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Anesthesia & the Autistic Child by Sym C. Rankin, RN, CRNA

Anesthesia & the Autistic Child by Sym C. Rankin, RN, CRNA

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T
14THE AUTISM FILE| www.autism\ue000le.com| info@autism\ue000le.com
REPRINTED WITH PERMISSION \u00a9 THE AUTISM FILE
ISSUE 33 2009

The trends I have seen should come
as no surprise because autism spectrum
disorders have reached epidemic numbers,
and autistic children tend to have health
problems. I am seeing an increase in
the number of these children needing
radiological procedures such as an MRI or
a CT scan as well as increasing numbers of
autistic children for various ENT and dental
procedures.

I am not the only one who has observed
these trends. Recently, my profession has
begun to address the special considerations
of autistic children and children with
behavioral problems. They are called
\u201cdif\ue000cult pediatric patients.\u201d1 This is a new
term in my profession; we didn\u2019t need such
a phrase 25 years ago when I started my
career.

A recent educational review article2
discussed anesthetic considerations for
cerebral palsy patients, based primarily
on their physical problems (e.g., risk for
aspiration, dif\ue000culties positioning the
patient, and interactions with anti-spastic
and anti-epileptic medications). Autistic
children, on the other hand, were primarily
looked at from a behavioral standpoint
(e.g., minimizing waiting time, providing
quiet areas for pre- and post-operative

care, and involving parents).

The typical anesthesia provider is
aware of the behavioral problems in our
children and will do anything to make
the anesthetic experience as smooth as
possible. Most anesthesia providers will
have a preoperative telephone interview
to discuss our children\u2019s needs. They will
minimize waiting times, provide quiet areas,
and be very open to parental involvement.
But that provider may not realize that
he or she needs to look at the metabolic
problems in autistic children and consider
how those problems may affect anesthetic
choice.

Anesthesia providers generally are aware
of the prevalence of diagnosed ADHD and
the various drugs those children may be
on. They understand that autistic children
may also be on stimulant or antipsychotic
drugs; therefore, they must regard speci\ue000c,
necessary anesthetic considerations. For
example, when some of these drugs are
combined with certain anesthetic drugs,
an increase in central nervous system
depression may result. Thus, the anesthesia
provider knows to avoid or minimize use of
the problematic agent. But the anesthesia
provider who sees that as the only concern
is missing something very important.

Sym C. Rankin, RN, CRNA, is a graduate of the

University of Southwestern Louisiana and the Charity
Hospital School of Nurse Anesthesia (New Orleans). As a
practicing anesthetist for over 25 years, she has witnessed
an alarming increase in chronic and autoimmune diseases.
Those observations became less academic and more
personal after her son was diagnosed with autism. Her

son\u2019s journey of recovery led to Sym\u2019s realization that
mainstream medicine is far more interested in merely
treating symptoms than in asking the dif\ue000cult questions
of why those symptoms exist. She recently joined the
practice at True Health Medical Center in Naperville,
Illinois, and hopes that she can help other families on the
same journey.

BIOMEDICAL
By Sym C. Rankin, RN, CRNA
his article represents my educated
observations as an experienced

nurse anesthetist who also happens
to be the mother of a child on the road
to recovery from an autism spectrum
disorder (ASD). I am also a practitioner
taking care of autistic children, so I look at
these issues from a different perspective
than my anesthesia peers. The following
observations suggest a need to take heed
of certain issues that might have an impact
on the delivery of anesthesia in individual
cases and also suggests a need for rigorous
study of the potential problems autistic
individuals may have when undergoing
anesthesia.

As a practicing anesthetist for over 25
years, I have been in a position to observe
trends in the patients I help treat. In recent
years, I have seen an increase in children in
the operating room for various procedures.
A disproportionate number of those
children have diagnosed developmental
delays and behavioral problems in addition
to their medical problems. There are
no available statistics to quantify the
numbers, but my anecdotal observations
tell me that children need anesthesia in
numbers that would have shocked us a
decade or more ago.

ANESTHESIA
The Autistic Child
15
ISSUE 33 2009
REPRINTED WITH PERMISSION \u00a9 THE AUTISM FILE
info@autism\ue000le.com| www.autism\ue000le.com| THE AUTISM FILE

Many parents tell me their child was
different or regressed after an anesthetic.
To those of us who have taken a hard look
at the biochemical problems underlying
our children\u2019s autistic manifestations,
those anecdotal reports should come as
no surprise. An anesthetic may represent
yet another toxic insult our children get
exposed to. Therefore, we must help
anesthesia providers understand the
physical and biomedical problems our
children have so that the providers may
minimize the insults. Not surprisingly, part
of the problem is the same mindset we see
in the mainstream medical community at
large.

Mainstream physicians generally react
to the physical problems of ASD children
in the way their training taught them.
Clinicians use pharmaceutical drugs to
manage behaviors, without looking at
what might be causing those behaviors.
Because most anesthesia providers are
very much part of the mainstream, they
see only \u201cautistic\u201d behaviors, and they
try to compensate for those behaviors by
sedating the child. Such a provider does
not understand the metabolic problems
underlying those behaviors. So, they will
default to protocols that may include drugs
that might cause problems.

It\u2019s hard to blame the anesthesia
community for its blindness, considering
the lack of any professional guidance and
resources. The Autism Research Institute
(ARI) has two articles devoted to concerns
with anesthesia on its Web site. The \ue000rst3
provides both a good general overview of
anesthesia for parents and some general
advice to anesthesia providers. Although
the advice is accurate to a point, it fails to
warn of speci\ue000c problems autistic children
may encounter with anesthetic drugs.

The second ARI article addresses
anesthesia for dental procedures4. The
author states, \u201cThere are no data that
any anesthetic drugs cause or worsen
autism, nor are there any published data on

preferred drugs for anesthetizing autistic
children.\u201d Although it was true (at least
when the article was written) that there
were no studies directly examining the
impact of anesthesia on children with ASD,
there is published data that cautions about
using particular agents with patients who
have certain metabolic problems. Many
of those metabolic problems are the same
physical problems that, depending on one\u2019s
point of view, are underlying many autistic
manifestations (or at least would be labeled
comorbidities).

Recently published research supports the
potential for problems5. A retrospective
study based on medical and school records
from over 5,000 children born between
1976 and 1982 in Olmstead County,
Minnesota, found that one exposure to
anesthesia was not harmful. More than
one exposure, however, doubled the risk
that a child would be identi\ue000ed as having
a learning disability before the age of 19.
That risk increased with a longer duration
of the anesthetic. The exposures were
between birth and four years of age: a very
critical time of brain development.

The anesthetics primarily used in

the procedures under review in the
Olmsted County study were halothane
and nitrous oxide. Halothane is a very
fat-soluble drug that is dif\ue000cult for the
liver to metabolize. Nitrous oxide can
deactivate methionine synthase, which
is a B12 dependent enzyme important in
the methylation cycle. What we can learn
from that study is that administering a
fat-soluble toxin, followed by inhibition of
DNA methylation, may result in \u201clearning
disabilities.\u201d Although use of halothane
and nitrous oxide is not as common as it
used to be, it is not a terribly great leap to
hypothesize that use of similar chemicals
and toxins may play a role in triggering or
exacerbating manifestations of ASD.

All that being said, anesthesia is
unavoidable for children who need to
undergo surgical procedures. The goal
in such cases is to minimize the risk. To
do that, the anesthesia provider must be
made aware of the unique problems your
child has.

In general, these are the things your
anesthesiologist does not know:
\ue000Your child has a medical disease \u2014
not some mysterious mental disease
that is solely genetic in origin.
\ue000Your child may have gastrointestinal

dysfunction, immune system
dysregulation, in\ue001ammation,
mitochondrial dysfunction, heavy
metal poisoning, oxidative stress,
and chronic in\ue001ammation.

\ue000Most importantly, your child

probably has impaired detoxi\ue000cation
systems and may not be able to
metabolize drugs ef\ue000ciently.

In basic terms, anesthesia consists of three distinct elements controlled by pharmaceutical agents:

\ue000Amnesia (i.e., the patient is asleep
and remembers nothing);
\ue000Analgesia (i.e., the patient feels no
pain); and
\ue000Muscle relaxation (i.e., the patient
doesn\u2019t move).

An anesthetic may represent yet another toxic insult
our children get exposed to. There\ue000ore, we must help
anesthesia providers understand the physical and
biomedical problems our children have so that the
providers may minimize the insults.

16THE AUTISM FILE| www.autism\ue000le.com| info@autism\ue000le.com
REPRINTED WITH PERMISSION \u00a9 THE AUTISM FILE
ISSUE 33 2009

There is no single agent to handle all
three elements, so a combination of drugs
must be used. The anesthesia provider
titrates the drugs to effect a proper
balance, taking into account the unique
condition of the patient. (Indeed, because
anesthesiologists and nurse anesthetists
are used to taking unique biochemical
factors into account for each patient, you
may \ue000nd it easier to discuss your child\u2019s
condition with them than you have with
other mainstream physicians.)

Anesthesia is generally administered
through two methods: intravenous
and mask induction of gas. For adult
patients, an IV is started, and usually
a sedative and/or narcotic is given as a
premedication. Then an induction agent is
given to put the patient to sleep. Propofol
is often used as the induction agent. Then
the airway is secured and an anesthetic gas
is used to keep the patient asleep. Often a
narcotic is added for pain relief.

Sometimes using an intravenous
catheter is possible for children, but more
often that access is not easily obtained and
an inhalation induction is used instead. A
high \ue001ow rate is used for the gas, which
is delivered through a mask on the child.
After a few breaths, the child is asleep, IV
access is able to be obtained, the airway
is secured, and gas is used to maintain the
anesthetic.

When you meet with your
anesthesiologist or nurse anesthetist,
be prepared to discuss the methods of
anesthesia delivery and the exact drugs he
or she intends to use. Do not be afraid to
ask questions about the nature of speci\ue000c
drugs and how they work in the body.

Many of the drugs used in anesthesia
should be considered relatively safe. For
example, Versed\u00ae (a benzodiazepine used
for sedation, amnesia, and anti-anxiety)
and fentanyl (a potent narcotic) are
relatively short-acting and are not heavily
metabolized.

Other drugs may present opportunities
to make choices. Propofol, a short-acting
agent, is administered intravenously
and is used for induction and also for
maintenance of a general anesthetic (i.e.,
keeping the patient asleep). It may be
problematic for patients with an allergy
to soy or eggs; it contains soybean oil
and egg phospholipid. Concerns have

also been raised regarding a potential
for propofol to exacerbate mitochondrial
disease. Unfortunately, however, all
general anesthetics have a tendency to
inhibit mitochondrial function. Moreover,
the documented dif\ue000culties noted with
propofol stem from long-term use in the
ICU setting, exceeding the exposure most
patients would encounter6.

Under most circumstances, propofol
can be safely used. But if there is a
concern about its use, your provider may
determine that inhalation induction may
be appropriate using sevo\ue001urane. Only
two-to-\ue000ve percent of sevo\ue001urane is
metabolized in the body, making it an
excellent choice for many patients. (An
older inhalant, halothane, is rarely used
now because of its tendency to be heavily
metabolized.)

Sometimes the provider may want
to use ketamine. It is a dissociative
anesthetic; in essence, it is a
hallucinogenic. It is usually used for
sedation, especially for short procedures
like changing dressings on burns. In
children \u2013 especially so-called dif\ue000cult
pediatric patients \u2013 it may be used to
make it easier to start an IV. Ketamine\u2019s
advantage is that it doesn\u2019t depress
respirations like other anesthetics might.
It\u2019s also easy to use; it can be given orally,
intramuscularly, or intravenously. Typical
side effects, however, include open eyes,
nystagmus, increased salivation, and
emergence delirium. Ketamine alters the
patient\u2019s sensory perception, which raises
questions about its use for our children
due to the sensory issues many autistic
children have.

Special attention must be paid to the
use of nitrous oxide. It is one of the oldest
anesthetics used today and is still used for

sedation in dental procedures. In addition,
it is used on occasion as a carrier gas with
sevo\ue001urane in mask inductions. That is,
nitrous oxide is utilized for a second-gas
effect to increase the concentration of
another inhaled anesthetic agent, thereby
allowing the patient to get to sleep faster.

In the last decade, various concerns
have been raised about the use of nitrous
oxide: inactivation of methionine synthase,
increase of post-operative nausea,
relatively poor amnesic properties, and
even contribution to greenhouse gasses.
Because of these concerns, nitrous oxide
use in the operating room has dramatically
declined in recent years and will likely
approach zero in the coming years.

That being said, nitrous oxide is still
being used (especially in the dental
setting) and may present speci\ue000c
problems for autistic children with
common underlying conditions. Nitrous
oxide depletes the B12/folate system. It
deactivates methionine synthase, which is
an enzyme that catalyzes the conversion of
homocysteine and methyltetrahydrofolate
to methionine and tetrahydrofolate. Such
a deactivation in a patient with a defect
in the MTHFR (methylenetetrahydrofolate
reductase) gene, which is associated with
diminished enzyme activity, could result in
increased homocysteine levels, increased
oxidative stress, and activated NMDA
glutamate receptors. All of these could
contribute to in\ue001ammation; additionally,
nitrous oxide also may cause hematologic
problems, neuropathy, and neurotoxic

effects7.

For years, the anesthetic community
was told that nitrous oxide was the
perfect anesthetic. Now we know better.
A study published in 2003 discussed
the effects of two subsequent nitrous
oxide exposures, MTHFR mutation, and
the fatal neurological outcome due to a
methionine de\ue000ciency.8 In 2007, Dr. Victor
Baum presented a paper at a pediatric
anesthesiology meeting that made us
all rethink using nitrous oxide as an
anesthetic.9

BIOMEDICAL

Special attention must be paid to the use o\ue000 nitrous oxide.

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