Introduction

Every anesthesiologist has encountered a patient whose reactions appear “disproportionate” to the situation—
a child who fights the mask with surprising strength,
an adult who becomes silent or withdrawn without warning,
a teenager whose pain expression feels puzzlingly out of sync with clinical findings.

These are not behavioral quirks. These are neurobiological signatures of the autistic brain.

Autism Spectrum Disorder (ASD) represents a distinct neurodevelopmental configuration. Its sensory pathways, predictive systems, autonomic responses, and neurochemical networks follow patterns that differ from neurotypical physiology. For anesthesia practice, this means that the perioperative environment, transitions, communication, and drug effects interact differently with this neurobiology.

The goal of this chapter is to integrate basic science, clinical fundamentals, and compassionate practice into a coherent framework that is academically rigorous yet deeply human-centered.

1. Predictive Coding: The Architecture That Governs Stress and Cooperation

The brain is fundamentally a prediction engine. It continually attempts to minimize “prediction error”—the mismatch between expected and actual sensory input.

In ASD:

• Predictions are narrower and more precise.

• Incoming sensory data carries more weight.

• Small mismatches produce disproportionately large autonomic responses.

Clinical meaning

Unannounced touch, sudden mask placement, or abrupt movement triggers limbic activation, cortisol release, and sympathetic surges—not because the patient is “difficult,” but because the predictive model has been violated.

Understanding this transforms clinical care:
the anesthesiologist’s greatest asset is not pharmacology, but predictability.

2. Sensory Hyperacuity: High-Gain Input in a Low-Noise System

Many autistic individuals experience an amplified sensory world:

• Visual cortex shows stronger responses to light.

• Auditory cortex exhibits heightened gain for sudden sounds.

• Tactile pathways show reduced habituation.

• Thalamic filtering is less efficient.

This creates a bandwidth–noise imbalance: the sensory system receives too much high-fidelity data and too little suppression.

CLINICAL CONSEQUENCES

• A cold stethoscope feels disproportionately painful.

• The OR’s beeping monitors accumulate into overwhelming auditory load.

• Bright overhead lights “flood” visual cortex and increase stress.

• Light touch (mask, ECG electrodes) may be perceived as intrusive or threatening.

This is why sensory-adapted anesthetic care is not a courtesy—it is physiology-driven medicine.

3. Autonomic Nervous System: The Fragile Symmetry of Arousal

Autonomic instability is one of the most clinically relevant aspects of ASD.

Neurophysiological studies reveal:

• Lower baseline vagal tone

• Exaggerated sympathetic surges

• Slower return to autonomic baseline after distress

• Heightened amygdala–locus coeruleus signaling loops

CLINICAL RELEVANCE

Expect:

• Tachycardia during mask induction

• Hypertension with environmental overstimulation

• Movement in response to unexpected touch

• Prolonged agitation during...