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Rev. Bras. Anestesiol. vol.58 no.3 Campinas May/June 2008
Pacientes con secuelas de poliomielitis. ¿La técnica anestésica impone algún riesgo?
Daniela Pessini Sobreira RezendeI; Mônica Rossi RodriguesI; Verônica Vieira CostaI; Érika Carvalho Pires ArciII; Renato Ângelo Saraiva, TSAIII
IAnestesiologista do Hospital SARAH
IIEstatística do Hospital SARAH
IIICoordenador de Anestesiologia da Rede SARAH de Hospitais
BACKGROUND AND OBJECTIVES: Several questions arise before performing
neuro-axis block in patients with sequelae of poliomyelitis. Reports in the
literature are scarce. The objective of this study was to describe the anesthetic
techniques used in patients undergoing surgeries and possible complications.
METHODS: We undertook a retrospective study of patients with sequelae of poliomyelitis who underwent surgeries during a five-year period. Demographic data, physical status (ASA), onset of the disease, body part affected, diagnosis of post-poliomyelitis syndrome, surgeries and type anesthesia used, postoperative analgesia, intra- and postoperative complications, outpatient follow-up, and development of neurological changes were evaluated.
RESULTS: One-hundred and twenty-three patients who underwent 162 surgical procedures were evaluated. Most patients (n = 82; 66.6%) had neurological sequela in a lower limb. Patients developed acute poliomyelitis at approximately 28 months of age. Orthopedic surgery was performed in 87.7% of patients. Neuro-axis block was used in 64.1% of the cases; epidural block was more frequent. Intraoperative complications reported included: accidental puncture of the dura-mater (n = 1; 0.61%), bradycardia (n = 1; 0.61%), hypotension (n = 2; 1.23%), and apnea and thoracic rigidity (n = 1; 0.61%). Postoperative complications included: vomiting (n = 2; 1.23%), urinary retention (n = 4; 2.64%), and complex regional pain syndrome type I (n = 2; 1.23%). Patients were followed for 22 months and worsening of the neurological disorder was not observed.
CONCLUSIONS: Patients with sequelae of poliomyelitis who underwent neuro-axis block did not develop any postoperative complications or worsening of their neurological status that could be attributed to the anesthetic technique used.
Key Words: ANESTHETIQUE TECHNIQUES, Regional: epidural, subarachnoid; ANESTHESIA, General; DISEASES, Neurologic: poliomyelitis.
Y OBJETIVOS: Existe un cuestionamiento antes de la realización de
la técnica anestésica en el neuroeje en los pacientes con secuela
de poliomielitis. Los datos de la literatura son escasos. El objetivo de este
estudio fue describir las técnicas anestésicas realizadas en pacientes
sometidos a procedimientos quirúrgicos y a eventuales complicaciones.
MÉTODO: Estudio retrospectivo de pacientes con secuelas de poliomielitis, sometidos a operaciones, por un período de cinco años. Evaluados los datos demográficos, estado físico (ASA), inicio de la enfermedad, el segmento corporal acometido, diagnóstico de síndrome pos-poliomielitis, operación y anestesia realizadas, analgesia postoperatoria, complicaciones intra y postoperatorias, acompañamiento ambulatorial e incidencia de alteraciones neurológicas.
RESULTADOS: Evaluados 123 pacientes sometidos a 162 intervenciones quirúrgicas. La mayoría de los pacientes (n = 82; 66,6%) presentaba secuela neurológica en un miembro inferior. La poliomielitis aguda sucedió como promedio a los 2 años y 4 meses de edad. Se sometieron a operaciones ortopédicas 87,7% de los pacientes. La técnica anestésica en un 64,1% de los casos fue por bloqueo en neuroeje. El bloqueo epidural fue el más utilizado. Complicaciones relatadas: punción inadvertida de la duramadre (n = 1; 0,61%), bradicardia (n = 1; 0,61%), hipotensión arterial (n = 2; 1,23%), apnea y rigidez de tórax (n = 1; 0,61%) en el intraoperatorio. En el postoperatorio, vómitos (n = 2; 1,23%), retención urinaria (n = 4; 2,46%) y síndrome doloroso complejo regional tipo I (n = 2; 1,23%). El acompañamiento ambulatorial fue de 22 meses y no se observó un empeoramiento neurológico.
CONCLUSIONES: Los pacientes con secuela de poliomielitis, sometidos al bloqueo del neuroeje no presentaban ninguna complicación o empeoramiento neurológico en el postoperatorio que pudiese ser atribuido a la técnica anestésica.
Poliomyelitis (also called infantile paralysis or acute anterior poliomyelitis) is an acute viral infectious disease that can present in two forms: asymptomatic infection or paralytic disease. Poliomyelitis can cause permanent sequelae or lead to the death of the patient 1,2.
Paralytic disease is characterized by the sudden onset of flaccid paralysis associated with fever. It usually affects the lower limbs causing muscular flaccidity, a reduction or loss of neurological reflexes, and preserved sensitivity 1-4.
Patients with sequelae of poliomyelitis usually undergo several surgical procedures that need anesthesia and, most of the time those are orthopedic surgeries in which patients benefit from neuroaxis block to control postoperative pain. Anesthesiologists always question the use of neuroaxis block since patients already have neurological sequelae. In reality, disorders of the central (CNS) and peripheral nervous system constitute a relative counter indication to spinal blocks 5.
The objective of this study was to describe the anesthetic techniques used in patients undergoing surgeries and possible complications, emphasizing those related with the neuroaxis block.
After approval by the Ethics Committee of the hospital, the records of all patients with sequelae of poliomyelitis who underwent surgeries from 2000 to 2005 were reviewed.
Demographic data (age, gender, weight), physical status (ASA), age of onset of the disease and body part affected, the presence of a diagnosis of post-poliomyelitis syndrome, surgery performed, anesthetic technique used, type of postoperative analgesia, intra- and postoperative complications, duration of the follow-up, and the development or lack of new or progressive neurological changes were recorded on a standard case form.
One-hundred and twenty-three records of patients who underwent 162 surgeries were analyzed.
Patients had a mean age of 34.8 years and mean weight of 62.5 kg. The number of female patients (n = 78; 63.4%) was greater than male patients (n= 45; 36.6%). There was a slight predominance of physical status ASA II (n = 62; 50.4%), and the lower limb was affected more frequently (n = 82; 66.6%) (Table I).
The types of surgeries included orthopedic, plastic, neurosurgery, and general (Table II).
The mean age of onset of poliomyelitis was 28 months.
Patients received oral midazolam or diazepam as pre-anesthetic medication and were monitored with continuous electrocardiogram (ECG), non-invasive blood pressure (BP) and pulse oximetry. When general anesthesia was used, monitoring also included a capnograph, gas analyzer, and esophageal thermometer.
Table III shows the anesthetic techniques used.
Propofol and isoflurane were the drugs used more often for induction and maintenance when the patient underwent general anesthesia (n = 94). The majority of patients (n = 55) were ventilated through a laryngeal mask. Intravenous opioids were used in 41 surgical procedures and neuro-muscular blockers were used in 38 (Table IV).
Neuroaxis block (Table V) was used in 104 cases, and epidural block (simple or continuous) was the most frequent technique (n = 96).
In 30 patients, the epidural catheter remained in place for a mean of two days for postoperative analgesia. Continuous infusion of an analgesic solution of 0.1% bupivacaine with adrenaline associated with 3 or 5 µg.mL-1 of fentanyl was used. Three patients received spinal morphine for analgesia (0.1 mg). Six patients received patient controlled analgesia with intravenous morphine. The remaining 84 patients received "conventional" analgesia with common analgesics (dypirone, tenoxicam, paracetamol, tramadol, and morphine) intravenously followed by oral administration.
On neuroaxis blocks, 0.5% bupivacaine was the anesthetic used more often, associated with adrenaline only when administered epidurally. In 58 cases of epidural block, fentanyl without preservatives was associated with the local anesthetic. Patients undergoing only regional block received intraoperative sedation with midazolam associated or not with intravenous fentanyl.
Complications related to the anesthetic technique included: accidental puncture of the dura-mater with headache (n = 1; 0.61%), bradycardia (n = 1; 0.61%), hypotension (n = 2; 1;23%), apnea and thoracic rigidity after sedation (n = 1; 0.61%), vomiting (n = 2; 1.23%), urinary retention (n = 4; 2.46%), and complex regional pain syndrome type I (n = 2; 1.23%) (Table VI).
Three out of 123 patients (2.4%) were suspected as having post-poliomyelitis syndrome and underwent seven surgeries. Continuous epidural, combined epidural and subarachnoid, general, and regional intravenous block were the anesthetic techniques used in those patients, and complications were not reported (Table VII).
Patients were followed-up as outpatients for a mean of 22 months by the surgical and physical therapy departments. Neurological changes that could be related with the anesthetic technique used were not observed.
There are very few reports in the literature on anesthesia in patients with sequelae of poliomyelitis. This is probably the reason why some anesthesiologists hesitate to indicate neuroaxis blocks to patients with muscular deficits, worrying about the risk of exacerbating preexisting disorders or the difficulty to evaluate possible complications 3. A few factors contribute to justify their caution, including increased risk of mechanical trauma by the needle or catheter, toxicity of the local anesthetic, neural ischemia secondary to epinephrine, patient predisposition, and medical-legal implications 5,6. However, it is not clear whether those risk factors were associated with neurological deterioration in patients with preexisting neurological disorders 5.
In the present study, patients were already followed regularly at the outpatient clinic and, therefore, had a diagnosis including diagnostic tests before pre-anesthetic evaluation. Evaluation of 104 patients who underwent neuroaxis block, neurological complications and worsening of the preoperative disorder related to the anesthetic technique were not observed. Only one patient, a 37-year old female, 47 kg, with sequel of poliomyelitis in the lower limbs and scheduled for an orthopedic foot surgery developed dyspnea and thoracic rigidity after continuous epidural block, sedation with midazolam (3 mg), and fentanyl (100 µg), which was treated with succinylcholine and tracheal intubation. Some authors argue that poliomyelitis increases the risk of chronic hypoventilation and sleep apnea, which are usually reported in association with the post-poliomyelitis syndrome. One can consider that this condition increases the risk of intra- or postoperative respiratory failure after sedation or analgesia with opioids, regardless of whether the patient has thoracic deformities or not, motor deficits, or prior respiratory symptoms 7,8.
There is a report in the literature of a 51-year old patient with sequela of poliomyelitis who underwent foot surgery under general anesthesia and postoperative analgesia with subcutaneous morphine, who developed respiratory arrest in the room 60 minutes after the surgery. The patient was resuscitated, but had brain lesion. This episode was attributed to marked sedation by the administration of opioids in a patient who could possibly have sleep apnea 3,7.
Another report described the case of 79-year old patient, who developed postoperative respiratory failure, which was deemed secondary to undiagnosed post-poliomyelitis syndrome 3,9.
Several survivors of acute poliomyelitis (28.5% to 64%) are susceptible to the development of post-poliomyelitis syndrome 25 to 35 years after the initial infection 7,10. Diagnostic criteria for the diagnosis of post-poliomyelitis syndrome includes: history of paralytic poliomyelitis with residual motor deficit; a period of neurological recovery followed by an interval (15 years or more) of neurological and functional stability; sudden or gradual onset of new muscular weakness or abnormal muscular fatigue, muscular atrophy, or generalized fatigue; and exclusion of clinical, orthopedic, and neurologic conditions that could cause those symptoms 3,10. Patients with post-poliomyelitis syndrome may have altered respiratory function, chronic pain syndromes, cold intolerance, risk of aspiration, and increased sensitivity to anesthetics (induction drugs, inhalational anesthetics, neuromuscular blockers, and opioids) 3,5,11. Three patients with a diagnosis of post-poliomyelitis syndrome who participated in the present study underwent different anesthetic techniques (continuous and simple epidural block, subarachnoid block, general anesthesia, and regional intravenous block), since they underwent several surgeries, and they did not develop any intra- or postoperative complications.
There is a great debate on the causes of post-poliomyelitis syndrome. Overload or premature aging of motor units affected by poliomyelitis are the reasons accepted by most experts. Other possible reasons include: musculoskeletal disuse; normal loss of residual motor units; vascular or glial changes that predispose patients to premature degeneration of motor neurons; persistent infection or viral reactivation; and normal reduction in growth hormone levels 3.
Recently, a prospective study of patients with a history of CNS disorders undergoing spinal anesthesia or analgesia from 1988 to 2000 was published. One-hundred and thirty-nine (n = 139) patients were identified. Subarachnoid block with bupivacaine with adrenaline was the anesthetic technique used more often (53%). Post-poliomyelitis syndrome was the central nervous disorder more frequent (n = 79; 56%). New neurologic deficits or worsening of existing deficits were not observed 5.
In the present study, two patients had a diagnosis of complex regional pain syndrome type I (CRPS I) in the late postoperative period. A 42 years old female patient who underwent triple arthrodesis of the left foot under continuous epidural block, remained on epidural analgesia for 24 hours and, on the 12th postoperative day developed cellulitis and afterwards CRPS I. After one year of medical treatment her symptoms subsided. Another 52 years old female patient who underwent surgery of the flexor foot retinaculum of the right foot under venous regional block and developed, on the 18th postoperative day, early symptoms of CRPS I; treatment was instituted immediately with improvement of symptoms. It is unlikely that the anesthetic technique employed was somehow related with the complications developed in the late postoperative period. It has been already established that regional blocks can be an effective technique to prevent and treat CRPS I after orthopedic surgeries 12-15.
Other complications observed (headache after accidental puncture of the dura-mater, bradycardia, hypotension, vomiting, and urinary retention) are also observed in patients with no neurologic deficits.
The decision to use general anesthesia or regional bock should be based on the evaluation of the risk/benefit ratio of each technique 5,16. There are very few reports in the literature on anesthesia in patients with sequelae of poliomyelitis and there are no reports on the adverse effects of regional block in those patients, but this does not necessarily exempt regional block of risks 3.
Besides rigorous monitoring in the immediate postoperative period, the anesthesiologist should undertake careful preoperative evaluation of patients with sequelae of poliomyelitis, including details of the acute disease, record of baseline deficits, as well as the possibility of post-poliomyelitis syndrome in those patients 3. It is also important to determine the presence of sleep apnea, and symptoms suggestive of dysphagia and gastroesophageal reflux.
We concluded that patients with sequelae of poliomyelitis who underwent surgical procedures from 2000 to 2005 were exposed to different anesthetic techniques in which neuro-axis block was more frequent (n = 104; 64.1%), associated with general anesthesia or not, and worsening of their neurological condition that could be attributed to the anesthetic technique used was not observed.
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Correspondence to: Submitted em 14
de maio de 2007 * Received from
Hospital SARAH, Brasília, DF
Dra. Daniela Pessini Sobreira Rezende
SQS 315 Bloco D Apt. 506 Asa Sul
70384-040 Brasília, DF
Accepted para publicação em 19 de fevereiro de 2008
Submitted em 14
de maio de 2007
* Received from Hospital SARAH, Brasília, DF