Combination of Oral Clonidine and Midazolam as Premedication When Ketamine is not an Option in an Uncooperative Autistic Patient

Abstract

Autism spectrum disorder is a neurodevelopmental disorder with qualitative abnormalities in reciprocal social interaction and patterns of communication. Patients with autism, or an autism spectrum disorder (ASD), are sometimes difficult to manage from an anesthetic perspective because they may become scared, or at least very inquisitive of what is, and what will be happening to them. In the pre-operative holding they may become agitated, self-destructive, or resistant because it is a change in their normal routine; sometimes leading them to refuse to cooperate during induction. If such behaviors are observed, or expected based on the preoperative evaluation and/or the conversation with the parent or caregiver, a premedication should be considered. Depending on the severity of the displayed or expected behavior, the premedication options at our institution often range from none, midazolam, or a combination of benzodiazepines and ketamine. However, there are cases where ketamine cannot be used (e.g., prior adverse event, allergy), thus alternative options are needed. We present a case report of a 22 yearold patient with severe autism who responded to a premedication combination of oral clonidine and midazolam, given due to a previous adverse reaction to ketamine.