What are the key considerations in managing Guillain-Barré Syndrome (GBS) in the Intensive Care Unit (ICU)?

Managing Guillain-Barré Syndrome in the ICU

Admit GBS patients to the ICU if they have evolving respiratory distress with imminent respiratory insufficiency, severe autonomic cardiovascular dysfunction, severe swallowing dysfunction or diminished cough reflex, or rapid progression of weakness. 1

Critical Respiratory Monitoring

Apply the "20/30/40 rule" immediately upon ICU admission to identify imminent respiratory failure: vital capacity <20 ml/kg, maximum inspiratory pressure <30 cmH₂O, or maximum expiratory pressure <40 cmH₂O. 1, 2

Additional respiratory assessments to perform:

• Single breath count ≤19 predicts need for mechanical ventilation and should trigger preparation for intubation 1, 2
• Monitor for use of accessory respiratory muscles, which indicates impending respiratory failure 1
• Obtain arterial blood gas measurements if any respiratory compromise is suspected 1
• Up to 30% of GBS patients develop respiratory failure requiring mechanical ventilation, and this can occur rapidly without obvious dyspnea 3, 4
• Use the Erasmus GBS Respiratory Insufficiency Score (EGRIS) to calculate probability of requiring ventilation 5

Cardiovascular and Autonomic Monitoring

Cardiovascular and respiratory dysfunction cause up to two-thirds of deaths in GBS, making continuous monitoring essential. 1

Specific monitoring requirements:

• Continuous ECG monitoring for arrhythmias 2
• Blood pressure monitoring for both hypertension and hypotension 2
• Monitor bowel and bladder function for autonomic dysfunction 1, 2
• Assess heart rate variability as indicator of autonomic instability 1

Bulbar and Airway Assessment

Monitor swallowing and coughing difficulties rigorously to prevent aspiration, which is a common and life-threatening complication. 1, 2

• Assess bulbar muscle weakness and facial weakness at each examination 5
• Evaluate dysphagia and provide nutritional support if necessary 5
• Diminished cough reflex is an ICU admission criterion and requires close monitoring 1

Neurological Assessment

Perform regular muscle strength assessments using the Medical Research Council grading scale in neck, arms, and legs. 1, 2

• Document functional disability using the GBS disability scale 1, 2
• Monitor for rapid progression of weakness, which indicates higher risk of respiratory failure 1, 6
• Assess deep tendon reflexes (typically reduced or absent in GBS) 1

Immunotherapy Initiation

Initiate intravenous immunoglobulin (IVIg) at 0.4 g/kg body weight daily for 5 consecutive days as first-line treatment as early as possible in the disease course. 1, 5, 2

• IVIg is preferred over plasma exchange because it is easier to administer, more widely available, and has higher completion rates 5, 2
• Plasma exchange (200-250 ml plasma/kg body weight in five sessions) is an equally effective alternative if IVIg is contraindicated 1
• Do not use corticosteroids alone as they have shown no significant benefit and may have negative effects 1, 5
• Treatment should be initiated within 2 weeks of symptom onset for maximum effectiveness 2, 7

Medication Precautions

Avoid medications that can worsen neuromuscular function: β-blockers, IV magnesium, fluoroquinolones, aminoglycosides, and macrolides. 1, 5

Complications to Monitor

Hospital-acquired infections, pressure ulcers, and deep vein thrombosis are common preventable complications requiring prophylaxis. 1

• Provide DVT prophylaxis given immobility 5
• Implement pressure ulcer prevention protocols 1, 5
• Monitor for nosocomial infections and ventilator-associated pneumonia in intubated patients 4
• Treatment-related fluctuations occur in 6-10% of patients within 2 months of initial improvement 1, 2

Pain Management

Pain is common in GBS and significantly impacts quality of life, requiring early recognition and treatment. 1, 2

• Use gabapentin, pregabalin, or duloxetine for neuropathic pain 5
• Avoid opioids as first-line agents 5
• Monitor for hallucinations, anxiety, and depression 1

Prognosis Indicators

Use the modified Erasmus GBS outcome score (mEGOS) to assess outcome and guide family discussions. 7

• 80% of patients regain independent walking ability at 6 months 5, 2
• Mortality is 3-10%, primarily from cardiovascular and respiratory complications 5, 2
• Risk factors for mortality include advanced age and severe disease at onset 5, 2

Critical Pitfall

Respiratory failure can develop rapidly, often without obvious clinical signs of dyspnea, making scheduled objective measurements more reliable than clinical observation alone. 1 Emergency intubation may lead to life-threatening complications, so anticipate the need based on objective criteria rather than waiting for clinical deterioration. 4