Polio and the Science of Inducing Sleep

| TIPS AND TECHNIQUES FOR POLIO SURVIVORS

By Dr. Richard L. Bruno

I’ve talked here recently about drugs that make polio survivors sleepy. But, I haven’t discussed medications that are intended to put polio survivors to sleep.

In our 2000 Post-Polio Survey, 237 polio survivors told us about complications after receiving anesthesia. Polio survivors’ biggest problem reported was being excessively sedated after being “put under.” Just over half told us that they were snowed after receiving a general anesthetic and 43% said that they were overly sedated when they had an endoscopy or colonoscopy, sometimes with frightening results: “It took two days to awaken from the general anesthetic after a hysterectomy,” one respondent reported. “ It took probably six weeks to feel fully awake.”

After a colonoscopy, another respondent said, “I was in the recovery room at 10:00 a.m. but didn’t wake up until 6:00 p.m. I was very frightened and very sleepy. But the nurses made me leave, even though I was not fully awake, and were angry because it would prolong their workday if they had to put me in the hospital.”

The 2000 Survey also found that 20% of polio survivors had difficulty breathing after receiving general anesthesia, in part because breathing neurons were damaged in everyone who had polio and can be “turned off” by anesthetics. Curare-like drugs during major surgery (which paralyze muscles to be cut and makes it easier for the ventilator to fill the lungs while patients are on the table) also affect breathing. Obviously, any drug that interferes with already damaged motor neurons—including spinal anesthesia—will prevent polio survivors from moving or even breathing for hours longer than would non- polio patients.

Breathing difficulties are both frightening and can be life threatening, as another poll respondent described: “My operation was at 9:00 a.m. and I was to be in recovery and awake by 10:00 a.m. At 2:00 p.m., I was in intensive care, not breathing and on a ventilator. I eventually woke at 4:00 p.m. The ventilator was removed the next afternoon, but I really had to fight for every breath. I had a very difficult time breathing and staying awake for three days.”

Some anesthetics seem better for polio survivors. Propofol should be the only drug given to induce anesthesia and for endoscopies, not the old cocktail of Valium, Vistaril and Demerol. The anesthetic gas Desflurane also seems better tolerated by polio survivors who need general surgery. What’s more, a BIS (Bispectral index) monitor that measures brain waves and depth of anesthesia, should always be used so that polio survivors undergoing surgery can be give as little anesthetic as possible.

The bottom line is the first of our rules for preventing complications, the Rule of 2: Doctors need to divide by 2 the amount of anesthesia or sedative medication and polio survivors need 2 times longer for the effect of anesthesia to wear off.

This rule is not intended to dictate the dose of anesthetic polio survivors receive, but to remind anesthesiologists that polio survivors typically need less anesthetic. As always, the dose of anesthetic must be individually adjusted for body weight and other factors, be adequate to keep patients under during surgery, but should not cause polio survivors to stop breathing and sleep for a week.

Another finding of our survey was that 20% of polio survivors vomited, sometimes violently and for several days, after general anesthesia. Today, anti-vomiting drugs are widely used and typically given before and after surgery. Ask for them!

Because of polio survivors’ classic intolerance to cold, it’s no surprise that nearly one third of subjects told us that they were freezing in the recovery room. You should ask for a heated water blanket or a Bair Hugger, an electric, warm-air filled device that surrounds you, during surgery and in recovery.

Because of these issues, there is another Rule: Polio survivors should never have same-day surgery or procedures.

Even applying all the Rules, polio survivors may be very sedated, if not asleep, for hours after surgery. This is why same-day surgery—even complicated dental procedures—is not advisable. Sedated polio survivors cannot be expected to return home and take care of themselves after surgery, since surgical complications may go unnoticed and sedation-impaired coordination makes falling likely. Doctors should perform simple procedures that would usually be done in their offices—including endoscopies—in the hospital and be prepared to admit polio survivors overnight for their own safety.

Next time I’ll talk about the single most troublesome problem after surgery: pain control.

Dr. Richard Bruno is Director of The Post-Polio Institute at Englewood (NJ) Hospital and Medical Center.