1. Preparing the Child with Special Needs
Presented by: Danyel Dorn RN, MSN, CPN
Clinical Nurse Educator-Pediatric service line

2. Purpose
The registered nurse will plan individualized, evidence based nursing care for patients with special needs. There is a broad spectrum of children with special healthcare needs who require anesthesia. Although autism and Down syndrome are discussed in this module, interventions proposed can be used with any special needs patient.

3. Competency Statement
The perianesthesia registered nurse will identify components of an effective perianesthesia plan for a child with special needs.

4. Autism Spectrum Disorder (ASD)
Includes: Asperger’s, pervasive developmental delay-not otherwise specified, childhood disintegrative disorder, Autism
Social communication disorder = those children with communication difficulties seen in ASD, but no repetitive/restricted behaviors

5. ASD 1/88 people have some form of autism
Males are affected four times more often than females
Diagnosis usually occurs between months
Possible comorbidities include seizures, GI disorders, developmental delay, hyperactivity, sleep disturbances, anxiety and depressive illness

6. ASD Associated with Fragile X syndrome and/or Rett’s disorder
Characteristics of ASD are on a continuum of mild to severe and include: social communication impairment (impaired language development/communication patterns, impaired development of age appropriate social skills) and repetitive/restricted behaviors (non-normative development of restricted interests or stereotyped behaviors)

7. ASD
Patients with ASD may have difficulty with transitions to new activities or people, struggle with even slight changes to daily routines, exhibit intolerance to sensory overstimulation and may be challenged with interpreting and expressing conversation and emotional cues from other people

8. Down Syndrome
Characteristics include: hypotonia, micrognathia, large tongue, flattened occiput, flattened nasal bridge, short neck, small and low set ears, broad hands with single palmar crease, fifth finger curves in towards thumb, joint hyperflexibility, upward slanging eyes with epicanthal folds

9. Down Syndrome
Possible comorbidities include abnormal airway anatomy such as choanal atresia, narrow airway or laryngomalacia, obstructive sleep apnea, pulmonary artery hypertension, cardiac defects, duodenal atresia, wide range of developmental delays (may be nonverbal), immunodeficiencies with frequent upper respiratory infections, hypothyroidism, atlanto-axial instability, seizures, higher incidence of leukemia
1/691 babies are born in the US with Down syndrome (CDC, 2016)

10. Perianesthesia Considerations
Preoperative Evaluation:
Use of Screening tool
Determine the developmental level and somatosensory disturbances = may require private room or quiet bed space, plan for consistent staff throughout the procedure
Discuss presence of any emotional disturbances = manifestation and triggers

11. Perianesthesia Considerations
Discuss strategies used to reduce anxiety and gain cooperation = comfort items, special toy, home pajamas, music.
Use a reward or token system to gain cooperation
Discuss how patient responds to new faces, determine best way to approach patient

12. Perianesthesia Considerations
Identify components of the patient’s daily routine that can be accommodated in the hospital
Plan for family presence in PACU as early as possible, preferably before patient awakens from anesthesia
Determine the causes of agitation and respond and manage early on

13. Communication Techniques
Bring communication devices on day of procedure
Provide sign language interpreters for nonverbal patients who use sign language
Use clear simple language
Identify signs and behaviors the patient uses to communicate pain

14. Medical Comorbidities
Down syndrome patients will need airway and cervical spine evaluation by anesthesia team
May require preop cervical spine imaging if physical exam is concerning
Many of these special needs patients will have a ASA score of II, III, IV.

15. Perianesthesia Considerations
Determine method of medication administration
Previous anesthetic and surgical experience
Discuss the option of a tour of the facility
Include education regarding the possibility of preoperative delays, the need to adhere to NPO guidelines, and a brief description of the typical preop routine and equipment
Need for anxiolytics and involve child life

16. Day of Surgery Review plan with team members
Modify physical environment to minimize sensory stimulation
Provide extra staff if needed to assist with the patient
Avoid use of restraints
Discuss with team effective induction and pain management plans
Use topical anesthetic cream for IV placement
Administer anxiolytic if ordered

17. Intraoperative Considerations
Review induction plan
Consider parental presence
Review emergence plan
Advocate for antiemetic and pain medication administration prior to leaving the operating room
Advocate for early IV removal while sedated if possible

18. Postoperative Considerations
Phase I: monitor for airway compromise (Down’s = large tongue = obstruction)
Provide for pain and comfort management
Encourage parental visitation as soon as possible
Ensure patient safety when emerging (gurney pads)
Allow Phase I and II in the recovery room if possible to reduce transitions

19. Postoperative Considerations
Minimize sensory stimulation as much as possible
Noise: provide quiet area for recovery; reduce alarm volumes if deemed safe
Visual: dim lights if deemed safe
Tactile: minimize excessive physical stimulation if agitated by touch

20. Phase II Recovery
Discharge to inpatient unit or home as soon as possible once discharge recovery criteria are met.
Review patient needs with receiving staff
Evaluate effectiveness of plan, eliciting feedback from family if possible.
Communicate changes in the plan, to the team, as patient may be back for other procedures.

21. Reference
ASPAN (2016). A Competency Based Orientation and Credentialing Program for the Registered Nurse Caring for the Pediatric Patient in the Perianesthesia Setting.

22. Answers C A B