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Anesthesia and Sedation Options for Kids with Autism

Does your child with ASD need sedation for a dental or surgical procedure? Wondering what your options are? Anesthesia and sedation choices need to be carefully considered for a child with complex medical needs.

Why Is This So Important?

Many of our kids have genetic mutations which affect their ability to detoxify. Kids with a high toxic load can struggle with the extra burden of anesthetics. Many kids also have reduced mitochondrial and/or autonomic nervous system functions which are further hindered by anesthetics. These underlying issues are often misunderstood by mainstream doctors and dentists. So, our job as educated advocates becomes even more critical.
 
When Bear needed sedation for some extensive dental procedures Lily immediately started researching. She connected with another mom who is a pediatric anesthetist nurse and has a kiddo on the spectrum. This sweet mom agreed that we could share the safety guidelines and information she recommended for Lily’s situation.
 
This is not medical advice. But, it can help you understand some of the most common medicines used, pros and cons, and some other safety and comfort considerations. Keep these in mind to discuss with your provider and your anesthesiologist.
 
This blog is a companion to our YouTube video, Anesthesia and Sedation Options for Kids with Autism. Lily covers some additional tips and shares the story of Bear’s regression after sedation. She also covers how she was able to get him back on track. Be sure to check it out!
 
These are six things often used during sedation or anesthesia for children. It’s helpful to have an understanding of these if you are facing a medical or dental procedure for your child.

Nitrous Oxide

If you have been to the dentist, you have likely had nitrous oxide. It’s the “laughing gas” that makes you feel strange and reduces your anxiety about the procedure. Lily always hated it as a child and didn’t feel good for a day or two afterward.
 
Nitrous Oxide is one of the oldest drugs used for sedation. It’s cheap for providers to use which is part of why it’s so popular. For most people, the only side effects are occasional nausea or constipation. However, many children with ASD have methylation cycle defects including MTHFR. Nitrous Oxide depletes the b12/folate cycle and methionine synthase. This depletion causes a chain reaction in the body that can increase inflammation and oxidative stress. Children with methylation cycle defects are more susceptible to these negative effects. Repeated Nitrous Oxide exposure can even be fatal for a small subset of kids who go into a procedure with a severe methionine depletion.

 

Sevoflurane

Sevoflurane is a gas often used as an alternative to Nitrous Oxide. Only about 2-5% of it is metabolized. This means that instead of being processed by the liver, the majority of it is exhaled back out through the lungs. This happens within minutes of the gas flow stopping.  The speedy reversal minimizes the effects on mitochondrial function.
 
Lily’s guidance was to make sure the anesthesiologist knew she didn’t want any Nitrous Oxide mixed in with the Sevoflurane. It is a common practice because they are more effective together for non-sensitive patients.
 
The gas does have a pretty yucky smell. However, they often can put a gel that smells good inside the edge of the mask to make it more tolerable.

 

Versed

This drug is often given orally or intranasally right before surgery. It’s generally considered safe because it’s easily metabolized and has a short-acting time. Versed also has an amnesia effect. That means the child doesn’t remember or feel traumatized by the anesthesia or the procedure.
 
Lily allowed this with Bear before his sedation for his dental work. He became very relaxed and groggy which made it much easier to put him under with the sevoflurane. She allowed it again in the ER a couple of years later so he could get some stitches after a fall. It worked beautifully. They were able to get his stitches done without trauma or tears.

Propofol

The delivery for propofol is intravenous. Its function is to induce and maintain general anesthesia and a safe airway. Please note that it contains soy and egg phospholipids. If your child has an allergy or sensitivity to either of those be sure to let your provider know. It may exacerbate mitochondrial issues when used for longer periods. However, our nurse stated that a small bolus is okay for children over 65-70 pounds.

Definitely discuss any concerns with your provider and anesthesiologist. For more detailed information please see our link below for “When Propofol is Problematic”.

 

Ketamine

Ketamine is given orally, intravenously, or intramuscularly via injection. Some providers prefer it because it doesn’t affect breathing like some other drugs. Unfortunately, it’s hallucinogenic and dissociative properties can make its use for children questionable. These effects are particularly troubling for non-verbal children or those with a cognitive delay. They can’t express how they feel, understand what’s happening, or have help to process the experience afterward.
 
Ketamine has a higher incidence of postoperative delirium. This is a serious complication. The patient experiences confusion, agitation, and may not recognize family members. We don’t feel comfortable using it for our small kiddos, but we know parents who have had to use it with aggressive teens. Be sure to research it fully and ask a lot of questions if it’s suggested by your provider.
 
Some feel Ketamine is the most reliable preoperative sedative for kids with ASD. It is used if a child’s symptoms are more severe, if they are teens, or if they become physically aggressive and resistant to other methods. There are some studies using Ketamine as a behavioral treatment for adults with ASD, but there needs to be more research.

Precedex

Precedex, also called Dexmedetomidine, is an intravenous drug for sedation. It is not approved for use in children in any country according to the article linked in the resources below. It is often used off-label anyway. Studies of its potential negative effects in children are limited and sometimes conflicting. Precedex is sometimes associated with low heart rates and unsafe blood pressure changes. In recovery, patients may experience and pain, shivering, and agitation. Lily decided to avoid this one with Bear for the reasons listed above. We encourage you to do your research before you speak with your anesthesiologist. Understand the risks so you can ask good questions.

Lactated Ringers

Sometimes called ringers lactate. This is a mixture of sodium chloride, sodium lactate, potassium chloride, and calcium chloride in water. It’s given through the IV during surgical procedures to help replace electrolytes. Kids with mitochondrial issues are at risk for lactic acidosis. Lactated ringers in the IV make this condition worse or more likely.

Additional Information and Resource Links

  1. Risk of Anesthesia Regression in Children with Autism Spectrum Disorder and Mitochondrial Dysfunction
  2. Anesthesia & ASD by Sym C. Rankin, RN, CRNA
  3. When Nitrous Oxide is No Laughing Matter
    by Victor C. Baum, M.D.
  4. Anesthesia for children with special needs, including autistic spectrum disorder
  5. When Propofol is Problematic – The Society for Pediatric Anesthesia
  6. How Long Does Versed Stay In Your System
  7. (Precedex) Dexmedetomidine in Children: Current Knowledge and Future Applications
  8. Mitochondrial Disease and Anesthesia

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1 Comment

  1. Avatar
    Rita on February 11, 2021 at 8:38 am

    What would you advice for an 8 yrs old having to have 3 decade baby teeth out with anesethia

    Reply

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