When Standard Sedation Is Not Enough: A Stepwise Anesthetic Approach for Outpatient IUD Placement in a Nonverbal Autistic Adolescent

Background

Sensory hypersensitivity, anxiety, and difficulty communicating distress can make routine perioperative care especially difficult for patients with autism spectrum disorder (ASD). Pediatric ASD-specific sedation protocols have grown substantially in recent years, particularly dexmedetomidine-based and family-centered approaches for brief diagnostic procedures in younger children. However, most existing protocols address brief, single-encounter procedures in young children, commonly diagnostic imaging, rather than adolescents or reproductive health care. As nonverbal autistic patients age into adolescence, they still require routine reproductive healthcare, yet anesthesia teams have little established precedent to draw on for this population and procedure type. This case presents a stepwise IM-to-inhaled-to-IV sedation strategy developed to help close that gap.

Case Presentation

A 15-year-old nonverbal female with ASD, obesity (103 kg, ASA II), and a history of severe procedural anxiety presented for examination under anesthesia and levonorgestrel IUD placement. Previous IV access attempts had failed due to escalating distress. To prevent further agitation, she received IM midazolam 2 mg and ketamine 100 mg prior to entering the operating room, then was induced with inhaled nitrous oxide, enabling successful IV cannulation. IV induction was completed with propofol 300 mg, dexmedetomidine 24 mcg, and lidocaine 60 mg. A laryngeal mask airway was placed without difficulty. Analgesia included acetaminophen, ketorolac, dexamethasone, and ondansetron.

Results

Intraoperative parameters remained largely stable (heart rate 75 to 123 bpm; MAP 65 to 95 mmHg; SpO2 95 to 100%; ETCO2 37 to 45 mmHg). The patient emerged smoothly without agitation and was discharged home the same day. Critically, the staged IM-to-inhalational approach succeeded where direct IV attempts had previously failed, demonstrating that sequencing, not just drug selection, was the key variable in achieving safe, low-distress access.

Discussion & Conclusion

This case offers a concrete, reproducible sedation sequence tailored to a population and procedure type, adolescent and outpatient gynecologic, largely absent from current ASD anesthesia literature. The propofol-dexmedetomidine combination supported hemodynamic stability and calm emergence, reinforcing dexmedetomidine's role in minimizing emergence agitation in this population. A tailored, multimodal anesthesia approach can enhance procedural success, patient comfort, and perioperative stability in nonverbal autistic adolescents undergoing outpatient gynecologic or other invasive procedures. Development of standardized sedation pathways for neurodivergent adolescents remains an important need.