Adolescent with autism for elective surgery



·         Autism

·         Assessment

·         Logistics

·         Induction planning

·         Emergence planning



Common features

·      ±Intellectual disability

·      Difficulty with social interaction

·      Difficulty communicating

·      Restrictive, repetitive behaviour

Common triggers

·      Change to environment

·      Change to routine

·      Sensory overload – lights, noise, crowds

·      Strangers



Previous episodes

·      Pre-med

·      Induction and emergence

·      Drugs used

·      Recovery chart


·      Ask what has worked and failed

·      Ask about triggers and comforts

·      Involve parent in decision-making and patient care


·      Establish rapport if possible

·      Beware triggers

Play therapist

·      Ask for advice

·      Especially helpful if known to the child




·      Organise all scheduled procedures in one go

·      Notify admin + holding bay

·      Do paperwork before day of surgery

·      Early morning

·      Quiet room on arrival

·      Minimise time from admission to surgery

·      Minimise time from surgery to discharge


·      Notify assistant + scrub team + technician + surgeon

·      Prepare equipment and drugs before child’s arrival

·      Least monitoring possible without threatening safety

·      Induction in anaesthesia room


Induction planning:



·      Helpful for most patients. D/w parent.

·      Prefer least invasive route (PO -> IN -> IM)

·      Prefer most familiar person (patient -> parent -> nurse)

·      Prefer most tolerable presentation (own cup, [1]plain vs flavoured)

·      Consider location: quiet room + ease of monitoring


1.    PO: midazolam 0.5mg/kg (max 20mg) + ketamine 5mg/kg

2.    IN: dexmedetomidine 3mcg/kg

3.    IM: ketamine 5mg/kg


·      Usually helpful. D/w parent.

·      Prefer amethocaine (fast onset, vasodilatation)


·      Optimal technique variable. D/w parent.

o    Induction: IV or inhalation

o    Cannulation: visible vs hidden

·      Note dexamphetamine and methylphenidate increase MAC


Emergence planning:

Delirium prevention

·      Switch to propofol TIVA

·      ±Clonidine 1mcg/kg (note pre-med)

·      Quiet place

·      Parent present when safe

Symptom control

Avoid need to meds in PACU

·      Generous analgesia: consider clonidine

·      Generous anti-emetic: TIVA + dexamethasone + ondansetron

·      Adequate hydration

Remove devices

·      Deep extubation if safe

·      Remove IVC when safe

·      Remove monitoring (e.g. ECG dot) when safe



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