A Case of an Obese Autistic Patient Refusing Anesthesia Induction
Shahd Mohamed BSc1, Omowonuola Ogundele, BSc1, Titilopemi Aina-Jones, MD, MPH2
1. Department of Anesthesiology, University of Florida College of Medicine, Gainesville
2. Texas Children’s Hospital/Baylor College of Medicine
Introduction:
- Autism is a developmental disorder characterized by deficits in social communication and repetitive and restrictive behaviors [1,2].
- Manifestations range from normal intellectual and language abilities with challenges regarding only social communication to severely limited intellectual and language abilities [1,3].
- The care of patients with autism requires an understanding of their unique features, as shown in Figure 1 [4].
Case Report:
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 refused to wear a hospital gown. Preoperative IV placement was impossible due to lack of patient cooperation. 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 the mask. 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 agreed to an awake IV placement. She subsequently underwent an uneventful IV induction and tolerated the procedure well.
Discussion:
- Medical providers often lack familiarity with the care of patients with autism. Therefore, advance preparation is essential in these cases, as outlined in Figure 2.
- When explaining procedure to patients with autism, the use of supplemental materials (e.g. picture charts) may be beneficial.
- The use of media, such as video peer modeling, may lower anxiety of patients undergoing certain procedures8.
- If possible, parents should be encouraged to bring a toy or other item that comforts their child.
Important Considerations:
- Difficulty with communication may not be contingent with a difficulty with understanding information.
- When obtaining informed consent, patients may be presented with information at a tolerable level and given the opportunity to express assent or dissent.
- Depending on the situation, a parent or guardian may need to provide informed consent.
References:
1.Genovese A, Butler MG. Clinical Assessment, Genetics, and Treatment Approaches in Autism Spectrum Disorder (ASD). IJMS. 2020;21(13):4726. doi:10.3390/ijms21134726
2.Sanchack KE, Thomas CA. Autism Spectrum Disorder: Primary Care Principles. Autism Spectrum Disorder. 2016;94(12).
3.Hirota T, King BH. Autism Spectrum Disorder: A Review. JAMA. 2023;329(2):157. doi:10.1001/jama.2022.23661
4.Ahmedani BK, Hock RM. Health care access and treatment for children with co-morbid autism and psychiatric conditions. Soc Psychiatry PsychiatrEpidemiol. 2012;47(11):1807-1814. doi:10.1007/s00127-012-0482-0
5.Van Der Walt JH, Moran C. An audit of perioperative management of autistic children. Pediatric Anesthesia. 2001;11(4):401-408. doi:10.1046/j.1460-9592.2001.00688.x
6.Konia MR. Oral Thompson DG, Tielsch-Goddard A. Improving Management of Patients With Autism Spectrum Disorder Having Scheduled Surgery: Optimizing Practice. Journal of Pediatric Health Care. 2014;28(5):394-403. doi:10.1016/j.pedhc.2013.09.007
7.dexmedetomidine for preoperative sedation in an adult uncooperative autistic patient. Journal of Clinical Anesthesia. 2016;34:29-31. doi:10.1016/j.jclinane.2016.03.037
8.Isong IA, Rao SR, Holifield C, et al. Addressing Dental Fear in Children With Autism Spectrum Disorders: A Randomized Controlled Pilot Study Using Electronic Screen Media. Clin Pediatr (Phila). 2014;53(3):230-237. doi:10.1177/0009922813517169
