When to Start IVIG in GBS with Facial Diplegia
Start IVIG immediately in any GBS patient with facial diplegia, as facial weakness is a specific indication for urgent treatment regardless of ambulatory status. 1
Treatment Indication Criteria
The presence of facial diplegia in your GBS patient meets the threshold for immediate IVIG initiation based on the following framework:
Primary Indications for IVIG (Any ONE triggers treatment):
Inability to walk unaided - This is the most commonly cited threshold, with treatment recommended for any patient who cannot walk independently 2, 3
Facial weakness or bulbar weakness - Your patient's facial diplegia specifically qualifies as an indication for immediate treatment, even if they can still walk 1
Dysphagia or diminished cough reflex - These bulbar symptoms warrant urgent treatment 2
Any signs of respiratory compromise - Including vital capacity <20 ml/kg, maximum inspiratory pressure <30 cmH₂O, or maximum expiratory pressure <40 cmH₂O (the "20/30/40 rule") 1, 2
Rapid progression of weakness - Regardless of current severity 1
Timing is Critical
Treatment should be initiated as early as possible, ideally within the first 5 days of symptom onset, and definitely within 2 weeks. 1, 2
Early treatment (within first 5 days) reduces hospital length of stay by approximately 11 days compared to treatment after day 6 4
The standard recommendation is to start within 2 weeks of symptom onset for maximum effectiveness 2
Treatment effectiveness diminishes with delay, so do not wait for further progression once indication criteria are met 1
Standard IVIG Protocol
Administer 0.4 g/kg/day for 5 consecutive days (total dose 2 g/kg) 1, 2, 3
The 5-day regimen is preferred over accelerated 2-day protocols, as treatment-related fluctuations occur more frequently with shorter regimens 1, 3
This dosing applies to adults, children, and pregnant women alike 1
Critical Monitoring During Treatment
Your patient requires admission to a unit with rapid ICU transfer capability because: 1, 3
Respiratory compromise can occur even during treatment 1
Facial diplegia may progress to bulbar dysfunction affecting swallowing and airway protection 2
Monitor respiratory function using vital capacity, maximum inspiratory/expiratory pressures, and single breath count (≤19 predicts need for mechanical ventilation) 2
Common Pitfall to Avoid
Do not wait for the patient to lose ambulation before treating when other indications are present. The guideline stating "inability to walk unaided" is not the only criterion—facial weakness, bulbar symptoms, and respiratory compromise are equally valid indications for immediate treatment. 1 Your patient's facial diplegia alone justifies urgent IVIG initiation.
Medications to Avoid During Treatment
Avoid β-blockers, IV magnesium, fluoroquinolones, aminoglycosides, and macrolides, as these can worsen neuromuscular function. 1, 3
Expected Outcomes and Follow-up
Approximately 40% of patients do not improve in the first 4 weeks, which doesn't necessarily indicate treatment failure 1
Treatment-related fluctuations occur in 6-10% of patients within 2 months and may require repeating the full IVIG course 1, 2
About 80% of patients regain walking ability at 6 months 1, 2, 3