(Kanner syndrome, pervasive behavior disorder, autism spectrum disorders)

Prevalence: approx. 1 % ?  Boy/girl ratio: 4-9/1 if IQ is high, around 2/1 if IQ is low. The abilities and needs of people with autism are variable and may evolve over time. While some are able to live independently, others suffer severe handicaps that require lifelong care and assistance.

It manifests itself by:

-         poverty of social interactions: tendency to introversion and isolation; inability to socialize

-         difficult verbal communication : difficult expression (oral speech, sometimes absent) and limited understanding of oral instructions (unlike visual messages)

-         lack of interest for outdoor activities

-         behavior problems: repetitive, ritual pattern of behavior; sometimes aggressiveness; if IQ is high, often have a strong interest in a particular topic for which the child can become an expert (see Asperger syndrome)

-         highly variable IQ: it is lower than 70% in 55 % of cases

There are frequent sensory features: hypersensitivity to noise or odours, or even to the physical contact with an unknown person. This may cause inappropriate reactions  (shouts, panic, etc). Some children cannot bear to be looked into their eye. Very important associative memory. Epilepsy is associated in 30% of cases.

Many patients also present with digestive problems (malabsorption, maldigestion, coeliac disease) and poor orodental hygiene due to lack of collaboration.

The cause of autism is unknown and probably multifactorial: genetic (mitochondrial diesases, abnormal folates metabolism in the brain) and environmental factors ? Neurological pathologies such as tuberous sclerosis, fragile X syndrome, Angelman syndrome, untreated phenylcetonuria) and trisomy 21 can cause an autistic-like behavior.

Anesthetic implications: 

the help of the family is paramount !

*         Consultation: avoid any waiting time and sources of anxiety; prepare the visit with the parents or the usual caregiver: what are its reactions to novelty? Any hypersensitivity to? reaction to previous medical experience? usual tricks to communicate (imitation by mirroring, games, pretending, etc)? Avoid noises (telephone) and bright light during the visit, take time to assimilate the information with the help of gestures or visual media (pictograms), respecting a personal space that is probably wider in other patients.

*         Anesthesia: organize  the hospitalization with the parents, if possible on an outpatient basis.  A premedication (midazolam ± ketamine per os; dexmedetomidine 2 to 3 µg/kg p os) is often necessary.  Anticipate a difficult or long induction: flexibility and patience are mandatory ! Awakening in a  calm environment to avoid panic reactions. 
There are pictograms and apps for Ipad and Iphone designed to facilitate communication with autistic children.

*         risk of poor nutrition and/or nutritional deficiences (vitamins) in case of selective eating.

*        risk of refractory hypotension under G.A. in case of treatment by risperadone

References:

-          Rainey L, Van Der Walt JH. 
The anaesthetic management of autistic children. 
Anaesth Intensive Care 1998; 26: 682-6.

-         Van Der Walt JH, Moran C. 
A audit of perioperative management of autistic children. 
Pediatr Anesth 2001; 11: 401-8

-         Asahi Y, Kubota K, Omichi S. 
Dose requirements for propofol anaesthesia for dental treatment for autistic patients compared with intellectually impaired children. 
Anaesth Intensive Care 2009; 37: 70-3.

-         Arnold B, Elliott A, Laohamroonvorapongse D, Hanna J, Norvell D, Koj J. 
Autistic children and anesthesia: is their perioperative experience different? 
Pediatr Anesth 2015; 25: 1103-10.

-         Vlassakova BG, Emmanouil DE.
Perioperative considerations in children with autism spectrum disorder. 
Curr Opin Anaesthesiol 2016; 29: 359-66

-        Lee R.
Refractory hypotension in an autistic child on risperidone.
Anaesthesia Cases 2017 ; 5 : 10-2.

-        Swartz JS, Amos KE, Brindas M, Girling LG, Graham R.
Benefits of an individualized perioperative plan for children with autism spectrum disorder.
Pediatr Anesth 2017; 27: 856- 62

-        Swed-Tobia R, Haj A, Militianu D, Eshach O et al.
Highly selective eating in autism spectrum disorder leading to scurvy: a series of three patients.
Pediatr Neurol 2019; 94 : 61-3.

-        O'Brien EM, Stricker PA, Harris KA, Liu H, Griffis H, Muhly WT.
Perioperative management and outcomes in patients with autism spectrum disorder: a retrospective cohort study.
Anesth Analg 2024;138 :438-46.

Updated: March 2024