Avantages d'un plan périopératoire individualisé pour les enfants avec un diagnostic de "trouble du spectre de l'autisme"

Aperçu: G.M.

Les soins périopératoires pour les enfants avec un diagnostic de "trouble du spectre de l'autisme" peuvent être difficiles. Les chercheurs ont cherché à déterminer l'utilité d'un plan individualisé basé sur la décision de fournir une sédation pré-opératoire stratifiée selon le niveau de gravité du "trouble".

Entre 2012 et 2014, les chercheurs avons réussi à préparer un plan pour 246 (98%) de 251 procédures chirurgicales ou diagnostiques chez 224 patients. Le niveau de gravité a été réparti avec 45% avec un niveau de gravité 1 et Asperger, 25% avec un niveau de gravité 2 et 30% avec un niveau de gravité 3. La majorité (90%) des cas ont été programmés comme une opération de jour. La sédation préopératoire a augmenté avec le niveau de gravité croissant: niveau de gravité 1 (21%) ou Asperger (31%), niveau de gravité 2 (44%) et niveau de gravité 3 (56%). 

La coopération à l'induction de l'anesthésie était de 90% dans l'ensemble, avec une sédation préopératoire administrée à 94 patients (38% de l'ensemble de la cohorte). La coopération a été la plus grande dans le degré de gravité 1 (98%) et les patients d'Asperger (93%) et un peu moins (85%) chez les patients dans les niveaux de gravité 2 et 3.  

Les résultats suggèrent qu'un plan individualisé est utile dans la prise en charge périopératoire des enfants avec un diagnostic de "trouble du spectre de l'autisme"  et que la connaissance du niveau de gravité des TSA peut être utile pour déterminer le besoin de sédation préopératoire. 

Paediatr Anaesth. 2017 Jun 15. doi: 10.1111/pan.13189.

Benefits of an individualized perioperative plan for children with autism spectrum disorder

Swartz JS¹, Amos KE², Brindas M³, Girling LG¹, Ruth Graham M¹.

Author information

1

Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.

2

Department of Nursing, Child Health, Children's Hospital, Health Sciences Centre, Winnipeg, Manitoba, Canada.

3

Child Life Department, Children's Hospital, Health Sciences Centre, Winnipeg, Manitoba, Canada.

Abstract

BACKGROUND:

Perioperative care for children with autism spectrum disorder may be challenging. Previous investigators recommend development of an individualized perioperative management plan with caregiver involvement.

AIM:

The primary goal was to determine the usefulness of an individualized plan based on the decision to provide preoperative sedation stratified by autism spectrum severity level. Secondary goals were to assess the effectiveness of the plan based on subjective assessment of patient behavior at induction of anesthesia and caregiver satisfaction.

METHODS:

We developed an individualized plan for each child with autism spectrum disorder scheduled for anesthesia. Children were categorized by autism spectrum disorder severity level. With institutional ethics approval, we conducted a retrospective chart review to document need for preoperative sedation, sedation stratified by autism spectrum disorder severity level, behavior at induction, and caregiver satisfaction.

RESULTS:

Between 2012 and 2014, we successfully prepared a plan for 246 (98%) of 251 surgical or diagnostic procedures in 224 patients. Severity level was distributed as 45% Severity Level 1 and Asperger's, 25% Severity Level 2, and 30% Severity Level 3. The majority (90%) of cases were scheduled as day surgery. Preoperative sedation increased with increasing severity level: Severity Level 1 (21%) or Asperger's (31%), Severity Level 2 (44%), and Severity Level 3 (56%). The odds ratio for sedation use was 5.5 [CI: 2.6-11.5, P<.001] with Severity Level 3 vs Severity Level 1 patients. Cooperation at induction of anesthesia was 90% overall with preoperative sedation administered to 94 (38%) of the entire cohort. Cooperation was greatest in Severity Level 1 (98%) and Asperger's patients (93%) and somewhat less (85%) in patients in Severity Levels 2 and 3. The plan was helpful to guide sedation choices as cooperation did not differ between sedated and unsedated children at any severity level (overall χ² =2.87 P=.09). Satisfaction among caregivers contacted was 98%.

CONCLUSION:

The results suggest that an individualized plan is helpful in the perioperative management of children with autism spectrum disorder and that knowledge of autism spectrum disorder severity level may be helpful in determining the need for preoperative sedation.

© 2017 John Wiley & Sons Ltd.

PMID:28618130

DOI:10.1111/pan.13189

La connectivité fonctionnelle de l'état de repos du cerveau est préservée sous anesthésie de Sevoflurane chez les patients

Aperçu: G.M.

Les études de connectivité fonctionnelle jouent un rôle important dans la compréhension de la relation entre les connexions réseau et le phénotype comportemental des personnes avec un trouble envahissant du développement  (TED).

L'anesthésie générale est un facteur de confusion dans les études d'imagerie fonctionnelle en raison de son effet sur la connectivité fonctionnelle. L'objectif de cette étude est d'examiner la connectivité fonctionnelle de l'état de repos (RS-FC) sous anesthésie de sévoflurane chez des personnes avec TED.

Les données des sujets ont été comparées aux données de seize témoins sans TED non anesthésiés.

Un total de 13 patients a été étudié. Six réseaux ont été étudiés, le réseau de mode par défaut (DMN), le réseau de contrôle exécutif (ECN), le réseau de salience (SN) ainsi que les réseaux auditifs, visuels et sensori-moteurs.

Les rapports précédents ont suggéré que même des niveaux d'anesthésie légers pourraient réduire les niveaux globaux de fluctuation dans les principaux réseaux de cerveau tels que DMN et ECN. Cependant, ces résultats fournissent des preuves solides que ces réseaux peuvent supporter des niveaux d'activité détectables chez les patients avec TED, même avec des niveaux profonds d'anesthésie. 

Brain Connect. 2017 Apr 26. doi: 10.1089/brain.2016.0448.

Brain Resting State Functional Connectivity is preserved under Sevoflurane Anesthesia in patients with Pervasive Developmental disorders - a pilot study

Venkat Raghavan L¹, Bharadwaj S², Wourms V³, Tan A⁴, Jurkiewicz MT⁵, Mikulis DJ⁶, Crawley AP⁷.

Author information

1

Toronto Western Hospital, 26625, Department of Anesthesia , 399 Bathurst Street , Toronto, Canada , M5T 2S8 ; lashmi.venkatraghavan@uhn.on.ca.

2

Toronto Western Hospital, 26625, Department of Anesthesia, Toronto, Canada ; acharya.suparna@gmail.com.

3

University of Manitoba, 8664, Anesthesia, Winnipeg, Manitoba, Canada ; vpw130@mail.usask.ca.

4

King\'s College Hospital NHS Foundation Trust, 8948, Anesthesia, London, London, United Kingdom of Great Britain and Northern Ireland ; audreytan@me.com.

5

Hospital of the University of Pennsylvia, Division of Neuroradiology, Department of Radiology, Philadelphia, Pennsylvania, United States ; Michael.Jurkiewicz@utorotnto.ca.

6

Toronto Western Hospital, 26625, Joint Department of Medical imaging, Toronto, Canada ; mikulis@mac.com.

7

Toronto Western Hospital, 26625, Joint Department of Medical imaging, Toronto, Ontario, Canada ; crawley@uhnres.utoronto.ca.

Abstract

Background Functional connectivity studies play a huge role in understanding the relationship between the network connections and the behavioral phenotype of patients with Pervasive developmental disorders (PDD). However, some patients with PDD may not tolerate the imaging procedure while awake and they often need general anesthesia. General anesthesia is a confounding factor in functional imaging studies due to its effect on the functional connectivity. The objective of this study is to look at the resting state functional connectivity (RS-FC) under sevoflurane anesthesia in patients with pervasive developmental disorders. Method Adults with PDD scheduled for MRI of the brain under general anesthesia were recruited for the study. Resting state fMRI scans were acquired in all patients on a 3-Tesla scanner at 1 Minimum Alveolar Concentration (MAC) of sevoflurane. During the study period, end-tidal carbon dioxide and blood pressure were maintained at baseline value. Spontaneous BOLD fluctuations were measured, and a seed-voxel analysis done to identify the resting state networks. Subjects' data were compared with data from sixteen non-anesthetised healthy controls.. Results A total of 13 patients was studied. Six networks were investigated, the default mode network (DMN), executive control network (ECN), salience network (SN) as well as the auditory, visual and sensorimotor networks. At 1 MAC sevoflurane anesthesia, RS-FC was preserved in all the networks. Secondary analysis of connectivity showed a decrease in connectivity within the thalamus and an increase in DMN-ECN and DMN-SN cross-network connectivity in the anesthetized patient group compared to healthy controls. Conclusion Previous reports suggested that even mild levels of anesthesia could reduce overall fluctuation levels in major brain networks such as the DMN and ECN. However, our results provide strong evidence that these networks can sustain detectable levels of activity in patients with pervasive developmental disorders even under deep levels of anesthesia.

KEYWORDS:

Anesthesiology; Autism; Default mode network; Resting-state functional connectivity magnetic resonance imaging (R-fMRI)

PMID: 28443736

DOI: 10.1089/brain.2016.0448

Risk of autistic disorder after exposure to general anaesthesia and surgery: A nationwide, retrospective matched cohort study

Traduction partielle: G.M.

Eur J Anaesthesiol. 2014 Aug 6. 

Risque de troubles autistiques après l'exposition à l'anesthésie générale et chirurgie: Une étude rétrospective de cohorte appariée à l'échelle nationale

Ko WR1, Huang JY, Chiang YC, Nfor ON, Ko PC, Jan SR, Lung CC, Chang HC, Lin LY, Liaw YP.

Author information

Abstract

BACKGROUND:

Deficits of learning, memory and cognition have been observed in newborn animals exposed to general anaesthetics. However, conclusions from clinical studies conducted in humans to investigate the relationship between anaesthesia and neurodevelopmental disorders have been inconsistent. Autistic disorder is typically recognised earlier than other neurobehavioural disorders. Although certain genes apparently contribute to autistic disorder susceptibility, other factors such as perinatal insults and exposure to neurotoxic agents may play a crucial role in gene-environmental interaction.

OBJECTIVE:

This study was designed to investigate the association of exposure to general anaesthesia/surgery with autistic disorder. We hypothesised that exposure to general anaesthesia and surgery before 2 years of age is associated with an increased risk of developing autistic disorder.

DESIGN:

A retrospective matched-cohort study.

SETTING:

A medical university. Data from the National Health Insurance Research Database of Taiwan from 2001 to 2010 were analysed.

PATIENTS:

The birth cohort included 114 435 children, among whom 5197 were exposed to general anaesthesia and surgery before the age of 2 years. The 1 : 4 matched controls comprised 20 788 children.

MAIN OUTCOME MEASURES:

The primary endpoint was the diagnosis of autistic disorder after the first exposure to general anaesthesia and surgery.

RESULTS:

No differences were found in the incidence of autistic disorder between the exposed group (0.96%) and the unexposed controls (0.89%) (P = 0.62). Cox proportional regression showed that the hazard ratio of exposure to general anaesthesia and surgery was 0.93 [95% confidence interval (95% CI) 0.57 to 1.53] after adjusting for potential confounders. Age at first exposure did not influence the risk of autistic disorder. No relationship was found between the total number of exposures and the risk of autistic disorder.

CONCLUSION:

Exposure to general anaesthesia and surgery before the age of 2 years, age at first exposure and number of exposures were not associated with the development of autistic disorder.

L'exposition à l'anesthésie générale et la chirurgie avant l'âge de 2 ans, l'âge à la première exposition et le nombre de vues ne sont pas associés avec le développement de troubles autistiques. 

PMID: 

25101714

 

Anaesthesia and the autistic child.

Traduction: G.M.

Anesthésie et l'enfant autiste.

Bagshaw M. source L'université de Bournemouth. maria.bagshaw @ salisbury.nhs.net

Résumé

Il semble y avoir peu de littérature en pratique pédiatrique anesthésique pertinente pour les enfants souffrant d'autisme (Rainey & Van der Walt, 1998).

Des découvertes récentes suggèrent la nécessité d'une étude rigoureuse des problèmes potentiels que les enfants autistes peuvent avoir lorsqu'ils subissent une anesthésie (Kirz 2007).

Certains professionnels de la santé n'ont pas de connaissances ou l'orientation professionnelle suffisante pour être en mesure d'identifier ces enfants (DH 2001, Disability Rights Commission 2006, DH, 2008a, b, 2009, Rankin 2009).