Management of Guillain-Barré Syndrome Complications
The management of Guillain-Barré Syndrome (GBS) complications requires comprehensive monitoring and treatment of respiratory function, autonomic dysfunction, pain, and psychological symptoms, with first-line immunotherapy using IVIG (0.4 g/kg/day for 5 days) or plasma exchange (4-5 exchanges over 1-2 weeks) for patients unable to walk independently. 1
Critical Monitoring and Respiratory Management
Respiratory Assessment
Apply the "20/30/40 rule" for respiratory monitoring 1:
- Vital capacity < 20 ml/kg
- Maximum inspiratory pressure < 30 cmH₂O
- Maximum expiratory pressure < 40 cmH₂O
- Single breath count ≤ 19 predicts need for mechanical ventilation
Monitor patients closely for respiratory compromise, as approximately 30% of GBS patients develop respiratory failure requiring mechanical ventilation 2
Consider intubation when PaO2 < 60 mmHg on supplemental oxygen, PaCO2 > 50 mmHg, or pH < 7.3 3
Cardiovascular Monitoring
- Monitor for dysautonomia including blood pressure fluctuations, heart rate abnormalities, and temperature dysregulation 1
- Remain vigilant during recovery phase as up to two-thirds of GBS deaths occur during this period, mostly from cardiovascular and respiratory complications 4
Immunotherapy Options
First-Line Treatment
For patients unable to walk independently (GBS disability score ≥3):
- IVIG: 0.4 g/kg/day for 5 consecutive days, OR
- Plasma exchange: 4-5 exchanges over 1-2 weeks 1
Important considerations:
- Treatment should be initiated within 2 weeks of symptom onset for IVIG (can consider up to 4 weeks) 5
- Plasma exchange is effective if started within 4 weeks of symptom onset 5
- Plasma exchange is equally effective as IVIG but has higher complication rates 1
- Combination therapy (PE followed by IVIG) is not recommended as it shows no additional benefit 1
Treatment-Related Fluctuations (TRFs)
- TRFs occur in 6-10% of patients within 2 months of initial treatment 4, 1
- Consider repeating the full course of IVIG or plasma exchange for patients with TRFs, although evidence supporting this approach is limited 4
- Be alert for development of acute-onset chronic inflammatory demyelinating polyradiculoneuropathy (A-CIDP) in approximately 5% of patients initially diagnosed with GBS 4, 1
Pain Management
- First-line: Gabapentinoids (pregabalin, gabapentin) 1
- Second-line options: Tricyclic antidepressants or carbamazepine 1
- Avoid opioids when possible 1
- Actively inquire about pain, as it is a frequent complication that significantly impacts patient wellbeing 4
Managing Additional Complications
Prevention of Common Complications
- Implement standard preventive measures for:
- Pressure ulcers
- Hospital-acquired infections (pneumonia, urinary tract infections)
- Deep vein thrombosis 4
GBS-Specific Complications
- Address swallowing difficulties in patients with bulbar palsy
- Prevent corneal ulceration in patients with facial palsy
- Prevent limb contractures, ossification, and pressure palsies in patients with limb weakness 4
Psychological Support
- Screen for and treat hallucinations, anxiety, and depression 4
- Remember that patients usually have intact consciousness, vision, and hearing even when completely paralyzed 4
Multidisciplinary Rehabilitation
- Arrange comprehensive rehabilitation before discharge 1
- Address potential long-term issues:
- Fatigue
- Chronic pain
- Psychological distress
- Physical function restoration 1
- Approximately 80% of patients regain independent walking by 6 months, but recovery can continue for more than 3 years 1
- Use the modified Erasmus GBS outcome score (mEGOS) to predict recovery of walking ability 1
Prognosis and Long-Term Monitoring
- Mortality rate is 3-10% despite optimal care 1
- Recurrence is rare (2-5% of cases) 1
- Long-term residual complaints such as pain, weakness, and fatigue are common 1
- Monitor patients who have recently left the ICU and those with cardiovascular risk factors closely for potential arrhythmias, blood pressure shifts, or respiratory distress 4