a family centered approach in preoperative care for …...a family centered approach in preoperative...

A family centered approach in preoperative care for children with autism

OPANA Conference , Nov 2 , 2013 Nancy Rudyk MN. CNS

Katie Brazel CLS Preanesthesia Clinic

Sickkids

November 11, 2013 2

6 per 1000 / 1 in 88 children in Canada ( 2013) 4:1 ratio > more prevalent in boys than in girls In 2009 : 48,000 children 0-19yrs and 144,000

adults within Canada

Prevalence rates have risen , why remains unclear Parental reported ASD *

ASD has surpassed rates for children with

conditions such as cancer, Downs syndrome Scarpinato N. , et al . Caring for the child with autism spectrum disorder in the acute care setting. JSPN Vol 15, July 2010 Canadian Senate Report on Autism 2013

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Presentation Notes

Broader range of diagnosis Earlier diagnosis More systematic assessment practices

November 11, 2013 3

“new criteria May 2013” Aspergers and PDD terminology no longer

exists Criteria for ASD: Persistent deficits in Social Communication and

interactions : 3/3 symptoms Restricted , repetitive behavior, interests or

activities : 2/4 symptoms

DSM V , Carpenter, L.. Feb 2013

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Presentation Notes

Examples :Unusual social initiations: intrusive touching Does not initiate conversation , failure to respond to name Does not share Failure to engage in simple social games Lack of coordinated verbal or nonverbal communication / abnormal volume, pitch Repetitive speech: jargon, pedantic speech Excessive adherence to rituals or routines or excessive resistance to change

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Level 3 : severe deficits in verbal and non verbal social communication skills, fixated rituals and/or repetitive behaviors (RBB) interferes in all spheres

Level 2: marked deficits in verbal and non verbal social communication skills, RBB

Level 1: without supports in place , deficits in social communication cause noticeable impairments in 1 or more contexts

DSM V , Carpenter, L.. Feb 2013

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Presentation Notes

Marked distress when rituals interrupted, very difficult to redirect Distress or frustration when Distress or frustration when RBB is interrupted ; difficult to redirect 3.resists attempts by others to interrupt RBB or be redirected from fixated interest

November 11, 2013 5

Lifelong disorder; no cure ASD can be identified early: usually symptoms

noted by parents between the ages of 12 and 36 months

Cause of autism is unknown : vaccine theory unproven ,

50% are non verbal 75% have a secondary diagnosis i.e. epilepsy( 36%),

GI disorders, sleep disorder, mood disorders (26%), aggression (32%) Medical management of these conditions may result

in acute and planned hospitalization………………… Scarpinato N. , et al . Caring for the child with autism spectrum disorder in the acute care setting. JSPN Vol 15, July 2010 Canadian Senate Report on Autism 2013

Presenter

Presentation Notes

Irregular sleep patterns, early waking GI : consitpation, abdominal pain

November 11, 2013 6

Preoperative assessment and planning is key in the care of children with ASD admitted for surgery Preop Screen and triage based on level of ASD and surgical procedure completed via : 1)telephone assessment 2)clinic consultation *Hypersensitivity to sensory stimuli ( noise and touch ) is an issue for many children with ASD often resulting in increased anxiety for the child . The hospital setting is an environment that can be a challenge for child and family = Minimize unnecessary visits!! Scarpinato N. , et al . Caring for the child with autism spectrum disorder in the acute care setting. JSPN Vol 15, July 2010

November 11, 2013 7

How does the child communicate? Verbal or non verbal? What tool do they use? Is your child sensitive to noise? Touch? What is the best way to approach you child? How does the child react to new situations? Other adults? Children? What may agitate your child? When your child becomes agitated or over stimulated what are the interventions that may work? Scarpinato N. , et al . Caring for the child with autism spectrum disorder in the acute care setting. JSPN Vol 15, July 2010

November 11, 2013 8

Child’s previous experience with surgery? What was helpful? sedation and/or parent

present for induction, child life specialist What was not helpful? What recommendations does the parent or

child have for this surgical experience?

November 11, 2013 9

How are medications given? i.e. Respiradone, Abilify, anti- reflux, laxative, Complimentary and Herbal medications: i.e. B6, B12, D, Carnosine, Omega 3, Melatonin Special Diet : Gluten free, Casein free

November 11, 2013 10

• Preop plan of care for children with ASD may include : • Arrival to hospital 45 minutes prior to surgery time • Arrange for a quiet room • Hallway access to walk • No vital signs! No changing of clothes! No touching! • Preoperative sedation/ child life specialist

Presenter

Presentation Notes

Decreases fluids and fatty liver Metformin can support weight loss ?? CRITERIA IDENTIFIED BY TEAM AS A SUCCESSFUL CANDIDATE HAVE STABILIZED WIEGHT GAIN OR HAVE HAD SOME WEIGHT LOSS COMMITTMENT TO HEALTHY LIFESTYLE CHANGES HAVE FAMILY SUPPORT BEFORE, DURING AND AFTER SURGERY HAVE COMPLETED PUBERTAL MATURITY HAVE STOOPED OR NEARLY STOPPED GROWING NOT PREGNANT OR PLANNING TO BE PREGNANT IWITHIN 2 YEARS DO NOT HAVE AN EATING DISORDER


• Preanesthesia Assessment Clinic •Preoperative Care unit •Operating Room •PACU

*Assessment form identifying the key social , communication , behaviors for children with ASD will be a tool readily accessed for all staff to review in the Periop unit : completion 2013

Presenter

Presentation Notes

GERD IS REPORTED IN 20% of morbid obese patients – normal weight children 2% OSA is reported in 13- 59% of obese patients – normal weight children 1-2 % Pediatric obesity correlates with reduction on functional residual capacity, expiratory reserve : - accentuated in the recumbent position when abdominal pressure is at the highest Bronchial asthma is reported in 30% of children 8- 18 years of age Physical activity level to determine cardiopulmonary compromise


Increased communication of prescreening assessment: Anesthesia staff , APN, Nurses, Preoperative Care unit, OR, PACU, Pain Service ,

Facilitates transitions of the patient and family throughout the hospitalization

Development of effective partnerships with family, patient and staff

Presenter

Presentation Notes

Hypertension 20-30% of patients Left ventricular hypertrophy


Nancy Rudyk CNS Preanesthesia Clinic [email protected] Katie Brazel CLS Perioperative Care Unit [email protected]

a family centered approach in preoperative care for …...a family centered approach in preoperative...

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