"Anaesthesia
Issues for Post Polio Patients"
Written by
Tessa Jupp RN (from a paper by Dr Selma Harrison Calmes MD) for the Post Polio
Network of WA
Many of us are having to face surgery as we are
getting older and there is a small pack of papers we send out for you to give
to your surgeon, anaesthetist and hospital staff if this is the case.
It is opportune that at the recent
International Warm Springs Polio Conference held in USA in April 2009, a paper
was presented by Dr Selma Harrison Calmes MD, an anaesthetist with much
experience in post polio. Mary-ann
Liethoff from Post Polio in Victoria attended this conference and notes have
been distributed to all states via Polio Australia.
Dr Calmes writes that in the absence of any
significant published information, these points are based on her clinical
experience and ideas developed after extensive study of polio and post polio
syndrome.
1. Post polios are nearly always very
sensitive to medications that sedate them and it may take longer to emerge
from sedation. It is probably due to
changes in nerve cells in the brain due to polio, especially in the Reticular
Activating System.
2. Muscle relaxants (particularly
non-depolarising) can cause loss of function for a longer time in post
polios. It is recommended that only half
the usual dose is used. More can be
added if necessary.
The polio virus has caused extensive changes in
neuromuscular junctions, even in seemingly normal muscles resulting in greater
sensitivity. Careful monitoring is needed to prevent overdose which is a
frequent problem. The significant
decrease in total muscle mass due to polio is a contributing factor as drugs
are taken up by muscle
3. Succinylcholine should be avoided as
it often causes severe generalised muscle pain post op.
4. Pain after surgery is often
significant due to the inflammatory response and pain pathways can be affected
by the original poliovirus.
5. Polio often affects the normal functioning of
the autonomic nervous system, leading to gastro-oesopageal reflux, fast
heart beat and difficulty maintaining blood pressure with anaesthetics.
6. Polios who used or nearly needed iron lungs,
or who now have sleep apnoea and/or use respiratory assistive devices, need
full respiratory evaluation tests before having anaesthetic. Their respiratory physician should be
involved in the pre-op and post-op care plans for these patients and provision
for ICU care post op should be made.
7. Muscle weakness from polio can cause
swallowing and laryngeal problems which can be worsened by intubation or upper
extremity blocks.
8. Body asymmetry due to polio can cause
difficulty in positioning on the operating table. Nerve damage can occur as well as fractures. Possible peripheral nerve damage is more
likely with longer times in surgery.
Loss of muscle and tendon bulk due to polio offers less protection.
9. Spinal anaesthetics and epidurals
should be considered with caution as recent studies have shown inflammatory
cytokines in the CNS of polios
Many polios have atrophied peripheral nerves
and exposure to local anaesthesia, especially for long periods should be
avoided or smaller doses given.
Supraclavicular and interscalene blocks of the
upper body puts diaphragmatic paralysis at high risk and should probably not be
used for polios.
SUMMARY
Polio patients can have anaesthesia and surgery
safely, with careful preparation. For an
optimal outcome, ALL aspects must be considered at high levels of performance. Few surgeries are truly urgent and there is
usually time to get data from the web and reputable polio clinics like that of
Dr Calmes at UCLA.
Take time to research the operation, the need
for it, the consequences and to prepare adequate and informed post-op options
for best recovery for the patient.
The usual post surgery recovery and
rehabilitation expectations may need to be revised taking into account the
consequences of polio on the patient’s physical anatomy, muscle strength
and ability, central nervous system, pain management, the immune system and
systemic inflammatory processes.
HELPFUL RESOURCES
1. Post Polio Health International: Dr Selma
Calmes see at www.post-polio.org/ipn/anes.html
2. “Post Polio Syndrome and Anaesthesia”
by David Lambert MD et al, University of Manitoba, Winnipeg, Canada in the Sept
2005 issue of Anesthesiology (Vol. 103, No. 3, pp 638—644) see at http://journals.lww.com/anesthesiology/Fulltext/2005/09000/Postpolio_Syndrome_and_Anesthesia.29.aspx