The Connections

You may already have an idea about anaesthetists. You might think we’re up the back of the theatre doing sudoku. Perhaps you think we just want people to shut up and the drugs are a convenient way to deliver some peace and quiet. Maybe you’re not quite sure what we are.

Perhaps we’re to blame for that. So maybe I should explain the things that anaesthetists do. Except that would take way too long.  Years of electronic tapping. But I can cover one part of our job. Anaesthetists produce connections.

Connections Anaesthesia Probably Isn’t Responsible For

This post is also about something else. This post is a little bit about autism. And a little about the different things you can focus on when you start with those two words: anaesthesia and autism.

If you do a quick search for those two words it won’t take long to find stuff claiming a big link between anaesthesia and the development of autism. On some sites it gets put in a basket with vaccinations. Or toxins. All sorts of things.

On the one hand you might assume I’ll be quick to dismiss this particular connection. You might think I’d be jumping at the chance to rip into a bit of pseudoscience. I’m just not sure taking a swing at people wrestling with something helps anyone.  So let’s not.

The other reason I’m not that keen to go down that road is there are legitimate questions to ask about the effects of anaesthesia on the developing brain. There’s more on this topic here, but the simple version is: we’re still elucidating the way anaesthetic agents work; in some animal models anaesthetic agents at big enough doses for long enough cause damage to neurones; researchers are still trying to figure out what this means in actual human-type creatures.

It’s also an understandable response when you’re trying to fill in a space where there is only a hole. You need some sort of truth to fill the hole and researchers haven’t done much of a job of making sense of that space for those families. The research is starting to catch up though.

In May this year a group from Taiwan published the results of a retrospective review looking for any association between general anaesthesia and autism. They looked back through a health database including 114,435 patients and then sifted out the 5197 who had an anaesthetic before the age of 2. They then matched a bunch of features  of these individuals to a cohort of controls. Not just a few controls either – 20,788 of them. The plan was to then follow them out to 5 years of age to see what the rates of autistic spectrum diagnoses were during that time frame.

Why those time points? Well, it’s generally held that the exposure needs to be before the diagnosis, and that most vaguely related things should have declared themselves by the age of 5. It’s worth noting that kids having anaesthesia after the age of 2 could still be in the control group because the time critical exposure still hadn’t occurred.

So what did they find? No difference in rates of an autistic disorder. No difference with repeat exposure to anaesthesia or surgery either. Age at the first exposure to anaesthesia? That made no difference.

Will this settle the concerns? Probably not, but it’s a start.

It’s also not the only important connection that we need to look at more.

Making Connections

To get to the point where you can give the anaesthetic to a kid, it helps to make a connection that lets you find a better way there. Sometimes parents help with that. Sometimes we get there in the light of bubbles. Sometimes we have a song.

Other times I bring a rocket. Well I usually start with the mask for the space crew, and then we add the space gas. (You all know it’s called space gas because it makes you feel like you’re starting to float up into space, right?)

Floating is good but you need to fire up the rocket to really get going. And sometimes you can smell the fuel for the rocket, which is a little bit smelly. Not as smelly as the stars when you get right up there of course. Once you’re really travelling you can smell the stars because everyone forgets to wash them. Have you ever seen someone washing the stars?

And then you’re asleep.

A connection helps you share the story. So what about those kids who you really, profoundly fail to make those connections with?

Here's one of the rockets I sometimes bring to work. [via the NASA Apollo photos just released]

Here’s one of the rockets I sometimes bring to work. [via the NASA Apollo photos just released]

Time and Space 

For the clinical anaesthetist, the most pressing research we need is how to make the whole experience better. Kids in the autistic spectrum (and it’s a big spectrum so let’s just allow for a huge amount of variability in this discussion) can find the hospital environment challenging. Turning up for an operation is a pretty extreme microcosm of hospital care.

As the autistic spectrum is actually a big range of conditions you see a big range of personalities and behaviours. And fears.

Some kids with a diagnosis in the autistic spectrum will have a degree of intellectual disability. Plenty won’t. Some have changes to fine motor control or the way they walk. Some have significant anxiety issues. Some can’t cope with touch. Some self-harm, particularly at times of stress.

All of these are part of a couple of main groups of characteristics: social communication difficulties (the sort that make a space story not always that exciting)  and ritualistic and repetitive behaviours.

So plenty of these kids will find social interaction and understanding really challenging. And usually they might find solace in a stable environment or repetitive movements or focussing on special, quite intense interests.

Step back for a second and consider what we ask of kids when they come for an operation. A procedure they don’t always understand. A total disruption to their routine. A long time with no food and a slightly shorter time with no drink. A quick succession of new adults doing a bunch of things you might not have tried before then finally a trip to a small room with lots of monitors and things on the wall. Then a mask, dizziness and the smell. And at the end it’s all so quick.

Contrast that with the things we probably should do for a lot of kids in the autistic spectrum. Prepare them slowly. Establish familiarity beforehand. Make sure the perioperative team understand particular things that make this patient more or less anxious. No sudden introductions to an environment with huge amounts of new stimuli. Maintain a degree of routine. Perhaps a premedication to help get things going. Get out of there as quickly as possible afterwards.

Where is the connection between those two scenarios?

The hospital setting is almost purpose-built to fail a lot of these kids at every step along the way. And these facilities are being built and expanded all the time. We need to carve out space for a slow, quiet lane in care. The needs that can be served by quick forward movement are always pressing.

So there’s another connection in anaesthesia we need to make. More research into ways to make the experience better for autistic patients so we can argue for the things they need.

Maybe starting with a bit more time to make that trip to space.

References and Notes:

I looked at a few papers for this one but the most useful were these ones:

Ko, W-R, Huang, J-Y, Chiang, Y-C, et al. Risk of autistic disorder after exposure to general anaesthesia and surgery: A nationwide, retrospective matched cohort study. Eur J Anaesthesiology. 2015;32:303-10. 

Taghizadeh N, Davidson A, Williams K, Story D. Autism spectrum disorder (ASD) and its perioperative management. Pediatr Anesth. 2015;25:1076-84.

And for a story around autism this Radiolab episode, “Juicervose”, is an interesting listen. I’m sure it can’t cover the experience of all people and families with an autistic spectrum diagnosis, but it’s still worth the time.





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