polio, postpolio syndrome and anesthesia
TRANSCRIPT
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 1/35
POLIO, POSTPOLIO SYNDROMEAND ANESTHESIA
Martha Richter, MSN, CRNA
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 2/35
POLIO
Objectives
review the disease of polio
Review the occurrence of post poliosyndrome
Recognize impact of these processes onchoice of safe anesthesia care planning
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 3/35
WHAT IS POLIO?
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 4/35
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
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 5/35
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
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 6/35
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
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 7/35
Polio
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 8/35
POLIO
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 9/35
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
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 10/35
POLIO
95% MINOR OR NO SYMPTOMS
5 % flu-like symptoms, slighttemporary paralysis
1% with symptoms Paralytic polio
2-5% children die
10-20% adults die http://americanhistory.si.edu/polio/americanep
i
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 11/35
POLIO
HUMANS ARE THE ONLY RESERVOIRFOR THE VIRUS!
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 12/35
POLIO
Enters body through intestines
Invades motor neurons via specificreceptors 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
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 13/35
POLIO
Unpredictable degree of paralysis
Regeneration process with
reinnervation=remodeling Large “motor unit” is formed
New axon growth (“sprouting”)
Enlargement of muscle cells
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 14/35
POLIO
Through remodeling, strength issteadily regained
Patients feel “cured”
Resumption of normal life
20 MILLION people have lifetimedisability
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 15/35
POLIO
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 16/35
POLIO
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 17/35
POST POLIO SYNDROME
Subtle and insidious
Diagnosis of exclusion
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 18/35
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
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 19/35
POST POLIO SYNDROME
GENERAL CONSENSUS
More severe initial paralysis and greatestfunctional recovery are having more
issues
15 years or more since “recovery”
Incidence peaks 30-34 yrs after acute
illness
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 20/35
POST POLIO SYNDROME
EMG chronic denervation
SFEMG changes consistent with
active denervation May include new muscle groups
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 21/35
POST POLIO SYNDROME
Diagnosis by exclusion
Arthritis
Disuse of muscles
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 22/35
POST POLIO SYNDROME
Theories:
Overburdening of axons with increasednumber of terminals
Normal aging influence
More rapid deterioration because of alreadyreduced number of neuromuscular
junctions
Overuse/underuse of muscles
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 23/35
POST POLIO SYNDROME
THEORIES
Damage to anterior horn motor
neurons leave them smaller thannormal (damaged) = fail earlier
Poliovirus persistence in body
Dormant
reactivation
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 24/35
POST POLIO SYNDROME
Treatment “bracing and pacing”
Use of canes, wheelchairs Remain as active as possible with
support as needed
Regular rest
Antidepressants pyridostigmine
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 25/35
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
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 26/35
THE SURVIVORS
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 27/35
NEW CASES
1959 1995
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 28/35
NEW CASES
WHO
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 29/35
ANESTHESIA AND A HISTORYOF POLIO
Usual “head to toe” evaluation
Co morbidities and status
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 30/35
ANESTHETIC CONSIDERATIONS
ANTICIPATE
“exquisite sensitivity” to sedatives
May have delayed emergence
Thought to be due to damage to reticularactivating system
Increased sensitivity to muscle relaxants
Less neurons to block
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 31/35
ANESTHETIC CONSIDERATIONS
Higher sensitivity to pain
Especially in paralyzed limbs
Possibly b/o damage to “endogenous
opioid-secreting cells in brain and spinalcord”
Stoelting & Dierdorf
http://www.post-polio.org
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 32/35
ANESTHETIC CONSIDERATIONS
Postop back pain
Scoliosis
Postop shivering Cold sensitivity
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 33/35
THE FUTURE
Massive global immunizationprograms
Vaccines now being manufactured inIndonesia to satisfy Muslim countries
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 34/35
THE FUTURE
Global cases 2006
1988
Endemic countries 1862
Non endemic countries 126
7/28/2019 Polio, Postpolio Syndrome and Anesthesia
http://slidepdf.com/reader/full/polio-postpolio-syndrome-and-anesthesia 35/35
2006 global cases
Pakistan 40 Kenya 2
Nigeria 1119 Ethiopia 17
India 672 Bangladesh 17
DRC 12 Niger 11
Somalia 36 Nepal 4
Chad 1 Indonesia 2
Angola 2 Yemen 1