Share this article on:

Anesthesia and Poliomyelitis: A Matched Cohort Study

Van Alstine, Luke W. MD; Gunn, Paul W. MD; Schroeder, Darrell R. MS; Hanson, Andrew C. BS; Sorenson, Eric J. MD; Martin, David P. MD, PhD

doi: 10.1213/ANE.0000000000000924
Patient Safety: Research Report

BACKGROUND: Poliomyelitis is a viral infectious disease caused by 1 of the 3 strains of poliovirus. The World Health Organization launched an eradication campaign in 1988. Although the number of cases of poliomyelitis has drastically declined, eradication has not yet been achieved, and there are a substantial number of survivors of the disease. Survivors of poliomyelitis present a unique set of challenges to the anesthesiologist. The scientific literature regarding the anesthetic management of survivors of poliomyelitis, however, is limited and primarily experiential in nature. Using a retrospective, matched cohort study, we sought to more precisely characterize the anesthetic implications of poliomyelitis and to determine what risks, if any, may be present for patients with a history of the disease.

METHODS: Using the Mayo Clinic Life Sciences System Data Discovery and Query Builder, study subjects were identified as those with a history of paralytic poliomyelitis who had undergone major surgery at Mayo Clinic Rochester between 2005 and 2009. For each case, 2 sex- and age-matched controls that underwent the same surgical procedure during the study period were randomly selected from a pool of possible controls. Medical records were manually interrogated with respect to demographic variables, comorbid conditions, operative and anesthetic course, and postoperative course.

RESULTS: We analyzed 100 cases with 2:1 matched controls and found that the peri- and postoperative courses were very similar for both groups of patients. Pain scores, postanesthesia care unit admission, length of postanesthesia care unit stay, intensive care unit admission, length of intensive care unit stay, and initial extubation location were not significantly different between the 2 groups. Looking at pulmonary complications in our primary outcome, there was no significant difference between the 2 groups (17% vs 14% for polio versus control, respectively; conditional logistic regression odds ratio = 1.5; 95% confidence interval, 0.7–3.3; P = 0.33). In addition, no difference was noted in those requiring a code or rapid response team intervention (4% vs 3% for polio versus control; P = 0.46) and the 30-day mortality rate was also not significantly different, with 2% of polio patients dying compared with 3% of controls (P = 0.79). The analysis of the primary outcome was repeated for the subset of patients with a history of poliomyelitis who had persistent neurologic deficits preoperatively (n = 36) and their matched controls (n = 72). In this subset analysis, there were 4 (11%) polio patients and 8 (11%) control patients who experienced pulmonary complications (conditional logistic regression odds ratio = 1.00; 95% confidence interval, 0.27–3.72; P = 1.00). The percentage of patients experiencing specific pulmonary complications of interest was similar between groups (postoperative mechanical ventilation: 6% vs 8% for polio and control patients, respectively; prolonged mechanical ventilation: 0% vs 1%; reintubation: 8% vs 4%; pulmonary infection: 6% vs 6%; and aspiration: 0% vs 1%).

CONCLUSIONS: This study suggests that patients with a history of poliomyelitis do not seem to have an increased risk of pulmonary complications in the perioperative period. However, an odds ratio as great as 3.3-fold may be present.

Published ahead of print August 13, 2015

From the Departments of *Anesthesiology, Biomedical Statistics and Informatics, and Neurology, Mayo Clinic, Rochester, Minnesota.

Paul W. Gunn, MD, is currently affiliated with Anesthesiology Associates of Medford, Medford, Oregon.

Accepted for publication June 6, 2015.

Published ahead of print August 13, 2015

Funding: Mayo Foundation and Mayo Anesthesia Clinical Research Unit Mayo Clinic Rochester, Minnesota.

The authors declare no conflict of interests.

Reprints will not be available from the authors.

Address correspondence to David P. Martin, MD, PhD, Department of Anesthesiology, Mayo Clinic, 200 First St., SW Rochester, MN 55905. Address e-mail to martin.david@mayo.edu.

Poliomyelitis is a viral infectious disease caused by 1 of the 3 strains of poliovirus. It is transmitted by the fecal–oral route. Most cases are either asymptomatic or result in mild flu-like illness, but approximately 1% to 2% of infections involve the central nervous system, resulting in paralytic polio because of the destruction of anterior horn motor neurons. Polio was endemic throughout the United States and throughout the world before 1900. The decline in epidemics seen in the United States during the first half of the 20th century was due in large part to improved sanitation, because fewer and fewer infants were exposed to poliovirus during infancy. Before the development of the polio vaccine, however, epidemics occurred every few years with thousands affected. While many survived their infection, thousands more were left with varying degrees of paralysis and disability.

The World Health Organization launched an eradication campaign in 1988. Although the number of cases of poliomyelitis has drastically declined, eradication has not yet been achieved, and there are a substantial number of survivors of the disease. Although the exact number is unknown, a National Health Interview Survey completed in 1987 reported approximately 1.6 million survivors of poliomyelitis in the United States.1 At least one advocacy organization reports that, worldwide, there are between 12 and 20 million survivors of polio now living.

Survivors of paralytic poliomyelitis have a diversity of outcomes ranging from complete recovery to severe disabling weakness. In individuals, deficits related to old polio vary by affected areas. Some patients’ weakness may be limited to the limbs, whereas others may have residual bulbar weakness. Typically, polio survivors report years of stability after the acute paralytic phase of their illness. However, a significant proportion of those patients years later will report deterioration in body regions that were initially affected but then recovered.2,3 The classical triad of symptoms includes progressive weakness, fatigue, and muscle atrophy. This syndrome has been called the “postpolio” syndrome (PPS). The etiology of PPS remains controversial, and there are no biomarkers. The diagnosis remains a clinical diagnosis in the proper clinical setting. PPS typically only affects regions of the body that were initially weakened by the paralytic polio and is most likely to occur in body regions that only partially recovered after the initial paralytic phase.4 Because patients were often very young at the time of their initial infection, many polio survivors naturally learned successful compensatory muscle activation patterns through childhood development that assist in their activities of daily living. As a result, many polio survivors are unaware of the true extent of their neurologic deficits. It is common that polio survivors often underestimate or minimize their degree of weakness when obtaining a medical history.5 Those with weakness of the pulmonary or swallowing muscles are believed to be at the greatest risk for postsurgical complications. Because of long-standing compensatory techniques, some patients with significant pulmonary weakness may not be aware of the extent of their underlying respiratory restrictions.6 These patients may represent the greatest challenge for the surgical team.

Survivors of poliomyelitis present a unique set of challenges to the anesthesiologist. The scientific literature regarding the anesthetic management of survivors of poliomyelitis, however, is limited and primarily experiential in nature. Anesthetic concerns include predisposition to respiratory complications (such as aspiration and postoperative respiratory failure), chronic pain syndromes, altered sensitivity to muscle relaxants and anesthetics, and positioning challenges.7 However, the primary literature to support these claims is limited to a short list of studies and case reports.6,8–11 The present study sought to more precisely characterize the anesthetic implications of poliomyelitis and to determine what risks, if any, may be present for patients with a history of the disease.

Back to Top | Article Outline

METHODS

This retrospective, matched cohort study was approved by the IRB of the Mayo Clinic, Rochester, Minnesota. Medical records were reviewed only for participants who had provided previous authorization for the use of their medical records in research (Minnesota Statute 144.335 [Subd. 3a. (d)]).

Back to Top | Article Outline

Case Selection

We performed a retrospective case series of patients with a history of paralytic poliomyelitis who underwent major surgery at our institution between 2005 and 2009. Study subjects were identified using the Mayo Clinic Life Sciences System Data Discovery and Query Builder, which is an electronic medical record interrogation tool. Patients aged 18 years and older were identified by a history of paralytic poliomyelitis in their medical record who underwent major surgery at Mayo Clinic Rochester between January 1, 2005, and December 29, 2009. Major surgery was defined as (1) all vascular surgeries (excluding thrombolytic therapy and percutaneous procedures); (2) noncardiac thoracic surgeries, including esophageal and pulmonary surgeries; (3) all major open abdominal surgeries, including laparoscopic procedures (excluding appendectomies and other lower abdominal procedures such as hernia repairs) and laparoscopic gastric bypasses; (4) nonorthopedic spine surgeries; (5) surgical procedures on the hips and knees; (6) cystectomies; (7) neurosurgical procedures (excluding ventriculoperitoneal shunts, stereotactic and peripheral nerve surgeries); and (8) head and neck surgeries. The electronic medical records of study subjects were manually interrogated with respect to demographic variables, comorbid conditions, operative and anesthetic course, and postoperative course. The following comorbid conditions were identified: (1) PPS, (2) cerebrovascular disease, (3) coronary artery disease, (4) heart failure, (5) chronic obstructive pulmonary disease, (6) restrictive lung disease, (7) sleep-disordered breathing, (8) chronic kidney disease, (9) diabetes mellitus, (10) cirrhosis, (11) preoperative chronic opioid use, and (12) persistent neurologic deficits. When each of these comorbid conditions was identified in a patient’s medical record, the diagnosis was presumed to be consistent with accepted definitions for each condition. Specifically, PPS was identified by documentation in the medical record of PPS consistent with accepted criteria for this syndrome.1 These criteria include (1) a previous episode of poliomyelitis with residual motor neuron loss (can be confirmed by typical history, neurologic examination, or electromyography); (2) a period (usually >15 years) of neurologic and functional stability after recovery from the acute illness; (3) the gradual or, rarely, abrupt onset of new weakness or abnormal muscle fatigue, muscle atrophy, or generalized fatigue; and (4) exclusion of other conditions that could cause similar manifestations.

Back to Top | Article Outline

Selection of Controls

The present study sought to compare the polio cases identified earlier with matched controls to determine relative risk with respect to postoperative complications. For each case identified with a history of poliomyelitis, we identified a pool of possible controls without a history of polio, again using the Mayo Clinic Life Sciences System Data Discovery and Query Builder. These controls were of the same sex, similar age (±10 years), and underwent the same type of surgical procedure during the study period (January 1, 2005, to December 31, 2009). From these pools of possible controls, we selected 2 controls for each polio patient (2:1 matching). We considered matching on ASA physical status but decided against this because doing so would likely have resulted in matching polio patients to patients who did not have polio but did have other chronic comorbidities.

Back to Top | Article Outline

Data Abstraction and Anesthetic History

With each patient, the electronic medical record was analyzed and data were abstracted for the perioperative period involving the major surgery identified by the Mayo Clinic Life Sciences System Data Discovery and Query Builder. For the major surgery identified, the type of surgery and primary anesthetic were noted, as well as the drugs used for induction and maintenance of anesthesia, the type of laryngoscopy and airway device used, the difficulty in mask ventilation, and the duration of anesthesia. Postoperative data were also abstracted and included length of postanesthesia care unit (PACU) stay, initial extubation location, and the following postoperative adverse events: (1) intensive care unit (ICU) admission, (2) length of ICU stay, (3) postoperative mechanical ventilation, (4) need for reintubation, (5) prolonged mechanical ventilation (defined as mechanical ventilation lasting longer than 21 days and for at least 6 hours per day, as defined by the Centers for Medicare & Medicaid Services12), (6) postoperative pulmonary infection, (7) aspiration, (8) code blue or rapid response team intervention, and (9) 30-day mortality. Postoperative pain management data were abstracted and included type of pain medications used, use of neuraxial and/or peripheral nerve blockade, and the average and maximum pain scores on postoperative days (PODs) 1 and 2. All abstracted data were entered manually into the Web-based Research Electronic Data Capture system (REDCap Software, version 4.13.17, © 2013 Vanderbilt University).

Back to Top | Article Outline

Statistical Analysis

Patient and procedural characteristics are summarized using mean ± SD for continuous variables and frequency counts and percentages for categorical variables. These characteristics were compared between patient groups using the 2-sample t test for continuous variables and the χ2 test (or Fisher exact test) for nominal variables. The primary outcome variable of interest was any pulmonary complication, including the need for postoperative mechanical ventilation, reintubation, prolonged mechanical ventilation, aspiration, or pulmonary infections. Secondary outcomes documented included difficult airway, any ICU admission (planned or unplanned), use (and dose) of muscle relaxants, mean maximal pain scores for POD1 and POD2, code and/or rapid response team intervention, and 30-day mortality. Given the matched set study design, binary outcomes were compared between groups using conditional logistic regression, and continuous outcomes were compared between groups using mixed linear models. In all cases, 2-tailed P values ≤0.05 were considered statistically significant.

From a preliminary review of the electronic medical records, we determined that approximately 100 polio patients would be eligible for the current study. The number of control patients to include for each polio patient was determined based on the assumption that the rate of any pulmonary complication is approximately 15% in the nonpolio population. Under this assumption, we determined that including 2 controls for each polio patient would provide statistical power of approximately 80% to detect an increased rate of pulmonary complications in polio patients consistent with an odds ratio of 2.3 (15% vs 29%).

Back to Top | Article Outline

RESULTS

The mean age of the cases was 71.1 years (SD = 7.6) and 70.9 years (SD = 7.3) for the controls; 66% were male. While not included in the matching criteria, the percentages of ASA physical status were nearly identical with 60% of both groups labeled as ASA physical status III and 34% of the polio patients identified as ASA physical status I or II compared with 35% of controls. Six percent of both groups were identified as ASA physical status IV, and only 1 control was labeled as ASA physical status V. With regard to their comorbid conditions, there were no statistical differences between cases and controls, except that controls were found to have a higher rate of cerebrovascular disease (23% compared with 12% of polio patients, P = 0.029), and more polio patients were identified with malignancies (73% compared with 61% of controls, P = 0.033; Table 1). Tobacco use was also similar between groups. There was a significant difference in the number of polio patients using preoperative opioids (27% compared with 14% of controls, P = 0.006; Table 1).

Table 1

Table 1

As expected, many of the polio patients had persistent neurologic deficits (36%), whereas none of the controls had any documented neurologic deficits. Neurologic deficits were defined as any diminished function documented by history or neurologic examination, but, unfortunately, it was not possible to assign causality to most of them. Neurologic deficits may represent a point on the spectrum of PPS before documented clinical diagnosis.

Of the 36 patients with persistent neurologic deficits, 4 carried the diagnosis of PPS. The oldest was a 91-year-old man with bilateral lower extremity weakness and gait instability requiring nursing home placement (walked with a 2-person assist) who had surgery for a lower extremity vascular bypass. Next was a 78-year-old man who underwent a urologic procedure. He was severely affected by hypercapnic and hypoxic respiratory insufficiency because of restrictive lung disease, hemidiaphragm paralysis, and severe obstructive sleep apnea, who was able to walk with a cane. He used supplemental oxygen 2 L/min during the day and bilevel positive airway pressure with 4 L/min at night. The third patient was a 71-year-old man who underwent carotid endarterectomy. Although ambulatory, he had proximal weakness and became dyspneic with exertion. The final patient was a 69-year-old man who was ambulatory but experienced early fatigue; he underwent a prostatectomy.

Back to Top | Article Outline

Surgical and Anesthetic Characteristics

Groups were matched on International Classification of Diseases and Injuries, Ninth Revision, surgical procedure code. The most common type of surgery was general (39%), followed by urologic (25%), and vascular (21%) (Fig. 1).

Figure 1

Figure 1

Table 2

Table 2

The primary anesthetic was general anesthesia for 99% of the polio patients, with 1 patient undergoing monitored anesthesia care; while slightly more controls underwent a monitored anesthesia care (7%), and 1 patient had a neuraxial as their primary anesthetic, 93% of the controls had general anesthesia, which was not significantly different (P = 0.06). Duration of anesthesia was very similar (polio: mean 4.4 hours, SD = 2.0; controls: 4.5 hours, SD = 2.3). With regard to airway management, the 2 groups were again very similar with no significant differences noted. No difference was noted in difficulty of mask ventilation, type of laryngoscopy, airway device used, or difficulty of direct laryngoscopy (Table 2). Muscle relaxants were used in a similar proportion for each group (95% of polio patients and 91% of controls, P = 0.22), and the type of drugs used was very similar, with vecuronium the most common nondepolarizing muscle relaxant used (77% of polio patients and 75% of controls; Table 2). Among patients who received vecuronium as their only muscle relaxant, the doses used were similar between polio patients and controls (13.1 ± 5.7 vs 13.9 ± 6.5 for polio versus control; P = 0.387).

Back to Top | Article Outline

Postoperative Outcomes

The postoperative course was very similar for both groups of patients. PACU admission, length of PACU stay, ICU admission, length of ICU stay, and initial extubation location were not significantly different between the 2 (Table 3). With regard to postoperative analgesia, slight differences were noted in modes of pain control. Control patients tended to be more likely to receive neuraxial anesthesia (14% compared with 8% of polio patients; P = 0.08), whereas peripheral nerve blockade was more common in polio patients (6% vs 0%; P = 0.001). Although not statistically significant, a lower percentage of polio patients compared with controls received opioids on POD1, and among those receiving opioids, the total dose received was significantly lower for polio patients versus controls (P = 0.025). On POD2, the percentage of patients receiving opioids was lower for polio versus control (P = 0.031), but the doses received were similar. Postoperative pain scores were very similar between the 2 groups. There was no significant difference in the maximum or average pain scores on POD1 and POD2 or in the number of patients who required pain service consultation (Table 3). There were no documented positioning injuries in either group of patients.

Table 3

Table 3

In looking at our primary outcome for any pulmonary complications, there was no significant difference between the 2 groups (17% vs 14% for polio versus control, respectively; conditional logistic regression odds ratio = 1.5; 95% confidence interval, 0.7–3.3; P = 0.33). Eleven percent of both groups required postoperative mechanical ventilation (P = 0.87), reintubation occurred in 4% of polio patients and 3% of controls (P = 0.66), pulmonary infections were noted in 7% of polio patients and 4% of controls (P = 0.26), and aspiration was documented in 2% of polio patients and 1% of controls (P = 0.49; Fig. 2). No difference was noted with those requiring a code or rapid response team intervention (4% vs 3% for polio versus control; P = 0.46). The 30-day mortality rate was also not significantly different, with 2% of polio patients dying, compared with 3% of controls (P = 0.79).

Figure 2

Figure 2

The analysis of the primary outcome was repeated for the subset of patients with a history of poliomyelitis who had persistent neurologic deficits preoperatively (n = 36) and their matched controls (n = 72). In this subset analysis, there were 4 (11%) polio patients and 8 (11%) control patients who experienced pulmonary complications (conditional logistic regression odds ratio = 1.00; 95% confidence interval, 0.27–3.72; P = 1.00). The percentage of patients experiencing specific pulmonary complications of interest was similar between groups (postoperative mechanical ventilation: 6% vs 8% for polio and control patients, respectively; prolonged mechanical ventilation: 0% vs 1%; reintubation: 8% vs 4%; pulmonary infection: 6% vs 6%; and aspiration: 0% vs 1%). The median pain scores on POD1 were also similar (2.2 ± 1.7 vs 2.2 ± 1.6 for polio and control patients, respectively), as was the percentage of patients receiving opioids on POD1 (69% vs 64%) and the median opioid dose in those receiving opioids (57.0 vs 58.5 mg).

Back to Top | Article Outline

DISCUSSION

The main finding of this study is that patients with a history of poliomyelitis do not seem to have an increased risk of pulmonary complications in the perioperative period. Although postoperative respiratory failure has been reported in a postpoliomyelitis patient,6 our study demonstrates that these patients do not have statistically significant rates of respiratory complications compared with matched controls. However, an odds ratio as great as 3.3-fold may be present. In addition, it shows that the immediate postoperative course of these patients is very similar to that of matched controls, with similar numbers of PACU admissions, PACU length of stay, and initial location of extubation. Although the overall percentage of polio patients admitted to an ICU postoperatively was higher, it was not significantly different and may represent heightened vigilance with these patients based on their history of poliomyelitis. This assertion is strengthened by the fact that the mean length of ICU stay was longer for the control population, and no other postoperative complication was found to be significantly higher in this group of polio patients. Furthermore, those requiring a code or rapid response team intervention postoperatively and the 30-day mortality rate were not significantly different.

Although chronic pain is commonly described in patients with a history of poliomyelitis, especially in patients with documented PPS,1,7,10 and preoperative opioid use was higher in the poliomyelitis group, our study did not find evidence of higher reported pain scores postoperatively or a need for increased amounts of opiates to control their pain. In fact, among those receiving opioids on POD1, the total opioid dose received was significantly lower for polio patients versus controls (P = 0.025). On POD2, the percentage of patients receiving opioids was lower for polio versus control (P = 0.031), but the doses received were similar. This study also shows that pain scores were similar for patients with and without a history of poliomyelitis undergoing similar operative procedures. No difference was found in the mean or maximum pain scores for POD1 and POD2. Although the use of nonsteroidal anti-inflammatory drug medications was significantly higher in the control group, it is unknown why this difference was present, and it does not appear to have influenced the amount of opiates used. If anything, it would indicate that the poliomyelitis group required fewer analgesic medications to achieve similar pain scores. The similarity in postoperative pain control is also evidenced by the lack of consults placed for our inpatient Pain Service in this study group.

In looking at the use of peripheral nerve blockade and neuraxial anesthesia, this study does shed some light on the use of these techniques in patients with a history of poliomyelitis. No evidence of sequelae from peripheral or neuraxial blockade was found in the polio patients in our study. Interestingly, 6 of our patients with a history of poliomyelitis received peripheral nerve blocks, whereas none of the controls did. This may represent a concerted effort by the anesthesiologist to avoid systemic opioids and decrease other anesthetics with concerns for postoperative sedation, or it may just represent a random sampling of patients that happened to capture no controls who received peripheral nerve blocks. In contrast, while it was not significantly different, there were many more control patients (14%) who received neuraxial anesthesia compared with the polio patients (8%; P = 0.08). This may represent a concern in performing neuraxial techniques in patients who have documented neurologic deficits or, again, it may just represent a random sampling of patients that happened to capture fewer polio patients who received neuraxial anesthesia for these procedures. As noted by Lambert et al.,7 the type of primary anesthetic used and the decision whether or not to use peripheral or neuraxial blockade must be made on an individual basis. The safety of peripheral nerve blockade and spinal anesthesia has been suggested in case reports,9,13 and a large case series showed no neurologic complications after neuraxial anesthesia in 79 patients with PPS.14

With regard to the use of nondepolarizing muscle relaxants, previous work by Gyermek8 analyzed the effects of D-tubocurarine, pancuronium, and gallamine in pediatric surgical patients with a previous history of poliomyelitis occurring 6 to 12 years before their surgical admission. He demonstrated that these pediatric patients with a history of poliomyelitis had significantly lower 50% effective dose (ED50) values for both D-tubocurarine and pancuronium compared with the controls, but recovery times were identical in the polio versus nonpolio groups. In our study, a number of different nondepolarizing muscle relaxants were used, but vecuronium was used most commonly (77% of polio patients and 75% of controls). Although we did not analyze specific recovery times, the vecuronium doses used were similar between polio patients and controls among patients who received vecuronium as their only muscle relaxant (13.1 ± 5.7 vs 13.9 ± 6.5 for polio versus control; P = 0.387). More studies are needed to specifically look at the response of poliomyelitis patients to modern nondepolarizing muscle relaxants, such as vecuronium and rocuronium, and in adult patient populations.

This study has several limitations, many of which are related to its design as a retrospective, matched cohort, single-center study. Although it is a valuable tool, passive medical record review for a diagnosis of polio has potential sources for error. When a history of polio is documented in a patient’s medical record, there is no control on the timing or accuracy of this diagnosis. This study relies on providers documenting this diagnosis accurately. While we were unable to assure the accuracy of this diagnosis, there was active review of each patient’s chart to ensure that this diagnosis had been established in the past and did not represent a false-positive identification. In addition, when using the Mayo Clinic Life Sciences System Data Discovery and Query Builder, we made sure to exclude reference to the polio vaccine to avoid identification of patients who had received the vaccine but did not actually have the disease. Another limitation of this study is the fact that some of the controls may have had polio in the past, without documentation in their medical record, or may have had subclinical infections that were never identified. While possible, each medical record of the controls was manually searched for a history of polio, and with the length of follow-up many of these patients have at our institution, missing this diagnosis in their record is unlikely.

Another potential weakness of our study is that the case population represented a somewhat milder burden of disease than expected. Few patients were severely affected by PPS. This may reflect a selection bias, wherein more severely affected patients may elect to avoid surgery.

When looking at postoperative respiratory complications as an outcome, our study does not control for every variable that could contribute to respiratory failure. With this in mind, we made every attempt to match our controls based on age, type of surgery, and type of primary anesthetic. As noted earlier, the comorbidities of these 2 populations correlated well and do not indicate any reason why one group or the other should be more prone to postoperative respiratory failure. This study is also limited by the demographics of the patient population, some of which are not documented (such as race). This group of patients may not be completely generalizable to the entire population, but it does represent a significant number of individuals diagnosed with polio and can be compared with many patient populations around the United States. With regard to the size and scope of our study, it is limited by the number of cases but, to our knowledge, this is the only matched cohort study looking at patients with a history of poliomyelitis. Nonetheless, given the limited number of patients with a history of poliomyelitis eligible for study, our study does not provide adequate statistical power to rule out potentially meaningful effects. Therefore, our study does not provide definitive evidence that patients with a history of poliomyelitis are not at increased risk for postoperative pulmonary complications.

Back to Top | Article Outline

CONCLUSIONS

This retrospective, matched cohort study suggests that patients with a history of poliomyelitis do not seem to have an increased risk of pulmonary complications in excess of those experienced by similar patients without a history of polio (i.e., upper limit of the odds ratio = 3.3).

Back to Top | Article Outline

DISCLOSURES

Name: Luke W. Van Alstine, MD.

Contribution: This author helped conduct the study, analyze the data, and write the manuscript.

Attestation: Luke W. Van Alstine has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Paul W. Gunn, MD.

Contribution: This author helped design the study, conduct the study, and write the manuscript.

Attestation: Paul W. Gunn has seen the original study data and approved the final manuscript.

Name: Darrell R. Schroeder, MS.

Contribution: This author helped design the study, analyze the data, and write the manuscript.

Attestation: Darrell R. Schroeder has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Andrew C. Hanson, BS.

Contribution: This author helped analyze the data and write the manuscript.

Attestation: Andrew C. Hanson has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Eric J. Sorenson, MD.

Contribution: This author helped design the study and write the manuscript.

Attestation: Eric J. Sorenson approved the final manuscript.

Name: David P. Martin, MD, PhD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: David P. Martin has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

This manuscript was handled by: Sorin J. Brull, MD, FCARCSI (Hon).

Back to Top | Article Outline

ACKNOWLEDGMENTS

We thank and acknowledge Selma Harrison Calmes, MD (Chairman (retired), Department of Anesthesiology, Olive View-UCLA Medical Center, Sylmar, California and Clinical Professor of Anesthesiology (retired), Department of Anesthesiology, the David Geffen School of Medicine at UCLA, Los Angeles, California) for her support of our project.

Back to Top | Article Outline

REFERENCES

1. Jubelt B, Agre JC. Characteristics and management of postpolio syndrome. JAMA 2000;284:412–4.
2. Mulder DW, Rosenbaum RA, Layton DD Jr. Late progression of poliomyelitis or forme fruste amyotrophic lateral sclerosis? Mayo Clin Proc 1972;47:756–61.
3. Nollet F, Beelen A, Twisk JW, Lankhorst GJ, De Visser M. Perceived health and physical functioning in postpoliomyelitis syndrome: a 6-year prospective follow-up study. Arch Phys Med Rehabil 2003;84:1048–56.
4. Sorenson EJ, Daube JR, Windebank AJ. A 15-year follow-up of neuromuscular function in patients with prior poliomyelitis. Neurology 2005;64:1070–2.
5. Laffont I, Julia M, Tiffreau V, Yelnik A, Herisson C, Pelissier J. Aging and sequelae of poliomyelitis. Ann Phys Rehabil Med 2010;53:24–33.
6. Magi E, Recine C, Klockenbusch B, Cascianini EA. A postoperative respiratory arrest in a post poliomyelitis patient. Anaesthesia 2003;58:98–9.
7. Lambert DA, Giannouli E, Schmidt BJ. Postpolio syndrome and anesthesia. Anesthesiology 2005;103:638–44.
8. Gyermek L. Increased potency of nondepolarizing relaxants after poliomyelitis. J Clin Pharmacol 1990;30:170–3.
9. Higashizawa T, Sugiura J, Takasugi Y. [Spinal anesthesia in a patient with hemiparesis after poliomyelitis]. Masui 2003;52:1335–7.
10. Liu S, Modell JH. Anesthetic management for patients with postpolio syndrome receiving electroconvulsive therapy. Anesthesiology 2001;95:799–801.
11. Sonies BC, Dalakas MC. Dysphagia in patients with the post-polio syndrome. N Engl J Med 1991;324:1162–7.
12. MacIntyre NR, Epstein SK, Carson S, Scheinhorn D, Christopher K, Muldoon S; National Association for Medical Direction of Respiratory Care. Management of patients requiring prolonged mechanical ventilation: report of a NAMDRC consensus conference. Chest 2005;128:3937–54.
13. Nagaoka T, Mizuno J, Ino K, Yoshimura T, Sakamoto H, Morita S. [Femoral and sciatic nerve blocks for open reduction and internal fixation of a femoral condylar fracture in a patient with post-polio syndrome]. Masui 2011;60:964–7.
14. Hebl JR, Horlocker TT, Schroeder DR. Neuraxial anesthesia and analgesia in patients with preexisting central nervous system disorders. Anesth Analg 2006;103:223–8.
© 2016 International Anesthesia Research Society