POLIO, POSTPOLIO SYNDROME AND ANESTHESIA

Martha Richter, MSN, CRNA

POLIO
Objectives
review the disease of polio Review the occurrence of post polio syndrome Recognize impact of these processes on choice of safe anesthesia care planning

WHAT IS POLIO?

POLIO
A VIRUS Known to occur prior to recorded time 1789 described in Britain 1894 first U.S. outbreak 1908 identified as virus 1916- first large outbreak U.S.
http://americanhistory.si.edu/polio/timeline/in dex.htm

POLIO
1921-FDR contracts disease 1929-iron lung developed 1930s distinguished 3 viruses 1938 March of Dimes 1953 Salk vaccine developed
Oral live virus

1955 trials deemed successful (US)

http://americanhistory.si.edu/polio/timeline/inde x.htm

POLIO
1957-59 Sabin trials in Russia 1962 Sabin vaccine instituted
Killed virus Cheaper, easier to administer

1979 last wild case in US

Amish community

1980s postpolio syndrome 1999 inactivated replaces oral in US

http://americanhistory.si.edu/polio/timeline/inde x.htm

Polio

POLIO

POLIO
Initially children were infected
Infantile paralysis

Epidemic of 1934
Los Angeles 5% MDs, 11% nurses infected

By 1940s-50s, 1/3 were adults

52,628 cases in US
http://americanhistory.si.edu/polio/americanepi

POLIO
95% MINOR OR NO SYMPTOMS 5 % flu-like symptoms, slight temporary paralysis 1% with symptoms
Paralytic polio 2-5% children die 10-20% adults die
http://americanhistory.si.edu/polio/americanep i

POLIO
HUMANS ARE THE ONLY RESERVOIR FOR THE VIRUS!

POLIO
Enters body through intestines Invades motor neurons via specific receptors at neuromuscular junction Migrates up axon to nerve cell body Eventually infects anterior horn of spinal cord, brain, and approx 95% motor neurons
L. Halstead, 1998

POLIO
Unpredictable degree of paralysis Regeneration process with reinnervation=remodeling
Large motor unit is formed New axon growth (sprouting) Enlargement of muscle cells

POLIO
Through remodeling, strength is steadily regained Patients feel cured Resumption of normal life 20 MILLION people have lifetime disability

POLIO

POLIO

POST POLIO SYNDROME

Subtle and insidious Diagnosis of exclusion

POST POLIO SYNDROME

Fatigue over course of day New weakness with muscle atrophy Muscular/joint pain Difficulty sleeping Difficulty breathing Difficulty swallowing Poor cold tolerance Unable to perform normal daily activities of living

POST POLIO SYNDROME

GENERAL CONSENSUS
More severe initial paralysis and greatest functional recovery are having more issues 15 years or more since recovery Incidence peaks 30-34 yrs after acute illness

POST POLIO SYNDROME

EMG chronic denervation SFEMG changes consistent with active denervation May include new muscle groups

POST POLIO SYNDROME

Diagnosis by exclusion
Arthritis Disuse of muscles

POST POLIO SYNDROME

Theories:
Overburdening of axons with increased number of terminals Normal aging influence
More rapid deterioration because of already reduced number of neuromuscular junctions Overuse/underuse of muscles

POST POLIO SYNDROME

THEORIES Damage to anterior horn motor neurons leave them smaller than normal (damaged) = fail earlier Poliovirus persistence in body
Dormant reactivation

POST POLIO SYNDROME

Treatment
bracing and pacing
Use of canes, wheelchairs

Remain as active as possible with support as needed Regular rest Antidepressants pyridostigmine

HOW DOES THIS AFFECT US?

1995 SURVEY
1,000,000 survivors 433,000 paralytic survivors
US statistics
http://www.post-polio.org/ipn/ir-usa.html

THE SURVIVORS

NEW CASES
1959 1995

NEW CASES
WHO

ANESTHESIA AND A HISTORY OF POLIO

Usual head to toe evaluation Co morbidities and status

ANESTHETIC CONSIDERATIONS
ANTICIPATE
exquisite sensitivity to sedatives May have delayed emergence Thought to be due to damage to reticular activating system Increased sensitivity to muscle relaxants Less neurons to block

ANESTHETIC CONSIDERATIONS
Higher sensitivity to pain Especially in paralyzed limbs Possibly b/o damage to endogenous opioid-secreting cells in brain and spinal cord
Stoelting & Dierdorf http://www.post-polio.org

ANESTHETIC CONSIDERATIONS
Postop back pain
Scoliosis

Postop shivering
Cold sensitivity

THE FUTURE
Massive global immunization programs Vaccines now being manufactured in Indonesia to satisfy Muslim countries

THE FUTURE
Global cases 2006
1988 Endemic countries 1862 Non endemic countries 126

2006 global cases

Pakistan Nigeria India DRC Somalia Chad Angola 40 1119 672 12 36 1 2 Kenya 2 Ethiopia 17 Bangladesh 17 Niger 11 Nepal 4 Indonesia 2 Yemen 1