Induction of anesthesia in a combative child; management and issues

Abstract

A developmentally delayed, 13-year old autistic boy required management of multifocal cerebral and pulmonary tumors, involving several anesthetics over a 4-month period. At each anesthetic he refused premedication, displayed increasing anxiety and became more combative. With parental guidance and involvement, a variety of anesthetists tried a range of techniques to achieve induction, each ultimately resorting to the use of physical restraint. Principles essential to the care of such a child include early recognition, parental support, multi-disciplinary planning of procedures requiring general anesthesia, continuity of anesthesia care, and clear guidelines about the perioperative management of uncooperative children, including the ethical use of restraint.

Combination of oral ketamine and midazolam as a premedication for a severely autistic and combative patient

“…One case report, by Christiansen and Chambers [8], described an autistic 13-year-old boy who had several anesthetics, all requiring restraints and forcible premedication, in order to have a successful induction of anesthesia. The patient in this case report refused or spat out the oral premedication drugs, possibly because the beverage used did not successfully hide the taste of the premedicant drugs.…”

Attention‐deficit hyperactivity disorder and anesthesia

“…It is unclear if children with ADD are unusually represented in the numbers requiring general anesthesia or if they are more at risk of perioperative behavioral disturbances. It would be very useful to know if a specialized anesthetic approach is appropriate in this group (13). Exacerbated ADD behavior has significant social implications with respect to dysfunction of family and school life, and antisocial behaviour.…”

Children who refuse anesthesia or sedation: a survey of anesthesiologists

“…Lack of cooperation in children may sometimes be predictable and manageable, although a child may become uncooperative unexpectedly, at which point the pediatric anesthesiologist must quickly decide on a new strategy including the use of distraction, coercion, premedication (new or additional), restraint or even postponement. Induction of anesthesia is a witnessed event, open to scrutiny and potentially stressful for all individuals present, particularly when the child is uncooperative (1).…”

“…Minors differ in this respect, and although the rights of minors to refuse treatment have been considered in circumstances involving emergency or life‐sustaining medical treatment (3,4) they have not been as well documented in circumstances where minors undergo elective surgery (3,5,6). There are a few case reports (1,6) and one editorial or opinion (7,8) which highlight the practical problems associated with induction of anesthesia (or sedation) in uncooperative children who refuse surgery. The purpose of this study was to survey pediatric anesthesiologists regarding their experience with assent and cooperation in children undergoing anesthesia, and techniques for anesthetizing reluctant children.…”