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Pre-surgical management of uncooperative, anxious adult with Autism Spectrum Disorder (ASD) and history of aggressive behavior.

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MULTIDISCIPLINARY MANAGEMENT of ADULT WITH AUTISM SPECTRUM DISORDER (ASD).

A CASE REPORT.

Dr. Shazia Khattak, DMD

Introduction:

Providing care to patients with Autism Spectrum Disorder (ASD) in the dental clinic can be challenging because each patient presents with a unique set of symptoms requiring individualized behavioral management. However, behavior management is not effective with all patients and an alternative protocol is needed to address the needs of neurodevelopmental disorders and intellectual disabilities (ND/ID), which alter their ability to cooperate for needed medical/dental care. Further, guidance and recommendations are needed to ensure safe pre-operative management and post-operative discharge for patients who are unwilling or unable to cooperate and have a history of aggressive behavior towards caregivers.

Case Report:

On initial presentation to the dental clinic parking area, the 21-year-old male patient would not exit the vehicle for examination despite pre-medication with 10 mg Valium for anxiety. From observational reports provided by patients’ mother, patient appeared to be in pain. On visual examination through the car window it was determined a dental abscess was causing the patients pain in the lower left quadrant.  This case presents a unique challenge to healthcare providers due to the patient’s weight (265lbs, BMI: 37.0, Ht: 71in.), history of aggressive behavior, reluctance to leave his vehicle and limited ability to communicate.

Behavioral guidance with pictures and weekly drives to the dental clinic were scheduled to encourage adaptive behavior. After 10 weeks of behavioral guidance patient showed no signs of altered behavior and no progress was made. Patient was scheduled for treatment in the OR under GA due to extent of dental treatment necessary (5-6 sextants on 9+ teeth) and inability to cooperate.

Pre-surgical planning: Due to patients fear and anxiety levels induced by the presence of medical personnel and history of aggression towards caregivers it was determined pre-medication would be needed to safely manage patient pre-surgically. After meeting with the anesthesia team, social worker and patient’s family it was decided patient should have at least two adults present on admission for the surgery. It was determined pre-medication would be administered to the patient the night before outside of the ED to facilitate safe transfer of the patient from the vehicle to a gurney and then into the OR. Use of ketamine dart was previously discussed with family to ensure the patient safely exited vehicle and was ready to administer by ED with presence of security if the patient was non-compliant.  A room in the emergency department was prepared for the anesthesia team who was ready for immediate induction after safe transfer of the patient into the hospital ED. The patient would then be transferred to the OR by Anesthesia team for dental care.

Post-operative discharge plans: It was determined admission of the patient to the hospital overnight would increase likeliness of the patient become un-cooperative. Thus, extensive post-operative discharge plan was required. After meeting with the anesthesia team, social worker and patient’s family it was decided two adults would be required for discharge to take the patient home. A third adult (preferably male) was required to meet the family at the home to help transfer patient into the home safely. In addition, it was recommended another adult stay with the mother and adult patient overnight. Family was instructed to keep the patient on the main floor of the home if the patients was discharged and not admitted to the hospital for observation. The help of seasoned Medical Aids was recommended.

Post-operative discharge planning for Autistic Patients

There are few reports on the postoperative discharge instructions provided to the families of uncooperative adult patients with ASD. Further, guidance and recommendations are needed to ensure safe pre-operative management and post-operative discharge instructions to the home for patients who are unwilling or unable to cooperate with dental treatment and have a history of aggressive behavior towards caregivers. It is essential to maintain strong lines of communication with the patient’s guardian and incorporate them in communication with other team members such as Anesthesia, Social Work and Risk Management prior to day of surgery. The compilation of an interdisciplinary team approach is essential in the planning and execution of comprehensive treatment for adult patients with ASD to properly manage there heightened anxiety in the healthcare setting.

Outcome

As a result of the teamwork of this case the patients was able to safely received comprehensive dental care under GA. Patients anxiety was managed pre and post admissions to the hospital. After implementation of behavioral management techniques it was not required to use restraints or force pre or post-dental treatment. After discussion with Anesthesia it was decided patient would receive Valium 10 mg the night prior and Valium 20 mg orally morning of surgery. An anesthesiologist administered 100 mg Versed Elixer with Coca Cola to the patient at car side. Ketamine dart was also not used. Patient willingly walked into emergency department and was transported via gurney to operating room. No complication or resistance during induction arose. Patient received dental care undergoing GA with no complications. Patient was extubated and awoke with no complications or signs of challenging or aggressive behavior. Post dental treatment patient was discharge as planned to three adults with light sedation with understanding that follow up care would be completed in home with newly established PCP. Establishment of a PCP willing to follow-up with this patient at the home was imperative. After review of labs drawn under GA, patient was found to have thyroid disease due to elevated Free-T4 and decreased levels of TSH. PCP is now treating patient through home visits for all further follow-up care.

DISCUSSION:

Behavior management is not effective with all patients and an alternative protocol is needed to address the unmet needs of patient with physical/ emotional disabilities, which alter their ability to cooperate for needed medical/dental care (Limeres-Posse at al 2014). According to (Jaganathan 2014) in “Autism Disorder (AD): An Updated Review for Pediatric Dentists” up to 30% of patients with ASD do not respond to any kind of behavioral management and full comprehensive treatment can only be provided under GA in the OR.

Patients with ASD generally react negatively to new environments which can trigger maladaptive behavior and can lead to “melt downs”. Adults with ASD can be difficult to restrain due to size and have a greater tendency for aggressive behavior if over stimulated (Limeres-Posse et al 2014). When patients cannot be managed with behavioral guidance, a pre-medication prior to treatment under GA is recommended. Patients with ASD have an altered pain threshold and frequently standard doses of medications are ineffective (Limeres-Posse et al 2014) Premedication’s can be used to prove amnesia, anesthesia and sedation to improve compliance during induction of GA. A premedication should be considered for children and adults with ASD to help curb the heightened anxiety and stress causes by over stimuli inherent within the dental office setting. As described by Shah in “Perioperative Management of a Patient with Autism” published in the Austin Journal of Anesthesia and Analgesia (2014) oral midazolam is the most widely used premedication in the United States due to “ its rapid onset, short duration of onset, and lack of major side effects with a routine dose of about 0.5 mg/kg”. Shah et al also describes the use of oral ketamine “in oral doses of 0.8mg/kg has shown to be more effective in improving compliance during induction”. Oral ketamine is favored over oral midazolam due to midalozam likeliness of causing repertory depression however ketamine is known to cause emergence delirium an adverse reaction for patients with ASD and history of aggression. Shah 2014 reports ketamine was not found to be effective when used alone as a premedication and should be use on moderate to severe cases after premedication with midazolam while midazolam alone is favors in patients with mild autism.

Complications that may arise with patients administered pre-medications include the patients being unwilling to drink the premedication and patient drinking only some or spitting up the pre-medication administered (Thompson & Goddard 2014). Bachenberg 1998 and Shailesh et al. 2009 recommend mixing the pre-medication with a drink favored by the patients, or something sweet such as “Dr. Pepper”.  In the event that complication arises the alternative is to use physical restraints and force (Shah 2014). However, this can be traumatic for both the patient and family. This does not build on trust between patients with ASD and the healthcare provider and can lead to increases in anxiety at all future encounters. For these reasons physical restraints/force is not recommended unless all other measures have been exhausted (Limeres-Posse et al 2014).

Conclusion:

In this case study it is likely the patient remembered parts of his previous visit to the dental clinic in 2014. At that time security was contact and ketamine was administered. This may have caused the patient to associate the location of the clinic with fear and anxiety leading to the patient refusing to exit his vehicle for follows up dental care in 2017. Thus, patients with ASD should be acclimated to new environments even for routine maintenance to maintain trust between the patient and caregivers/ hospital personnel to prevent future uncooperative behavior.

Extensive efforts where made to avoid the use of restraints and force in this case prior to day of surgery. As recommended, frequent drive by visits to the dental clinic prior to the day of surgery where also scheduled (Thompson & Goddard 2014, Nelson & Amplo, 2009).

A premedication was warranted in this case due to the patient’s pervious history of aggressive behavior towards caregivers and severe ASD. The anesthesia team administered oral Midazolam (Versed) mixed with soda to the patient.  Finally, post-discharge instruction form was compiled through a collective effort of the Dental, Anesthesia, Social Work and risk management teams.

Reference

Jaganathan, U. (2014). Autism Disorder (AD): An Updated Review for Pediatric Dentists. Journal Of Clinical And Diagnostic Research.

 

Thompson, D. G., & Tielsch-Goddard, A. (2014). Improving Management of Patients With Autism Spectrum Disorder Having Scheduled Surgery: Optimizing Practice. Journal of Pediatric Health Care, 28(5), 394-403.

 

Limeres-Posse, J., P. Castano-Novoa, M. Abeleira-Pazos, and I. Ramos-Barbosa. "Behavioural Aspects of Patients with Autism Spectrum Disorders (ASD) That Affect Their Dental Management." Medicina Oral Patología Oral Y Cirugia Bucal (2014): n. pag. Web. 16 Apr. 2017.

 

Nelson, D., & Amplo, K. (2009). Care of the autistic patient in the perioperative area. AORN J, 89(2), 391-397.

 

Bäckman B, Pilebro C. Visual pedagogy in dentistry for children with autism. J Dent Child. 1999;66:325-31.


 

Christiansen, E., & Chambers, N. (2005). Induction of anesthesia in a combative child: Management and issues. Pediatric Anesthesia, 15(5), 421-425.

 

Blomqvist, M., Dahllöf, G., & Bejerot, S. (2014). Experiences of Dental Care and Dental Anxiety in Adults with Autism Spectrum Disorder. Autism Research and Treatment, 2014, 1-9.

 

Shah SP. Perioperative Management of a Patient with Autism. Austin J Anesthesia and Analgesia. 2014;2(2): 1015. ISSN: 2381-893X

Bachenberg KL. Oral ketamine for the management of combative autistic adult. Anaesthesiology. 1998;89:549–550.

 

Marshall J, Sheller B, Williams BJ, Mancl L, Cowan C. Co- operation predictors for dental patients with autism. Pediatr Dent. 2007;29:369-76.


 

Shailesh Shah-Sonia Shah-Jesus Apuya-Senthil Gopalakrishnan-Timothy Martin – “Combination of oral ketamine and midazolam as a premedication for a severely autistic and combative patient, “Journal of Anesthesia – 2009

 

 

 

 

 

 

 

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