological and nonpharmacological interventions.

IMPLICATIONS FOR NURSING PRACTICE

Nurses must be able to implement appropriate interventions for the management of procedural pain and anxiety in youth with an autism spectrum disorder.

Solving the Autism Puzzle: Creating a Broad-Spectrum Tool to Improve Care Delivery in the Clinical Setting

PURPOSE

The purpose of this quality improvement (QI) project was to develop and implement an assessment tool to identify a patient's specific needs due to autism spectrum disorder (ASD). The use of an individualized plan of care related to sensory and behavioral differences correlates with improved experiences in the perioperative setting for patients with ASD.

DESIGN

Mixed methods, pre-post survey, retrospective data comparison.

METHODS

Metrics planned to evaluate intervention outcomes included: (1) Comparison of pre and postsurvey data obtained from perioperative staff members following ASD education, (2) Evaluation of the number of behavior response team calls made compared to retrospective data, and (3) Survey response data from families assessing the perceived experience of perioperative stay.

FINDINGS

Two hundred and fifty staff members responded to the learning needs survey; 164 in the preperiod and 86 in the postperiod. The perioperative process for these patients improved from the pre- to the postperiod in its ability to meet the needs of patients with autism (P < .001). Overall, respondents rated the sensory aids and the behavioral and sensory assessment tool as very useful (Median = 5, IQR = 2) and stated that they are likely to continue to use the tools in the future when caring for patients with autism (Median = 5, IQR = 1).

CONCLUSIONS

The caregivers of study patients felt they had a high level of satisfaction with their surgery or procedure experience. Health care providers also reported increased confidence working with individuals with ASD in the perioperative environment and satisfaction with the intervention program.

Use of an adaptive sensory environment in patients with autism spectrum disorder (ASD) in the perioperative environment: a parallel, randomized controlled trial

Background

Patients with autism spectrum disorders (ASD) experience higher rates of perioperative anxiety and are likely to receive premedication. Little is known about nonpharmaceutical interventions which may decrease anxiety. This study aims to evaluate the use of an adaptive sensory environment (ASE) to reduce ASD patient anxiety during the perioperative process.

Methods

Our feasibility study (ClinicalTrials.govNCT04994613) enrolled 60 patients in two parallel groups randomized to a control (no ASE) or intervention group (ASE). We included all surgical patients aged three to twelve years, with a formal diagnosis of ASD, Asperger's Syndrome, or pervasive developmental disorder not otherwise specified. Preoperative behaviors were recorded by an unblinded nurse utilizing the validated Modified Yale Preoperative Anxiety Scale (mYPAS). The difference in score on the mYPAS was the primary outcome, and an intention-to-treat analysis was employed. A generalized estimating equations model was used to compare mYPAS scores controlling for significant independent variables.

Findings

58 patients were analyzed after 1:1 randomization of 30 patients to each group. Groups were balanced except the median number of intraoperative pain medications was significantly lower in the ASE group (1 vs. 3, p = 0.012). Mean (SD) age for all patients was 7.2 (2.9) years, range 2.6-12.7. 72.4% (42/58) were White and all were Non-Hispanic or Latino. 74% were Male (21/30 ASE and 22/28 Control) and 26% were Female (9/30 ASE and 6/28 Control). No differences were found in mYPAS scores between groups at three time periods (43.5 vs. 42, p = 0.88, 47.8 vs. 48.4, p = 0.76, and 36.4 vs. 43.8, p = 0.15, ASE vs. control group, respectively). The ASE group had a significant within-group decrease in mYPAS scores from nursing intake to transition (p = 0.030).

Interpretation

An ASE did not significantly reduce perioperative anxiety. However, the promising results deserve further investigation.

Funding

Dayton Children's Hospital Foundation Robert C. Cohn Memorial Research Grant.

Perioperative Management and Outcomes in Patients With Autism Spectrum Disorder: A Retrospective Cohort Study

BACKGROUND

Autism spectrum disorder (ASD) is a neurocognitive disorder characterized by impairments in communication and socialization. There are little data comparing the differences in perioperative outcomes in children with and without ASD. We hypothesized that children with ASD would have higher postoperative pain scores than those without ASD.

METHODS

Pediatric patients undergoing ambulatory tonsillectomy/adenoidectomy, ophthalmological surgery, general surgery, and urologic procedures between 2016 and 2021 were included in this retrospective cohort study. ASD patients, defined by International Classification of Diseases-9/10 codes, were compared to controls utilizing inverse probability of treatment weighting based on surgical category/duration, age, sex, race and ethnicity, anesthetizing location, American Society of Anesthesiology physical status, intraoperative opioid dose, and intraoperative dexmedetomidine dose. The primary outcome was the maximum postanesthesia care unit (PACU) pain score, and secondary outcomes included premedication administration, behavior at induction, PACU opioid administration, postoperative vomiting, emergence delirium, and PACU length of stay.

RESULTS

Three hundred thirty-five children with ASD and 11,551 non-ASD controls were included. Maximum PACU pain scores in the ASD group were not significantly higher than controls (median, 5; interquartile range [IQR], 0-8; ASD versus median, 5; IQR, 0-8 controls; median difference [95% confidence interval {CI}] of 0 [-1.1 to 1.1]; P = .66). There was no significant difference in the use of premedication (96% ASD versus 95% controls; odds ratio [OR], 1.5; [95% CI, 0.9-2.7]; P = .12), but the ASD cohort had significantly higher odds of receiving an intranasal premedication (4.2% ASD versus 1.2% controls; OR, 3.5 [95% CI, 1.8-6.8]; P < .001) and received ketamine significantly more frequently (0.3% ASD versus <0.1% controls; P < .001). Children with ASD were more likely to have parental (4.9% ASD versus 1.0% controls; OR, 5 [95% CI, 2.1-12]; P < .001) and child life specialist (1.3% ASD versus 0.1% controls; OR, 9.9 [95% CI, 2.3-43]; P < .001) presence at induction, but were more likely to have a difficult induction (11% ASD versus 3.4% controls; OR, 3.42 [95% CI, 1.7-6.7]; P < .001). There were no significant differences in postoperative opioid administration, emergence delirium, vomiting, or PACU length of stay between cohorts.

CONCLUSIONS

We found no difference in maximum PACU pain scores in children with ASD compared to a similarly weighted cohort without ASD. Children with ASD had higher odds of a difficult induction despite similar rates of premedication administration, and significantly higher parental and child life specialist presence at induction. These findings highlight the need for future research to develop evidence-based interventions to optimize the perioperative care of this population.

Successful perioperative preparation of a child with autism spectrum disorder in collaboration with his school for special needs education: a case report

Introduction

The incidence of autism spectrum disorder (ASD) in children is greater than 1%. Children with ASD show an increased rate of hospital contact for several reasons. Perioperative preparation for children with ASD can be challenging; therefore, obtaining information from patients' families prior to surgery is important. However, no previous reports have described the collection of information from educational facilities.

Case report

A 12 years-old male patient with ASD was referred for surgery for traumatic dislocation of the left knee joint. Before admission, we obtained valuable information from his parents regarding expected behavioral problems and coping strategies during hospitalization and from his teachers at his school for special needs education. In particular, the information obtained from teachers was specific and practical. Consequently, we could effectively conduct perioperative management based on his specific autistic characteristics.

Conclusion

We report a pediatric case of ASD in which favorable perioperative management was successfully achieved by collecting information before admission from family members as well as teachers at the patient's school for special needs education. This management may help in future hospital admissions for children with autism.

An Analysis of Scoliosis in Autism Spectrum Disorder

BACKGROUND

Children with autism/Asperger are grouped into the diagnosis of autism spectrum disorder (ASD). It remains uncertain whether children with ASD and scoliosis have radiographic and clinical outcomes similar to idiopathic scoliosis (IS) patients.

METHODS

A single-center, retrospective review of a prospective scoliosis registry evaluated patients who had a posterior spinal fusion±Anterior Spinal Fusion and an underlying diagnosis of ASD between 1990 and 2021. A 2:1 match with AIS patients by age and sex was compared using demographic, radiographic, intraoperative, and SRS-22/30 variables.

RESULTS

Thirty patients with ASD (63% male, mean age at surgery 14.6±2.5 y) met inclusion criteria, with a follow-up of 2.46±1.00 years. Despite no differences in curve magnitude preoperatively, patients with ASD had a higher percent correction at 2-year follow-up (66% vs. 57%, P =0.01) and improved mean curve magnitude (20±10 degrees) at 2-year follow-up compared with IS patients (27±11 degrees, P <0.01). ASD patients had less lumbar lordosis preoperatively (40±12 vs. 53±14, P <0.01), but there were no significant differences in sagittal parameters at 2-year follow-up. There were no significant differences in the rate of complications at 2-year follow-up between ASD and AIS cohorts.

CONCLUSIONS

Although patients with ASD exhibited decreased lordosis compared with IS patients preoperatively, their radiographic outcomes at 2-year follow-up were the same. In addition, ASD patients maintained greater curve correction than IS patients at 2 years follow-up.

LEVEL OF EVIDENCE

Prognostic retrospective study.

A day surgery admissions pathway for children and young people with learning disabilities

Following feedback from parents and carers, a new pathway was developed by staff in the paediatric day surgery unit of a hospital in England for admitting children and young people with learning disabilities, some of whom are autistic. This article describes the All About Me pathway, which supports individualised admission planning and uses an interdisciplinary approach to enable multiple examinations or procedures to be completed under a single anaesthetic. The authors explain how the All About Me team works with families, schools and caregivers to gain a greater understanding of each child and young person. This enables the team to make reasonable adjustments to the environment and admission process to maximise the chance of a successful admission. Families have reported that the pathway has made significant improvements to their experience of healthcare services. The pathway continues to develop and has become the focus of a quality improvement project which is expected to demonstrate cost savings.

Comparison between oral midazolam versus oral ketamine plus midazolam as preanesthetic medication in autism spectrum disorder: double-blind randomized clinical trial

BACKGROUND

Conventional dental care is often impossible in patients with Autism Spectrum Disorder (ASD). Non-collaborative behaviors, sometimes associated with aggressiveness, are usual justifications for premedication in this population. Thereby, this research focuses on the effects of oral midazolam versus oral ketamine plus midazolam as preanesthetic medication in ASD.

METHODS

The sample included 64 persons with ASD, aged 2-59 years, scheduled for dental care under general anesthesia. The primary objective of this study was to compare degrees of sedation between two parallel, double-blinded, equally proportional groups randomized to receive oral midazolam (0.5 mg.kg^-1, maximum 15 mg) or oral midazolam (0.5 mg.kg^-1) associated with oral S(+)-ketamine (3 mg.kg^-1, maximum 300 mg). The secondary outcomes were the need of physical stabilization to obtain intravenous line, awakening time, and occurrence of adverse events.

RESULTS

According to the dichotomous analysis of sedation level (Ramsay score 1 and 2 versus Ramsay ≥ 3), oral association of S(+)-ketamine and midazolam improved sedation, with increased probability of Ramsay ≥ 3, Relative Risk (RR) = 3.2 (95% Confidence Interval [95% CI] = 1.32 to 7.76) compared to midazolam alone. Combined treatment also made it easier to obtain venous access without physical stabilization, RR = 2.05 (95% CI = 1.14 to 3.68). There were no differences between groups regarding awakening time and the occurrence of adverse events.

CONCLUSION

The association of oral S(+)-ketamine with midazolam provides better preanesthetic sedation rates than midazolam alone and facilitates intravenous line access in patients with autism.

Perioperative management and drug selection for sedated/anesthetized patients undergoing MRI examination: A review

In recent years, magnetic resonance imaging (MRI) technology has become an indispensable imaging tool owing to significant improvements in MRI that have opened up new diagnostic perspectives. Due to the closed environment, long imaging time, and need to remain still during the examination process, the examiner may cannot cooperate with the completion of the examination of the procedure, which increases the need for deep sedation or anesthesia. Achieving this can sometimes be challenging, especially in the special nontraditional environment of MRI equipment (unfamiliar and narrow spaces, away from patients, strong magnetic fields) and in special populations requiring sedation/anesthesia during examinations, which pose certain challenges for the perioperative anesthesia management of MRI. A simple "checklist" is necessary because it allows the anesthesiologist to become familiar with the particular environment and human and material resources as quickly as possible. For the choice of sedative/anesthetic, the traditional drugs, such as midazolam and ketamine, are still used due to the ease of administration despite their low sedation success rate, prolonged recovery, and significant adverse events. Currently, dexmedetomidine, with respiratory drive preservation, propofol, with high effectiveness and rapid recovery, and sevoflurane, which is mild and nonirritating, are preferred for sedation/anesthesia in children and adults undergoing MRI. Therefore, familiarity with the perioperative management of patient sedation and general anesthesia and drug selection in the MRI environment is critical for successful surgical completion and for the safe and rapid discharge of MRI patients receiving sedation/anesthesia.

Indifference or hypersensitivity? Solving the riddle of the pain profile in individuals with autism

ABSTRACT

Excitatory-inhibitory (E/I) imbalance is a mechanism that underlies autism spectrum disorder, but it is not systematically tested for pain processing. We hypothesized that the pain modulation profile (PMP) in autistic individuals is characterized by less efficient inhibitory processes together with a facilitative state, indicative of a pronociceptive PMP. Fifty-two adults diagnosed with autism and 52 healthy subjects, age matched and sex matched, underwent quantitative sensory testing to assess the function of the (1) pain facilitatory responses to phasic, repetitive, and tonic heat pain stimuli and (2) pain inhibitory processes of habituation and conditioned pain modulation. Anxiety, pain catastrophizing, sensory, and pain sensitivity were self-reported. The autistic group reported significantly higher pain ratings of suprathreshold single ( P = 0.001), repetitive (46°C- P = 0.018; 49°C- P = 0.003; 52°C- P < 0.001), and tonic ( P = 0.013) heat stimuli that were cross correlated ( r = 0.48-0.83; P < 0.001) and associated with sensitivity to daily life pain situations ( r = 0.39-0.45; P < 0.005) but not with psychological distress levels. Hypersensitivity to experimental pain was attributed to greater autism severity and sensory hypersensitivity to daily stimuli. Subjects with autism efficiently inhibited phasic but not tonic heat stimuli during conditioned pain modulation. In conclusion, in line with the E/I imbalance mechanism, autism is associated with a pronociceptive PMP expressed by hypersensitivity to daily stimuli and experimental pain and less-efficient inhibition of tonic pain. The latter is an experimental pain model resembling clinical pain. These results challenge the widely held belief that individuals with autism are indifferent to pain and should raise caregivers' awareness of pain sensitivity in autism.

Effect of midazolam in autism spectrum disorder: A retrospective observational analysis

BACKGROUND

While midazolam is commonly used as premedication for uncooperative patients, its effects are difficult to predict in patients with autism spectrum disorder for whom abnormalities in gamma-aminobutyric acid have been reported. This study aimed to investigate the influence of autism spectrum disorder on the effect of midazolam when used as premedication.

METHODS

This retrospective observational study was performed between April 2017 and August 2018. Before inducing general anesthesia with sevoflurane for dental treatment, 390 uncooperative patients received premedication with midazolam. Ordinal logistic regression analysis was performed with the Observer's Assessment of Alertness/Sedation score 30 min after premedication as the objective variable. Age, sex, American Society of Anesthesiologists physical status class, premedication route, dose per body weight, presence of specific disorders (autism spectrum disorder, intellectual disability, epilepsy, cerebral palsy, and other psychiatric disorders), and regular benzodiazepine or non-benzodiazepine psychotropic administration were included as explanatory variables. Kendall's rank correlation coefficient was used to assess the correlation between the Observer's Assessment of Alertness/Sedation score and cooperation level (1, obvious negative response; 2, negative response; 3, positive reaction; 4, obvious positive reaction) during admission and inhalation induction. All data were extracted from anesthesia and medical records.

RESULTS

Age (odds ratio 1.437 [95% confidence interval (CI) 1.213-1.708], P < .001), autism spectrum disorder (1.318 [1.079-1.612], P = .007), benzodiazepine medication (0.574 [0.396-0.827], P = .002), and intramuscular route (1.478 [1.137-1.924], P = .004) were significantly associated with the Observer's Assessment of Alertness/Sedation score, while the score was negatively associated with cooperation levels during admission (τ = -0.714, P < .001) and inhalation induction (τ = -0.606, P < .001).

CONCLUSIONS

Patients with autism spectrum disorder may be susceptible to premedication with midazolam; however, regular benzodiazepine administration may reduce the effect.

Positive Healthcare Encounters for Children With Autism Spectrum Disorder: Accommodations During Surgical Procedures

Children with autism spectrum disorder have unique needs during medical procedures involving anesthesia. However, with early patient identification, provider champions can adapt their practice to better serve this population, thereby improving patient satisfaction and outcomes. This article describes a novel protocol developed by an anesthesia resource center to modify care for children with autism spectrum disorder and their families. This information serves as a template for perianesthesia nurses and advanced care providers to implement practice accommodations. Two case examples, based on parent interviews and chart review, are presented to exemplify this protocol.

Adaptive Care for Perioperative Patients With Developmental Disabilities: An Exploration of Interventions and Family Experience

INTRODUCTION

Patients with developmental disabilities commonly experience psychological distress during health care visits. There is limited research describing which individualized interventions are being implemented to promote optimal care in the perioperative area.

METHOD

In this prospective observational study of 60 patients with developmental diagnoses, aged 3-21 years, we recorded adaptive care plan (ACP) interventions and assessed family experience.

RESULTS

Patients receiving ACPs had diverse diagnoses, including autism spectrum and 10 other unique syndromes. Most patients received previsit planning (90%), adaptations to standard protocols (60%), child life specialist preparation (67%), procedural support (90%), and were given fast-acting anxiolytics before anesthesia induction (68%). Families reported that ACPs were important for managing a child's stress (94%) and promoting safety (92%).

DISCUSSION

ACPs promote safe, productive health care encounters for patients with various diagnoses, ages, and coping abilities. Families find ACPs important for stress management and promoting safety.

Phelan-McDermid and general anesthesia with different hypnotics

Phelan-McDermid syndrome (PMS) is a rare neurodevelopmental disease, caused by an autosomal dominant mutation due to the terminal deletion of 22q13, leading to a defect in the SHANK3 protein. We present the clinical case of a 12-year-old patient with this syndrome, who underwent three interventions that required general anesthesia. In none of them did she present intraoperative or postoperative complications.

The Perioperative Anesthetic Management of the Pediatric Patient with Special Needs: An Overview of Literature

The perioperative management of pediatric patients with psycho-physical disorders with related relational and cognitive problems must be carefully planned, in order to make the entire hospitalization process as comfortable and as less traumatic as possible. This article reports an overview of the anesthetic management of non-cooperative patients between 6 and 14 years old. The pathologies most frequently responsible for psycho-physical disorders can be summarized into three groups: (1) collaboration difficulties (autism spectrum disorders, intellectual impairment, phobia); (2) motor dysfunction (cerebral palsy, epilepsy, other brain pathologies, neuromuscular disorders), and (3) craniofacial anomalies (Down syndrome, other genetic syndromes). Anesthesia can be performed safely and successfully due to careful management of all specific problems of these patients, such as a difficult preoperative evaluation (medical history, physical examination, blood sampling, evaluation of vital parameters and predictive indices of difficult airway) and the inapplicability of a "standard" perioperative path (timing and length of the hospitalization, anesthetic premedication, postoperative management). It is necessary to ensure a dedicated perioperative process that is safe, comfortable, tailored to specific needs, and as less traumatic as possible. At the same time, all necessary precautions must be taken to minimize possible complications.

Utility of a Structured Teaching Approach, Rehearsal, and Training for Patients With Autism Spectrum Disorder to Avoid Physical Restraint During Induction of Anesthesia

PURPOSE

We aimed to determine whether the use of a structured teaching approach, rehearsing, and training (SRT) for anesthesia induction in patients with autism spectrum disorder (ASD) could reduce the need for physical restraint.

DESIGN

Retrospective observational study METHODS: We retrospectively analyzed 63 patients (4 to 40 y old) with ASD who underwent general anesthesia for dental treatment. Patients were divided into SRT (n = 22) and non-SRT (n = 41) groups. In the SRT group, patients were presented with a visual guide based on a structured teaching approach at the pre-anesthetic consultation. The guide comprised photographs of the places, tools, and processes that the patient would experience prior to anesthesia induction. Patients then practiced these processes (rehearsal). Patients in the non-SRT group were administered anesthesia in a conventional manner without SRT.

FINDINGS

The percentage of patients needing physical restraint was significantly lower in the SRT (3/22, 13%) than in the non-SRT group (21/41, 51%, P < .001).

CONCLUSIONS

The SRT method reduces the need for physical restraint in patients with ASD during anesthesia induction.

Autism spectrum disorder in architecture perspective: a review of the literature and bibliometric assessment of research indexed in Web of Science

Purpose: The primary objective of this research paper was to explore the current state-of-the-art research on autism spectrum disorder from a designer's perspective. An increasing number of scholarly publications in this discipline have urged researcher interest in this topic; however, there is still a lack of quantitative analysis. Therefore, this paper aims to analyze global research output on autism spectrum disorder from a designer's perspective during 1992-2021. Methodology: A bibliometric method was employed to analyze the published literature from 1992-2021. 812 papers were downloaded from the Web of Science core collection for analysis focused on annual growth of literature, prolific authors, authorship pattern, productive organizations, countries, international collaboration, literature trends by keyword analysis, and identifying the funding agencies. Various bibliometrics and scientometrics software were used to analyze the data, namely Bibexcel, Biblioshiny, and VOS viewer. Results: There were 812 research papers published in 405 sources during 1992-2021. 2019 was noted as the most productive year (NP=101), and 2014 received the highest number of citations (TC=6634). Researchers preferred to publish as journal articles (NP=538; TC=24922). The University of Toronto, Canada, was identified as a productive institution with 42 publications and 5358 citations. The USA was the leading producing country with 433 publications, and most of the researchers publish their work in the journal "Scientific Reports" (NP=16). The word "autism" (NP=257) and "architecture" (NP=165) were the most frequently used keywords in autism research.

Autism spectrum disorder in architecture perspective: a review of the literature and bibliometric assessment of research indexed in Web of Science

PURPOSE

An increasing number of scholarly publications on autism spectrum disorder (ASD) have urged researcher interest in this topic; however, there is still a lack of quantitative analysis. Therefore, this study aims to cover the knowledge gap between the amount of literature published on ASD research on architectural and designers' perspectives compared to the medical and psychological fields. The study has analyzed global research output on ASD from a designer's perspective to recognize this gap related to designing the physical environment.  Methodology: The bibliometric method was employed to analyze the published literature from 1992-to 2021. 812 papers were downloaded from the Web of Science for analysis based on annual growth of literature, prolific authors, authorship pattern, organizations, countries, international collaboration, and subject development by keywords and thematic map analyses. Various bibliometric and scientometric software was used to analyze the data, namely Bibexcel, Biblioshiny, and VOS viewer.

RESULTS

The812 research papers were published in 405 sources. 2019 appeared as a productive year (NP=101), and 2014 received the highest number of citations (TC=6634). Researchers preferred to publish as journal articles (NP=538; TC=24922). The University of Toronto, Canada, was identified as a productive institution with 42 publications and 5358 citations. The USA was the leading producing country with 433 publications, and most of the researchers published in the journal " Scientific Reports" (NP=16). The word autism (NP=257) and architecture (NP=165) were more frequently used keywords.

CONCLUSION

The study identified a massive gap in the development of literature in ASD for architecture design and built environment perspective, the most important and trending keywords are missing, and the analyses also showed a lack of subject development. The authors have suggested areas and keywords for further research to fulfill the gap in the future.

A balancing act: An interpretive description of healthcare providers' and families' perspective on the surgical experiences of children with autism spectrum disorder

Children with an autism spectrum disorder (autism) are vulnerable to negative experiences within the surgical setting. This qualitative study used Interpretive Description. Individual interviews were conducted with 8 parents of children with autism who had recently undergone surgery, and 15 healthcare providers (HCPs) with experience caring for children with autism. Participants were asked open-ended questions on the approaches used to support children with autism around the time of surgery and their effectiveness, how the surgical experience could be improved, and the barriers and facilitators to potential improvements. Results yielded three main themes within an overarching metaphor of a balancing act. The first theme, finding your footing through an uncertain journey, described individual factors (e.g. anticipatory anxiety) that set the foundation for surgery-related experiences. The second theme, relationships can help to keep everyone steady, highlighted how interpersonal dynamics (e.g. collaboration and empathy) influence the experience. Finally, the systems shape the experience theme captured the impact of systemic factors (e.g. the hospital environment) on the balancing act. These findings enriched our understanding of how individual, interpersonal, and systemic factors influence the surgical experiences of children with autism, families, and HCPs. Insights gained from this study can be used to inform future interventions.

A concept mobility device with multi-positional configurations and child-kind restraint for safe perioperative transfer and induction of anaesthesia in children with autistic spectrum disorder - a cross sectional study

Background

Transfer into the operating room, onto the operating table and mask induction of anaesthesia are major challenges faced by children with Autistic Spectrum Disorder (ASD). In a pilot study, parents observed that perioperative transfer becomes unsafe and difficult when children with ASD becomes uncooperative.

Method

A CHILD-KIND CONCEPT mobility system comprising of multi-positioning seat configurations and restraining module was developed with inputs from multi-disciplinary healthcare professionals and parents with children with ASD. To appeal to children and motivate child-machine interaction, the seat configurations and restraining module are designed to take the form of child-friendly, non-threatening, fun and familiar items. The sitting configuration, sitting to supine transformation, the restraint modules resemble racing-car seat, reclining motion of a home massage chair, safety restraints found in airplanes and amusement rides respectively. Healthcare professionals (HCPs) involved in the perioperative patient care, parents of ASD children and children (neurotypical and ASD) experience the use of the system in a non-clinical environment and participated in a survey study. The acceptance of its functionality (HCPs, parents) for perioperative transfer and induction of anaesthesia, rating of the user experience and likes and dislikes of (parents and children) were obtained.

Results

Thirty-two HCPs, 30 parents and 23 children participated. Majority of parents and HCPs opined the use of the system enables improvement in the management of perioperative movement (90.0% parents, 100% HCPs), safe perioperative movement (86.7% parents, 96.9% HCPs) and promotes ease of anaesthesia induction (76.7% parents, 90.6% HCPs) for uncooperative combative ASD children. Overall, 93.8% HCPs and 86.7% parents would recommend its frequent use in their own practice and their ASD children respectively. Attractiveness and multi-functionality are attributes endorsed by parents and children. Children endorse its use for induction of anaesthesia (73.9%), dental chair (82.6%), intra-hospital transfer (95.7%).

Conclusion

A child-kind mobility device that integrates appeal with functionality of restraint and multi-positional transformation has a potential to promote safe perioperative movement and ease of induction of anaesthesia in anxious uncooperative ASD children.

Brief Report: Analysis of Dental Treatment Provided Under General Anaesthesia for Children and Young Adults with Autistic Spectrum Disorder and Identification of Challenges for Dental Services

Dental treatment provided under general anaesthesia (DGA) is an expectation for many children and young adults (CYA) diagnosed with Autistic Spectrum Disorder (ASD). Planning and delivery of DGA requires consideration of morbidity and mortality risks and implications for families and healthcare services. One hundred patient records of CYA with special healthcare needs were analysed to examine characteristics and experience of DGA revealing that 79% of CYA had a diagnosis of ASD. Forty-seven percent of CYA diagnosed with ASD had at least one previous hospital admission for DGA. For 24% of this repeat DGA group, the previous DGA was within a two-year period. Results highlight a high rate of DGA and need to investigate more effective primary dental care strategies.

Planning surgery for young people with learning disabilities

Surgery for spinal deformity is complex and preparation involves a wide multidisciplinary team. For young people with learning disabilities, especially those who have behaviour that challenges, there are further considerations to ensure that their hospital stay is a positive experience and all their additional needs are met. Staff and carers need to be well informed and there must be effective communication. Evaluation of one patient's journey through pre-assessment, surgery and rehabilitation has identified the need for more input from learning disability liaison nurses in acute children's services.

Behavioral and Emotional Disorders in Children and Their Anesthetic Implications

While most children have anxiety and fears in the hospital environment, especially prior to having surgery, there are several common behavioral and emotional disorders in children that can pose a challenge in the perioperative setting. These include anxiety, depression, oppositional defiant disorder, conduct disorder, attention deficit hyperactivity disorder, obsessive compulsive disorder, post-traumatic stress disorder, and autism spectrum disorder. The aim of this review article is to provide a brief overview of each disorder, explore the impact on anesthesia and perioperative care, and highlight some management techniques that can be used to facilitate a smooth perioperative course.

IMOVE-An Intuitive Concept Mobility Systems for Perioperative Transfer and Induction of Anaesthesia for Special Needs Children

Children with autistic spectrum disorder (ASD) often exhibit uncontrollable disruptive behaviour during transfer to the operating room and operating table and at the induction of anaesthesia (sleep). This process often involves the physical restraining of children. These children are then lifted onto the operating table by healthcare staff after being anaesthetized. This predisposes children to fall risk and hospital staff to musculoskeletal injuries. We developed two concept mobility devices, IMOVE-I and -II, based on robotics systems comprising of restraint modules and multi-positional modality (sitting, supine, Trendelenburg). The aim was to intuitively secure children to facilitate the safe induction of sleep and ease of transfer onto operating tables upon sleep. IMOVE-I loads the child in standing position using a dual arm restraint module that is activated by trained healthcare staff. IMOVE-II loads the child in the sitting position by motivating the self-application of restraints. Opinions were obtained from 21 operating theatre healthcare staff with experience in the care of ASD children and parents with ASD children. The mean satisfaction rating of IMOVE-I was 5.62 (95% CI 5.00, 6.27) versus 8.10 (95% CI 7.64, 8.55) in IMOVE-II, p < 0.001. IMOVE-II is favoured over IMOVE-I in system operation and safety, ease of use and module functionality.

Caring for Adult Patients With Autism in the Critical Care Setting

Many adults with autism spectrum disorders (ASDs) are admitted as an inpatient, and much has been reported on their ASD-related characteristics and aggressive behaviors that complicate their care during hospitalizations. A variety of surgical and medical clinical conditions have required their admissions in the critical care unit. A limited number of case studies are present for hospitalized adults with ASD; most literature about young children was on how to provide care for them. An interdisciplinary approach with a focus on determining information specific to adult patients with ASD, medical problems or common causes of challenging behaviors, and medication history, as well as nutritional needs, is essential in meeting the care needs of autistic adults. Suggestions informed by multiple sources of evidence are presented to assist critical care nurses on how to provide support to care needs of adult patients with ASD during their hospital stay and transition to home.

Behavioral training and mirroring techniques to prepare elective anesthesia in severe autistic spectrum disorder patients: An illustrative case and review

Children with autistic spectrum disorder are more likely to become distressed during induction of anesthesia. Inhalational induction is almost always the preferred route with acceptance of the face mask often presenting a considerable challenge. Tempering measures to facilitate gas induction such as forced premedication and physical restraint are no longer viable options except in extenuating circumstances. Recent research interest has focused on the need for advanced planning in collaboration with the caregiver to tailor an individualized perioperative plan. This plan may include both pharmacological and non-pharmacological interventions. Applied behavior analysis strategies have a well-documented efficacy in this unique population to systematically change an individual's usual behavior. These can be used, as a non-pharmacological strategy, to ensure a smooth perioperative course. We present a successful case of preoperative desensitization of a child with severe autistic spectrum disorder using a mirror demonstration technique associated with positive reinforcement to prepare him for general anesthesia. We discuss the potential application of applied behavior analysis strategies for anesthesia in this unique population. From a practical point of view, early communication with carers is required to establish who may benefit from this behavioral training. Planned individual preparation for general anesthesia must be provided by trained multidisciplinary staff.

Procedural sedation in children with autism spectrum disorders in the emergency department

BACKGROUND AND OBJECTIVES

Children with autism spectrum disorder (ASD) present more frequently to the emergency department (ED) than children with normal development, and frequently have injuries requiring procedural sedation. Our objective was to describe sedation practice and outcomes in children with ASD in the ED.

METHODS

We performed a retrospective chart review of children with ASD who underwent sedation at two tertiary care EDs between January 2009-December 2016. Data were collected on children 1-18 years of age with ASD who were sedated in the ED.

RESULTS

There were 6020 ED visits by children with ASD, 126 (2.1%) of whom received sedation. The most frequent indications for sedation were laceration repair (24.6%), incision and drainage (17.5%), diagnostic imaging (14.3%), and physical examination (11.9%). The most common sedatives used were ketamine (50.8%) and midazolam (50.8%). Ketamine was most commonly given intravenously (71.9%), while midazolam was usually given intranasally (71.9%). Procedures could not be completed in 4 (3.2%) patients, and adverse events were noted in 23 (18.3%) patients. Only four (3.2%) patients required supplemental oxygenation, and one received positive pressure ventilation.

CONCLUSIONS

Children with autism in the ED commonly received sedation; one in four of which were for non-painful diagnostic procedures or physical examination. Over one-third received sedation via a non-parenteral route for intended minimal sedation. Sedative medication dosing and observed adverse events were similar to those reported previously in children without ASD. Emergency providers must be prepared to meet the unique sedation needs of children with ASD.

Procedural sedation in children with autism spectrum disorders: A survey of current practice patterns of the society for pediatric sedation members

BACKGROUND

Children with autism spectrum disorder are challenging to sedate because of communication, sensory, and behavioral challenges.

AIMS

The aim of this survey was to determine how procedural sedation is provided to children with autism spectrum disorders and whether sedation programs have specialized protocols for procedural sedation of these children.

METHODS

We surveyed physician Medical Directors of sedation programs who are members of the Society for Pediatric Sedation, asking about practice characteristics and resource utilization during procedural sedation of children with autism spectrum disorders.

RESULTS

Of 58 directors, 47 (81%) responded. Of the programs surveyed, 53% were either a large university medical center and 40% were a freestanding children's hospital. Only (12/47, 25.5%) of the programs used an individualized autism coping plan. To accomplish procedural sedation in this study cohort, 36% of the programs used additional nurses, whereas a child life specialist was used in 55% of the programs surveyed. Only 28% of the centers allotted additional time to accommodate children with autism spectrum disorders. Distraction methods were used in 80% whereas restrains were used in 45% programs for were used most commonly for i.v. catheter placement. Propofol was the preferred agent for 70% of programs for imaging, while propofol + fentanyl was used by 66% of programs for painful procedures. Although 57% of directors reported that their program staff was extremely comfortable providing procedural sedation for children with autism spectrum disorder, 79% of the directors wanted more education about behavioral management strategies for procedural sedation of these children.

CONCLUSION

Among the Society for Pediatric Sedation programs, significant institutional variation exists on the delivery of procedural sedation to children with autism spectrum disorders. A better understanding of resources required, standardization of behavioral management strategies and pharmacologic approaches, and protocol development may help optimize care to this vulnerable population.

Outpatient Procedural Sedation of Patients With Autism Spectrum Disorders for Magnetic Resonance Imaging of the Brain Using Propofol

OBJECTIVE

To quantify the number of personnel, time to induce and complete sedation using propofol for outpatient magnetic resonance imaging (MRI) of the brain, and the frequency of serious adverse events (SAEs) in children with autism spectrum disorder (ASD) compared with children without ASD.

RESULTS

Baseline characteristics were the same between both groups. Overall sedation success was 99%. Although most children were sedated with ≤3 providers, 10% with ASD needed ≥4 providers (P = .005). The duration of sedation was less for the ASD group compared with the non-ASD group (49 minutes vs 56 minutes, P = .005). There was no difference in SAE frequency between groups (ASD 14% vs non-ASD 16%, P = .57).

CONCLUSION

Children with ASD can be sedated for brain MRI using propofol with no increased frequency of SAEs compared with children without ASD. Sedation teams should anticipate that 10% of children with ASD may need additional personnel before propofol induction.

Identifying Best Practice for Healthcare Providers Caring for Autistic Children Perioperatively

This column shares the best evidence-based strategies and innovative ideas on how to facilitate the learning and implementation of EBP principles and processes by clinicians as well as nursing and interprofessional students. Guidelines for submission are available at https://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1741-6787.

A prospective study comparing perioperative anxiety and posthospital behavior in children with autism spectrum disorder vs typically developing children undergoing outpatient surgery

BACKGROUND

Research describing the experience of youth with autism spectrum disorders in the perioperative setting is limited. This study compared youth with autism spectrum disorder to typically developing children in the perioperative setting and examined group differences in: child anxiety, parent anxiety, premedication patterns, induction compliance, and changes in behavior postprocedure.

METHODS

Participants were 60 youth (32 with autism spectrum disorder, 28 typically developing) of ages 2-19 years undergoing outpatient surgery and their parents. Parents and research assistants rated children's anxiety at 3 time points (waiting room, preoperative holding, separation), and parents rated their own anxiety in the waiting room and at separation. The anesthesiologist rated induction compliance. Postprocedure behavior change was assessed via phone survey 1 and 7 days postprocedure. Analyses examined group differences in anxiety, medication patterns, and behavior.

RESULTS

Children with autism spectrum disorder had higher research assistant reported anxiety than typically developing youth in the holding room only. There were no group differences in parent report of their own anxiety or their child's anxiety across time points. Compared to typically developing youth, children with autism spectrum disorder were more likely to receive a premedication (including nonstandard premedication), and had poorer induction compliance. Groups did not differ on posthospital behavior change 1 or 7 days postsurgery.

CONCLUSION

Findings revealed ratings of anxiety in youth with and without autism spectrum disorder facing surgery varied by reporter and setting, highlighting the importance of using multiple reporters in research of youth with autism spectrum disorder in the perioperative period. Furthermore, while results showed group differences in premedication patterns and induction compliance, groups did not differ in level of negative behavior change after surgery. Future research can examine how individual differences in youth with autism impact anxiety in the perioperative setting and degree of behavior change postprocedure.

Benefits of an individualized perioperative plan for children with autism spectrum disorder

BACKGROUND

Perioperative care for children with autism spectrum disorder may be challenging. Previous investigators recommend development of an individualized perioperative management plan with caregiver involvement.

AIM

The primary goal was to determine the usefulness of an individualized plan based on the decision to provide preoperative sedation stratified by autism spectrum severity level. Secondary goals were to assess the effectiveness of the plan based on subjective assessment of patient behavior at induction of anesthesia and caregiver satisfaction.

METHODS

We developed an individualized plan for each child with autism spectrum disorder scheduled for anesthesia. Children were categorized by autism spectrum disorder severity level. With institutional ethics approval, we conducted a retrospective chart review to document need for preoperative sedation, sedation stratified by autism spectrum disorder severity level, behavior at induction, and caregiver satisfaction.

RESULTS

Between 2012 and 2014, we successfully prepared a plan for 246 (98%) of 251 surgical or diagnostic procedures in 224 patients. Severity level was distributed as 45% Severity Level 1 and Asperger's, 25% Severity Level 2, and 30% Severity Level 3. The majority (90%) of cases were scheduled as day surgery. Preoperative sedation increased with increasing severity level: Severity Level 1 (21%) or Asperger's (31%), Severity Level 2 (44%), and Severity Level 3 (56%). The odds ratio for sedation use was 5.5 [CI: 2.6-11.5, P<.001] with Severity Level 3 vs Severity Level 1 patients. Cooperation at induction of anesthesia was 90% overall with preoperative sedation administered to 94 (38%) of the entire cohort. Cooperation was greatest in Severity Level 1 (98%) and Asperger's patients (93%) and somewhat less (85%) in patients in Severity Levels 2 and 3. The plan was helpful to guide sedation choices as cooperation did not differ between sedated and unsedated children at any severity level (overall χ² =2.87 P=.09). Satisfaction among caregivers contacted was 98%.

CONCLUSION

The results suggest that an individualized plan is helpful in the perioperative management of children with autism spectrum disorder and that knowledge of autism spectrum disorder severity level may be helpful in determining the need for preoperative sedation.

Behavioral regression in 2 patients with autism spectrum disorder and attention-deficit/hyperactivity disorder after oral surgery performed with a general anesthetic

BACKGROUND AND OVERVIEW

Routine dental care for people with autism spectrum disorders can be complex. There is little published on postoperative behavioral changes associated with use of general anesthetics in this population.

CASE DESCRIPTION

The authors describe postoperative behavioral changes in 2 patients with autism spectrum disorder and attention deficit hyperactivity disorder that the patients' caretakers described as regression. In both cases, behaviors representative of autism spectrum disorder and attention deficit hyperactivity disorder worsened after uncomplicated oral surgery after receipt of a general anesthetic in the operating room. In both cases, behavioral changes caused great difficulties for the patients and caretakers and were difficult to address.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

With little in the scientific literature, these 2 cases have a great importance for the dental care practitioner. Awareness must be raised so that further investigation can occur regarding this phenomenon.

Management of Children with Autism Spectrum Disorder in the Anesthesia and Radiographic Context

OBJECTIVE

As a primary objective, this study purports to develop guidelines to better care for children with autism spectrum disorder (ASD), particularly regarding these children's preparation for anesthesia and radiologic procedures.

METHODS

Using a Delphi method with an online distribution of questionnaire, guidelines for caring for children with ASD were created. Twenty-one participants were included in the expert panel. These participants were working with children with ASD in several anesthesia and radiology departments in Sweden. A list of items was created from a previous survey and the literature. In the first round, the items with <60% agreement were discarded. Items were merged, and a new list was created. Two more similar rounds were performed. In the last 2 rounds, 21 participants responded, and 80% agreement was considered to be consensus.

RESULTS

The final guidelines consisted of 14 items and a checklist of 16 factors. The 5 areas covered by the items and the checklist were as follows: planning involving parents/guardians, features in the environment, and use of time, communication, and the health care professionals. The organization was important in making it possible for the health care professional to care for the individual child according to the child's needs. It was important to involve the parents/guardians to obtain knowledge about the functioning of the child.

CONCLUSION

A caring encounter involving a child with ASD in the anesthesia and radiology contexts requires advance planning, catered specifically to the individual needs of each child. To accomplish this, general knowledge regarding ASD and ASD's particular manifestation in the child entrusted to their care is required from the health care workers. The organization needs to have structures in place to facilitate this process.

Pediatric Traumatic Brain Injury and Autism: Elucidating Shared Mechanisms

Pediatric traumatic brain injury (TBI) and autism spectrum disorder (ASD) are two serious conditions that affect youth. Recent data, both preclinical and clinical, show that pediatric TBI and ASD share not only similar symptoms but also some of the same biologic mechanisms that cause these symptoms. Prominent symptoms for both disorders include gastrointestinal problems, learning difficulties, seizures, and sensory processing disruption. In this review, we highlight some of these shared mechanisms in order to discuss potential treatment options that might be applied for each condition. We discuss potential therapeutic and pharmacologic options as well as potential novel drug targets. Furthermore, we highlight advances in understanding of brain circuitry that is being propelled by improved imaging modalities. Going forward, advanced imaging will help in diagnosis and treatment planning strategies for pediatric patients. Lessons from each field can be applied to design better and more rigorous trials that can be used to improve guidelines for pediatric patients suffering from TBI or ASD.

Perioperative and Anesthesia Guidelines for Children with Autism: A Nationwide Survey from Sweden

OBJECTIVE

The overall aim of this study was to describe the current set of guidelines for the preparation and care for children with autism spectrum disorder (ASD) in the perioperative setting across Sweden and explore the content of these guidelines in detail.

METHOD

An online questionnaire was distributed to the chairpersons of all anesthesia departments (n = 68) and pediatric departments (n = 38) throughout Sweden. Follow-up phone calls were made to those departments that did not return the questionnaire. The presence of guidelines was analyzed through descriptive statistics. These guidelines and comments on routines used in these departments were analyzed inspired by conventional content analysis.

RESULTS

Seven of the 68 anesthesia departments and none of the 38 pediatric departments across Sweden have guidelines for preparing and/or administering care to children with ASD within the perioperative setting. From the guidelines and routines used, 3 categories emerge: "lacking the necessary conditions," "no extra considerations needed," and "care with specific consideration for children with ASD." These 3 categories span a continuum in the care. In the first category, the anesthesia induction could result in the child with ASD being physically restrained. In the last category, the entire encounter with the health care service would be adapted to the specific needs of the child.

CONCLUSION

There is a lack of evidence-based guidelines specifically designed to meet the needs of children with ASD in the preoperative period in Sweden. Further research is needed to understand if children with ASD would benefit from evidence-based guidelines.