Information & Resources
Anaesthesia and Down Syndrome
Overview
Down syndrome is associated with a wide spectrum of anatomical, physiological, and neurodevelopmental differences. Individuals vary significantly in their abilities, vulnerabilities, and medical needs. A tailored, person-centred approach is essential.
Communication
Speak directly to the patient wherever possible. Use accessible language, visual aids, and repetition. Recognise that communication may be non-verbal, and that familiar carers are often the best source of insight into what works for the individual patient.
Hospital passports or “About Me” documents contain vital information about communication preferences, anxiety triggers, behavioural support needs, and medical history.
Reasonable adjustments and capacity
The hospital learning disability team can support the creation of social stories, provide advice on communication strategies, and help advocate for reasonable adjustments in care. Consent and capacity should be carefully assessed, and best-interest discussions held where needed. Maintaining access to hearing aids, glasses, and other communication supports is essential. Predictability and preparation can significantly reduce distress and improve cooperation.
Consider opportunistic investigations under anaesthesia — such as blood tests, imaging, or hearing assessments — particularly where cooperation is difficult when awake.
Preoperative Considerations
Cardiac
- Up to 60% of individuals with Down syndrome have some form of congenital heart disease, most commonly AVSDs.
- Pulmonary hypertension (PH) is significantly more common at all ages.
- Consider echocardiogram and liaison with cardiology.
- Autonomic nervous system dysfunction may have intraoperative implications and can influence baseline cardiovascular status and stress responses.
Airway and Respiratory
- Increased risk of airway obstruction and perioperative respiratory complications due to structural and functional airway differences.
- Obstructive sleep apnoea (OSA) is common.
- Respiratory tract infections are more frequent, prolonged, and severe.
- Increased risk of aspiration.
Cervical Spine
- Craniovertebral instability occurs in up to 30% of individuals with Down syndrome on imaging (most often atlantoaxial), although only 1–2% develop neurological symptoms.
- Routine screening not recommended in asymptomatic individuals.
- Ask about neck pain, reduced mobility, gait disturbance, or incontinence at preoperative assessment.
- Intraoperatively, a neutral neck position should be maintained, and head and neck movements minimised.
Gastrointestinal
- Delayed gastric emptying and gastro-oesophageal reflux are common.
- Constipation is common and may worsen perioperatively.
Metabolic
- Higher incidence of diabetes (type 1 and type 2).
- Obesity more common.
Neurodevelopment and behaviour
- Cognitive and behavioural profiles vary widely.
- Consider the need for visual supports, involvement of familiar carers, and play specialist input.
- Consider a quiet recovery area and/or early access for carers.
- Increased risk of Alzheimer’s disease from the age of 40.
Intraoperative considerations
Induction
- A smaller-than-expected endotracheal tube (typically 0.5–1.0 mm smaller) is often required due to subglottic stenosis and shorter tracheal length.
- Consider video laryngoscopy.
- A neutral neck position throughout airway management is essential, especially if atlantoaxial instability is known, suspected, or unassessed.
- Children with Down syndrome may be more prone to bradycardia during sevoflurane induction, likely due to altered autonomic tone.
- Vascular access may be challenging due to body habitus, joint laxity, or cooperation difficulties.
Maintenance
- There may be lower MAC requirements due to altered neurophysiology.
- Depth of anaesthesia monitoring (e.g. BIS) may help avoid under- or over-sedation, particularly in adults with cognitive impairment or dementia.
- Joint laxity, short stature, and hypotonia increase the risk of injury in positioning.
- Cervical spine should remain in a neutral position throughout.
Emergence and recovery
- Recovery areas should be calm and quiet, with minimal sensory stimulation.
- Arrange early access for familiar carers wherever possible.
- Patients with OSA, hypotonia, or reflux are at higher risk of post-extubation obstruction or desaturation.
- Ensure prompt return of hearing aids, glasses and communication devices.
Postoperative care
Airway and breathing
- Higher risk of postoperative airway obstruction.
- Consider use of nasopharyngeal airways, high-flow oxygen, or non-invasive ventilation in those with OSA or significant hypotonia.
Pain and behaviour
- Pain often under-recognised in those with limited verbal communication.
- Use visual pain scales where possible and seek input from carers.
- Agitation may reflect pain, sensory distress, or confusion.
- Opioids should be used cautiously and balanced with other analgesic strategies. Co-prescribe laxatives.
Level of monitoring
- HDU or enhanced recovery may be appropriate for some.
- Minimise unfamiliar stimuli, enable access to carers, and maintain routine and predictability in the postoperative setting.
Additional Resources
“Anaesthesia and Down syndrome: An Overview”
Dr Anna Petsas, Consultant Anaesthetist, University College London Hospitals
Foundation Trust, July 2025
“Anaesthetic management of children and adults with trisomy 21” Paediatric Anaesthesia, 2024 DOI: 10.1016/j.pae.2024.04.005
“Anaesthesia and adults with Down syndrome: implications for general hospitals” The Lancet, 2017 DOI: 10.1016/S1474-4422(17)30042-0
“Anaesthetic management of children with Down syndrome” Anaesthesia, 2017 DOI: 10.1016/j.bja.2017.03.004