2024 FSA Podium and Poster Abstracts
P100: A CASE OF AN OBESE AUTISTIC PATIENT REFUSING ANESTHESIA INDUCTION
Omowonuola Ogundele1; Titilopemi Aina-Jones, MD, MPH, FASA2; 1University of Florida College of Medicine; 2Texas Children's Hospital/Baylor College of Medicine
Introduction: Autism spectrum disorder (ASD) is a developmental disorder characterized by deficits in social communication and repetitive and restrictive behaviors, patterns and interests (1,2). Navigating the healthcare system can be challenging for these patients, especially when communicating with providers(3).
Parental survey responses on children with autism revealed that 38% express their needs through sign language or gestures, 31% use communication tools and 23% express themselves verbally (4). Fifty-seven percent of children understand new information through communication tools, 23% understand verbally and 9% understand using written information. To express pain, 32% cry or scream, 27% use self-injury or aggression and 19% use spoken language(4).
Methods: Report of case
Case Description: A 20-year-old, 120kg female with autism, epilepsy and obesity presented for scheduled wisdom teeth extraction. Her past procedural history included MRI, EUA/IUD placement, and previous dental procedures. After admission, she remained in her own clothes as she refused to wear a hospital gown. When directed to her bed, she only agreed to lean back after being allowed to sit up for several minutes. IV placement, which is typically performed in the preoperative area, was nearly impossible due to her resistance. Mask induction in the operating room followed by IV placement was planned and the patient was transferred to the operating room accompanied by her mother.
When the mask was introduced, she became agitated and refused it. The team called for additional assistance to help restrain her, but all efforts were fruitless. The mother asked for a reduction in the number of personnel and after reassurance and gentle coaxing, the patient eventually agreed to an awake IV placement. She subsequently underwent an uneventful IV induction and tolerated the procedure well.
Discussion: The care of patients with autism requires understanding the patient’s unique features and the joint effort of medical providers and family members. Being notified in advance is pertinent when a patient with autism requires anesthesia(5). Days before surgery, staff may gather information on autistic severity, behaviors exhibited when stressed and prior to a meltdown. This information can be used to formulate an anesthesia plan and may be printed for easy accessibility to all perioperative staff(6). Patients should ideally be scheduled first on the operating list, admitted shortly before their procedure, and if available, should be placed separately in the ward to limit exposure to other people. Some patients have exhibited reduced anxiety when video peer modeling of planned procedures and/or recordings of their favorite movies were made available to them(7). Oral agents have successfully been used to provide moderate sedation(8) followed by inhalation induction. Parents should be involved early in the recovery phase and I.V. drips and cannulas should be promptly removed.
As with the other aspects of care, obtaining informed consent- which requires capacity to understand information given, communication of their choices and understanding of the consequences of their decisions(9)- should be adjusted based on the patient’s unique qualities. Patients may also be presented with information at a tolerable level and given the opportunity to express assent or dissent.