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

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.

Autistic patients' experiences of the hospital setting: A scoping review

AIM

To explore the factors that affect the experiences of autistic patients in the hospital setting.

DESIGN

A scoping review.

DATA SOURCES

A systematic literature search using the databases CINAHL, Medline and Google Scholar was undertaken in September 2021 and updated in January 2023. This review is based on the methodological framework of Arksey and O'Malley (International Journal of Social Research Methodology, 8(1):19-32, 2005), which was further refined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews.

RESULTS

Autistic patients, as well as their families and healthcare staff, face several barriers that can impact their healthcare experiences within hospital settings. Of 211 articles screened, 30 were eligible and included. Through our review, we identified two main themes. The first theme, 'challenges to hospital experiences', includes four sub-themes: (1) communication, (2) a mismatch between the needs for autistic patients and the hospital environment, (3) challenges related to parents' experiences and (4) challenges related to hospital systems. The second theme, 'facilitators that improve hospital experiences', includes three sub-themes: (1) provision of care pathways, (2) partnership between parents and experts and (3) facilitators to improve hospital systems. By understanding these themes, we can work to address the barriers that autistic patients and their families face, while leveraging the facilitators to improve their hospital experiences.

CONCLUSION

It is critical to understand the experiences of autistic patients in the hospital setting because they present a substantial risk of hospital admission due to their associated acute to chronic health conditions. Additionally, nurses and other medical staff must understand the unique hospital experiences and challenges of autistic patients to improve care and facilitate better hospital experiences. This review further highlights the crucial need to adopt a collaborative and inclusive approach between autistic patients, their families and healthcare staff. To achieve this, co-design initiatives that incorporate the perspectives and lived experiences of the autistic community are necessary. By placing autistic voices at the forefront of these initiatives, it is hoped that changes are meaningful, relevant and can be sustained.

IMPACT

Understanding the unique hospital experiences and challenges of autistic patients can improve their quality of life and well-being by reducing stress and anxiety during hospitalization, leading to better health outcomes and potentially shorter hospital stays. It can also promote a more positive view of healthcare among autistic individuals, encouraging them to seek medical care when needed and have broader societal impacts such as reducing healthcare costs and improving the overall health and well-being of the population. Autistic patients present a substantial risk of hospital admission due to their associated acute to chronic conditions. Nurses and other medical staff must understand the unique hospital experiences and challenges of autistic patients to improve care and facilitate better hospital experiences.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

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.

Association of Intellectual Disability with Delayed Presentation and Worse Outcomes in Emergency General Surgery

OBJECTIVE

To examine the association between intellectual disability and both severity of disease and clinical outcomes among patients presenting with common emergency general surgery (EGS) conditions.

BACKGROUND

Accurate and timely diagnosis of EGS conditions is crucial for optimal management and patient outcomes. Individuals with intellectual disabilities may be at increased risk of delayed presentation and worse outcomes for EGS; however, little is known about surgical outcomes in this population.

METHODS

Using the 2012-2017 Nationwide Inpatient Sample, we conducted a retrospective cohort analysis of adult patients admitted for 9 common EGS conditions. We performed multivariable logistic and linear regression to examine the association between intellectual disability and the following outcomes: EGS disease severity at presentation, any surgery, complications, mortality, length of stay, discharge disposition, and inpatient costs. Analyses were adjusted for patient demographics and facility traits.

RESULTS

Of 1,317,572 adult EGS admissions, 5,062 (0.38%) patients had a concurrent ICD-9/-10 code consistent with intellectual disability. EGS patients with intellectual disabilities had 31% higher odds of more severe disease at presentation compared with neurotypical patients (aOR 1.31; 95% CI 1.17-1.48). Intellectual disability was also associated with a higher rate of complications and mortality, longer lengths of stay, lower rate of discharge to home, and higher inpatient costs.

CONCLUSION

EGS patients with intellectual disabilities are at increased risk of more severe presentation and worse outcomes. The underlying causes of delayed presentation and worse outcomes must be better characterized to address the disparities in surgical care for this often under-recognized but highly vulnerable population.

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.

Effect of Distraction Interventions on Anxiety in Children Undergoing Surgery: A Meta-Analysis

Due to the unfamiliarity of the surroundings, children having surgery endure worry and tension. Untreated anxiety in children impairs postoperative healing and causes changes in postoperative behavior. The purpose of this review was to determine the efficacy of distraction therapies on anxiety in children undergoing surgery. The systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards. PubMed via MEDLINE, CINAHL, ProQuest, Web of Science, and the Cochrane Central Register of Controlled Trials were used to find relevant trials. Full-text papers published in English from January 1, 2000 to December 31, 2021 were included. Children undergoing surgery aged 1 to 18 years were included. A data extraction form was created to extract data from the selected studies. According to the Cochrane risk of bias assessment tool, studies were classified as “low risk,” “high risk,” or “unclear risk.” Review Manager software was used to do a quantitative meta-analysis. Thirteen studies looked at the effect of distraction intervention on children. Nine of them were selected for meta-analysis. The distraction interventions included in this review were: handheld video game, play dough and play with blocks and puzzles, tablet-based interactive distraction, animated video, painting and storytelling, age-appropriate video, distraction with video glasses, watching a movie, and bringing favorite toy during hospital stay. Meta-analysis showed that distraction interventions are effective on preoperative anxiety in children (standardized mean difference = –17.07, 95% confidence interval: 27.11–7.02, p = 0.0009).

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.

Self-produced audio-visual animation introduction alleviates preoperative anxiety in pediatric strabismus surgery: a randomized controlled study

Background

Hospital anxiety caused by strabismus surgery has an unpleasant and disturbing feeling for both children and their parents. This study aimed to determine the effect of viewing a self-produced audio-visual animation introduction on preoperative anxiety and emergence agitation of pediatric patients undergoing strabismus surgery.

Methods

In this prospective randomized study, 1 hundred children scheduled for strabismus surgery with aged 3 ~ 6 years. The children were randomly divided into 2 groups (n = 50 for each), Group A: using a self-produced audio-visual animation introduction; Group C: controlled group without audio-visual animation introduction. Children’s preoperative anxiety was determined by the modified Yale Preoperative Anxiety Scale (mYPAS) at different time points: the night before surgery(T1), at pre-anesthetic holding room(T2), and just before anesthesia induction(T3). The Spielberger State-Trait Anxiety Inventory (STAI) was used to record the anxiety of parents at T1,T2 and T3. The incidence and the degree of emergence agitation were recorded.

Results

The mYPAS scores at T2 and T3 were higher than T1(p < 0.05) in both groups. The average score of mYPAS in Group A was significantly lower than in Group C at T2 and T3(p < 0.05). The STAI scores in Group A at T2 and T3 were significantly lower than in Group C(p < 0.05). The incidence of agitation in Group A was lower than that in Group C(p < 0.05).

Conclusions

Based on the findings, viewing a self-produced audio-visual animation can effectively alleviate the preoperative anxiety for both children and their parents in pediatric strabismus surgery, and it was effective for reducing emergence agitation as well.

Trial registration

The trial was prospectively registered before patient enrollment at Chinese Clinical Trial Registry (Clinical Trial Number: ChiCTR1900025116, Date: 08/12/2019).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-021-01922-6.

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.

Injuries in children and adolescents with psychiatric disorders

BACKGROUND

Unintentional injuries are a leading cause of morbidity and mortality in children of all ages. Prevention strategies require knowledge of risk factors, and behavior and psychiatric disorders have been suggested to influence the risk of injury during childhood. While externalizing disorders have been found to increase the risk for injuries, results are mixed regarding internalizing disorders, such as affective and anxiety conditions, and Autism Spectrum Disorders (ASD). There is a need for large scale studies relying on robust data sources. The aim of the present study was to examine the association between psychiatric disorders and injuries requiring medical attention, in a large population-based cohort of 350,000 children and adolescents in Sweden.

METHODS

Data were obtained from the regional health care database Vega. Psychiatric diagnoses and injury diagnoses obtained during 2014-2018 for individuals aged 0-17 years in 2016 were extracted. Descriptive statistics were used to examine differences in 5-year injury prevalence between children with and without different psychiatric diagnoses. Logistic regression was used in age-stratified models to test the association between psychiatric diagnoses and injuries requiring medical attention.

RESULTS

The results show an increased risk for concurrent injuries in general, but the patterns vary by age and psychiatric disorder. Externalizing disorders and anxiety conditions were associated with concurrent injuries, while individuals with ASD had a lower risk for most injuries included. Affective disorders were associated with an increased risk for wounds, concussion, complications and poisoning, while the risk for fractures was decreased. Self-inflicted injury was more common in all psychiatric conditions investigated during adolescence, except for ASD. Children and adolescents with many types of psychiatric disorders were also at increased risk for a concurrent maltreatment diagnosis.

CONCLUSIONS

A general pattern of increased risk for concurrent injuries in children and adolescents with most psychiatric diagnoses was found, but the associations vary by age and type of psychiatric disorder. The results add to the literature on risk factors for injuries in children and adolescents, supporting diagnosis specific patterns. Several psychiatric diagnoses were associated with a marked increase in injury risk, indicating a high burden of disease for affected individuals.

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.

Behavioral Coping Plans: One Inter-Professional Team's Approach to Patient-Centered Care

BACKGROUND

Surgical encounters for children with Autism Spectrum Disorder (ASD) are stressful to patients, families and health care providers. It is recognized that parents best anticipate needs of children with ASD. Including a family in the plan of care for the child is imperative. In response to the need for targeted, tailored care, an inter-professional surgical services team convened to determine best practices for addressing a behavioral and developmental plan for children with ASD in the surgical services arena.

PURPOSE

This evidence based practice project was conducted to optimize best practices for perioperative staff in caring for children with ASD through a targeted, individualized plan of care for the autistic child and his or her family.

METHODS

Psychosocial and medical care strategies were utilized to create a coping plan with standardized questions. The coping plan allowed for tailored interventions specific to each child's needs.

CONCLUSION

Actively reducing the anxiety a child experiences in a current encounter is paramount to the success of future visits. The coping plan is a formalized summary aimed at helping healthcare providers give individualized care, thereby decreasing the anxiety of both the parent and child. The individualized plan outlines the needs of the patient and allows for the medical team to make adaptations to lessen the stressors a health care visit can present. Plans are shared with the medical team, documented, and updated in the electronic medical record for future encounters. Information captured includes: previous healthcare experiences, sensory sensitivities, communication methods, stressors and coping suggestions. Utilizing best practice, patients are able to receive individualized care to foster positive coping experiences within healthcare.