What is the recommended management for a suspected Guillain-Barré Syndrome (GBS) case presenting with diplopia and quadriparesis?

Management of Suspected GBS with Diplopia and Quadriparesis

Initiate intravenous immunoglobulin (IVIg) at 0.4 g/kg/day for 5 consecutive days immediately and admit to the ICU for continuous cardiorespiratory monitoring, as this patient has severe GBS with cranial nerve involvement (diplopia) and inability to walk (quadriparesis). 1

Immediate Actions Required

ICU Admission and Monitoring

• Admit to ICU immediately because this patient meets critical criteria: quadriparesis (inability to walk) and cranial nerve involvement (diplopia suggesting bulbar weakness). 1
• Institute continuous ECG monitoring for cardiac arrhythmias and blood pressure monitoring for autonomic instability, as autonomic dysfunction contributes significantly to the 3-10% mortality rate. 2, 1
• Assess swallowing function and cough reflex urgently, as diplopia indicates cranial nerve involvement and bulbar dysfunction may be present or imminent. 1

Respiratory Assessment (Critical Priority)

• Apply the "20/30/40 rule" immediately: measure vital capacity (<20 mL/kg indicates imminent respiratory failure), maximum inspiratory pressure (<30 cmH₂O), and maximum expiratory pressure (<40 cmH₂O). 1, 3
• Perform single breath count test: inability to count to ≤19 in one breath is the most ominous bedside sign predicting need for mechanical ventilation and should trigger immediate preparation for intubation. 1, 3
• Repeat respiratory assessments every 2-4 hours, as 20-30% of GBS patients develop respiratory failure requiring mechanical ventilation, with 22% requiring it within the first week. 2, 3
• Do not rely on pulse oximetry or arterial blood gases as early indicators—they are late findings and will miss the window for safe intubation. 3

First-Line Immunotherapy

IVIg Administration

• Start IVIg 0.4 g/kg/day for 5 consecutive days as soon as possible, ideally within 2 weeks of symptom onset (though benefit may extend to 2-4 weeks). 1, 4
• IVIg is preferred over plasma exchange because it is easier to administer, more widely available, has higher completion rates, and better tolerability with fewer complications. 1
• Plasma exchange (200-250 mL plasma/kg over five sessions in 1-2 weeks) is an equally effective alternative if IVIg is contraindicated or unavailable. 1, 4

Treatment Expectations and Monitoring

• Do not expect immediate improvement: approximately 40% of patients show no improvement in the first 4 weeks, which does not indicate treatment failure. 5
• Most patients reach maximum disability within 2 weeks of onset, followed by a plateau phase lasting days to weeks before recovery begins. 2
• Monitor for treatment-related fluctuations (TRFs), which occur in 6-10% of patients within 2 months of initial improvement—these require repeat IVIg or switch to plasma exchange. 1, 5

Multidisciplinary Supportive Care

Neurological Monitoring

• Assess muscle strength using Medical Research Council grading scale and document functional disability using GBS disability scale at regular intervals. 1
• Monitor for progression: if weakness continues beyond 8 weeks, consider changing diagnosis to acute-onset CIDP (A-CIDP), which occurs in approximately 5% of initially diagnosed GBS cases. 4

Complication Prevention

• Implement deep vein thrombosis prophylaxis, pressure ulcer prevention, and monitor for hospital-acquired infections. 5
• Recognize and treat pain early, as it is common and significantly impacts quality of life—consider gabapentinoids, tricyclic antidepressants, or carbamazepine. 1, 4
• Monitor bowel and bladder function for autonomic dysfunction. 1

Early Rehabilitation

• Initiate multidisciplinary rehabilitation immediately with physiotherapists, occupational therapists, speech therapists, and dietitians. 1, 5
• Include range-of-motion exercises, stationary cycling, walking, and strength training, but monitor exercise intensity closely as overwork causes fatigue. 1, 5

Prognosis and Long-Term Considerations

• 80% of patients regain independent walking ability at 6 months, though recovery can continue for >5 years. 2, 1
• Mortality remains 3-10% even with optimal care, primarily from cardiovascular and respiratory complications during the recovery phase. 2, 1
• Advanced age and severe disease at onset are the strongest risk factors for poor outcome and mortality. 1