Guillain Barre Syndrome
Madhavi R. Muppidi M.D.
Attending Physician
Acute In-Patient Rehabilitation
Objectives
Define GBS and its incidence and cause.
List physiological threats to various organ
systems caused by GBS.
Describe rehabilitation care priorities of the
patient with Guillian Barre
Definition
ACUTE INFLAMMATORY DEMYELINATING
POLYNEUROPATHY
BODYS IMMUNE SYSTEM ATTACKS ITS OWN
NERVES, ESPECIALLY PERIPHERAL NERVES.
INCIDENCE
1-2/100,000 PEOPLE PER YEAR
INCREASES WITH AGE
PEAK AGE- 50-74 YEARS
RECURRENCE RATE IS 3%
MORTALITY AND MORBIDITY- 4-8 % EVEN
AFTER EFFECTIVE THERAPY
NO SEX OR GEOGRAPHIC PREDILICTION
CAUSE
UNKNOWN
PRECEDED BY INFECTIOUS ILLNESS SUCH AS
RESPIRATORY INFECTION OR STOMACH FLU
WITHIN 3 DAYS TO 6 WEEKS
OTHER PRECEDING FACTORS LIKE TRAUMA,
RECENT SURGERY
SYMPTOMS
PARESTHESIAS OF FINGERS AND TOES
WEAKNESS OF MUSCLES
UNSTEADYOR INABILITY TO WALK
SEVERE PAIN
LOSS OF BLADDER AND BOWEL CONTROL
DIFFICULTY BREATHING
CLINICAL OR NATURAL COURSE
PROGRESSION UP TO 2 WEEKS
PLATEAU FROM 2-4 WEEKS
RECOVERY AFTER 4 WEEKS ( 67 % OF
PATIENTS-RECOVERY UNDERWAY)
EMERGENCY MEDICAL HELP
ASCENDING SYMPTOMS OF PARESTHESIAS
RAPIDLY SPREADING SYMPTOMS
PARESTHESIAS INVOLVING BOTH FEET AND
HANDS
DIFFICULTY SWALLOWING
CHOKING ON SALIVA
SUPPORTIVE CARE
Extremely important
Nursing major role
30% of patients develop neuromuscular
respiratory failure requiring mechanical
ventilation
Autonomic dysfunction needing ICU
monitoring
DIAGNOSIS
Proper and detailed History
Spinal tap CSF reveals elevated protein
EMG/NCV testing
TREATMENT
Aim to decrease severity and suffering
Disease modifying treatment
- Plasma exchange
- IVIG
AAN Guidelines
IVIG/PE hasten recovery
Beneficial effects of PE/IVIG are equivalent
Combining the 2 treatments is not beneficial
AAN Guidelines
Plasma exchange:
Non- ambulatory adult GBS patient with 4 weeks
of onset of neuropathic symptoms
Ambulatory patients with in 2 weeks of onset of
neuropathic symptoms
4-6 treatments over 8-10 days.
AAN Guidelines
IVIG:
- Non ambulatory adult GBS patients with in 24 weeks of onset of Neuropathic symptoms.
Treatment for 5 days
0.4 g/Kg/day
Side-effects of PE
Hypotension
Sepsis
Side- Effects of IVIG
Aseptic Meningitis
Acute Renal Failure
Rarely Stroke secondary to Hyperviscocity
Anaphylaxis secondary to IgA deficiency
Supportive Care
DVT PPx
Bladder / Bowel care
PT/OT/ST as indicated
Pain Control
Psychological support
Respiratory Management
Monitor for impending Respiratory failure
15-30% need ventilator support
Monitor swallowing problems for risk of
aspiration
Inability to clear secretions
Impending Respiratory Arrest
FVC <20 ml/Kg
Maximum Inspiratory pressure < 30 cm of
H2O
Maximum expiratory pressure < 40 cm of
water
Respiratory Failure Predictors
Time of onset to admission < 7 days
Inability to cough
Inability to stand
Inability to lift elbows
Inability to lift the head
Increased liver enzymes
Continued
If at least 4 of the 6 above predictors are
present, patient requires mechanical
ventilation in 85 % of patients
Overall 43 % of patients admitted will need
mechanical ventilation
Respiratory Management
Keep HOB elevated 30 Degrees to promote
drainage and lung expansion, if not
contraindicated
Monitor for aspiration
Monitor for difficulty breathing/tachypnea
Autonomic Dysfunction
Dysautonomia in 70% of patients
Tachycardia
Urinary retention
Elevated or low BP
Orthostatic BP
Bradycardia
Arrhythmias
Ileus/ loss of sweating.
Cardiovascular Management
Instituted at the time of admission
Monitoring of BP and heart rate in severely
affected patients
Monitoring is needed until weaned off the
vent
Cardiovascular Management
Quadriplegic patients should not be left
unattended
Maintain intravascular volume
Avoiding medications which lower BP
Arrhythmias occur frequently during
suctioning
Monitor BP and electrolytes during Plasma
exchange
Cardiovascular Management
Paroxysmal HTN- 24 %
Orthostatic Hypotension- 19%
Sustained HTN-3%
Arrhythmias
Sinus tachycardia- 37%- no treatment
Severe Bradycardia/asystole in 4% of GBS
patients
Others- A fib, A flutter, V Tach, St and T wave
abnormalities
Bladder care
Monitor Urinary retention which is very
common
Need for catheter and catheter care
Bowel care
Adynamic Ileus is common
Daily abdominal auscultation is recommended
Treatment is Erythromycin or Neostigmine
Skin Integrity
Secondary to immobility
Skin assessment esp over body prominences
Prevent areas of moisture to skin
ROM exercises to prevent contractures
Nutrition
Monitor daily weights, serum albumin and
total protein
ST eval for gag reflex, aspiration and
swallowing
Initially pts may need enteral feeding to
prevent aspiration
Monitor gastric motility and dysphagia
Nutrition
Optimal Nutrition is essential for recovery and
good prognosis as malnutrition will delay
recovery
Pain
Neuropathic pain in about 40-50% of patients
with GBS
Gabapentin, carbamazepine, epidural
morphine in ICU setting
Long term treatment with tricyclics, tramadol,
gabapentin, carbamazepine, pregabalin
Massage, reposition, music, biofeedback, ice
and heat etc.
Cranial Nerve Involvement
85 % of cases
Facial nerve is commonly involved which
results in inability to smile, frown, whistle, use
of straws
IX and X cause dysphagia, laryngeal paralysis,
autonomic dysfunction
Keep eyes moist/artificial tears/eye mask
Psychological Issues
Fear
Anxiety
Depression
Feelings of being trapped and isolated in their
body
Psychological issues
Patients who cannot communicate easily, can
still hear, see, think and have sensation.
So please be cautious in your approach to
these patients
Communication
Communication Board for patients who can
make a small puff of air, move lips, blink, click
their tongue
Keep clock and calendar in view
Dont leave patient alone
Leave call device accessible (modify, prn)
Open visitation for family and significant
others
Sleep Pattern
Monitor for sleep pattern disturbances which
could be secondary to pain or dysautonomia
etc.
Schedule regular rest periods to prevent ICU
delirium
Anxiety
Monitor heart rate and BP
Consider antidepressants or anxiolytics
Ventilatory care
Wean patient off vent when FVC > 30 % and
Negative inspiratory force is 20 cm H2O or
more
After extubation:
- continue pulmonary toilet
- incentive spirometry
Acute Care Rehab
Gentle Strengthening and ROM exercises
Proper limb positioning
Posture
Post Acute Care Rehab
Inpatient Rehab Unit
PT/OT/ST as needed
Continued Rehabilitation Nursing care
Prevention of contractures, monitor skin
breakdown and monitor for infections
Poor Prognostic factors
Older age
Rapid onset (< 7 days)
Severe muscle weakness
Need for vent support
Average distal CMAP < 20 %
Preceding diarrheal illness
Long Term Outcomes
Patients walk independently
- in 6 months- about 80%
- 1 yr- about 84 %
14% - severe motor problems
5-10 %- incomplete recovery with need for
prolonged vent dependence
4-5 % Mortality
Causes of Death
Acute Respiratory Distress Syndrome
Sepsis
PE
Cardiac arrest- un explained
Relapses
10% of patients have a relapse
2% develop CIDP
Immunization and GBS
Not recommended during acute phase and up
to 1 year after onset of GBS
After that, given on need basis
Thank You
REFERENCES
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Systematic Reviews, 8, CD001446. doi:10.1002/14651858.CD001446.pub4
Khan, F., & Amatya, B. (2012). Rehabilitation interventions in patients with acute demyelinating inflammatory
polyneuropathy: a systematic review. European Journal of Physical and Rehabilitation Medicine, 48(3), 507522.
Khan, F., Ng, L., Amatya, B., Brand, C., & Turner-Stokes, L. (2010). Multidisciplinary care for Guillain-Barr syndrome. The
Cochrane Database of Systematic Reviews, (10), CD008505. doi:10.1002/14651858.CD008505.pub2
Khan, F., Ng, L., Amatya, B., Brand, C., & Turner-Stokes, L. (2011). Multidisciplinary care for Guillain-Barr syndrome.
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Khan, F., Pallant, J. F., Amatya, B., Ng, L., Gorelik, A., & Brand, C. (2011). Outcomes of high- and low-intensity rehabilitation
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Vriesendorp, FJ. (2013a, May 1). Clinical features and diagnosis of Guillain-Barr syndrome in adults. In UpToDate. Wolters
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Vriesendorp, FJ. (2013b, November 13). Treatment and prognosis of Guillain-Barr syndrome in adults. In UpToDate.
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