Modern anesthesia has become extremely safe, but many survivors fear it because of reports of problems during and after anesthesia. Potential problems include a greater sensitivity to paralyzing drugs (muscle relaxants), possible need for mechanical ventilation after surgery, and pain problems after surgery. All survivors, especially those with a history of respiratory involvement, need to tell their surgeon and anesthesiologist about having had polio (Calmes, 1997). The surgeon can help facilitate appropriate care by identifying the patient as a post-polio patient when the case is scheduled.
The kind of anesthesia chosen – general, regional, or monitored anesthesia care – depends on what operation/procedure is being done, the individual’s medical conditions and desires, and the skills of the anesthesiologist and surgeon. There are theoretical reasons to choose regional anesthesia (for example, nerve blocks, epidural and spinal anesthesia) if possible because it decreases the stress hormone response to surgery (Barker et al., 1995). Planning the proper anesthesia can only take place after the anesthesiologist learns of the survivor’s medical problems and takes into consideration the treatment plans for the period after surgery, such as whether mechanical ventilation might be needed, and how pain will be treated.
Past reports of not being able to reverse older muscle relaxants have contributed to the fear of general anesthesia. Polio survivors are very sensitive to muscle relaxants because they have fewer neurons to block (Gyermek, 1990). The muscle paralyzing drug, curare, is rarely used today. Anesthesiologists now choose from better and more controllable muscle relaxant drugs and routinely measure each person’s response to muscle relaxants using a nerve stimulator. A safe approach is for the anesthesiologist to use only half the normal dose at first and see how the individual does. More anesthetic muscle relaxant can be added, if needed, and the possibility of overdose is decreased.
No published study documents anesthesia problems in polio survivors. However, some survivors have thought that their typical post-polio symptoms became worse after regional anesthesia. If spinal anesthesia is used, the current recommendation, for the general population as well as survivors, is to use the local anesthetic bupivacaine instead of lidocaine. There are reports of possible nerve damage with lidocaine. However, it is considered to be safe for dental anesthesia and epidural anesthesia.
Post-operative mechanical ventilation may be necessary to help with breathing after surgery, especially major surgery. More common in the survivor who currently uses mechanical ventilation or needed it in the past, post-operative mechanical ventilation allows the lungs time to recover from the effects of surgery and anesthesia.
Many survivors seem to be very sensitive to pain, particularly in long-paralyzed limbs, and to need additional pain medicine post-operatively. It is important that post-operative pain management be planned. A combination of approaches often works best. The surgeon can inject local anesthetic at the surgical site; the anesthesiologist can give pain medication, so it is working when the individual awakens; and the patient can be given continuous infusions of pain medications that can be self-adjusted.
One of the most important decisions related to surgery is where the operation should take place. Questions to ask include:
- Does the hospital have a surgical team with experience in caring for polio survivors or people with neuromuscular disease?
- Is the ICU available if post-operative mechanical ventilation is needed?
- Is the anesthesiologist available ahead of time and does he/she show concern for post-polio problems?
- Does the anesthesiologist measure neuromuscular transmission routinely and will he/she in this case?
- Does the surgeon seem aware of possible post-operative problems from polio (and possible needed alternatives to going directly home?)
- If the procedure is going to be performed in a free-standing surgical center or as “day surgery,” ask if you can be one of the first cases scheduled for the day. This allows you the maximum time to be monitored and recover before being discharged.
Major medical centers with academic training programs in anesthesiology and an affiliated rehabilitation unit most often meet these criteria. People with fewer post-polio problems might be considered for surgery in an outpatient surgery unit, if it met the criteria above and if the individual has assistance at home after being discharged (see Hospitalization).
One should expect to see the anesthesiologist before having elective surgery (often, this occurs as a phone call on the day/evening prior to surgery or in the pre-operative holding area just prior to the procedure, but you have the right to ask for an in-person consultation in the days prior to the planned procedure) to discuss one’s health and concerns about anesthesia. If an individual is unable to communicate, it is important that an advocate who knows the potential problems speak with the anesthesiologist. If the anesthesiologist for either elective or emergency surgery does not seem to show proper concern, the individual has the right to refuse surgery until he or she is comfortable with the relationship. However, emergency operations are more difficult because there is little time to plan (see Hospitalization, Emergency).
For any surgery, polio survivors should be in the best possible health pre-operatively.
References
Barker, J.P., Robinson, P.N., Vafidis, G.C., Burrin, J.M., Sapsed-Byrne, S., & Hall, G.M. (1995). Metabolic control of non-insulin-dependent diabetic patients undergoing cataract surgery: Comparison of local and general anaesthesia. British Journal of Anaesthesia, 74(5), 500-505.
Calmes, S.H. (1997). Anesthesia concerns for the polio survivor. Polio Network News, 13(2), 1-2.
Gyermek, L (1990). Increased potency of nondepolarizing relaxants after poliomyelitis. Journal of Clinical Pharmacology, 30, 170-173.