What are the potential complications of Guillain-Barré Syndrome (GBS)?

Complications of Guillain-Barré Syndrome

Guillain-Barré Syndrome carries a 3-10% mortality rate even with optimal care, with respiratory failure and cardiovascular complications being the primary life-threatening events that require immediate recognition and intensive monitoring. 1

Life-Threatening Complications

Respiratory Failure

• Approximately 20% of patients develop respiratory failure requiring mechanical ventilation, which can occur rapidly and sometimes without obvious symptoms of dyspnea. 1
• Respiratory compromise is the leading cause of mortality and can progress without warning signs, making serial pulmonary function monitoring essential. 1
• Among ICU-admitted patients, 78% require mechanical ventilation with a median duration of 28 days. 2
• The "20/30/40 rule" identifies high-risk patients: vital capacity <20 ml/kg, maximum inspiratory pressure <30 cmH₂O, or maximum expiratory pressure <40 cmH₂O. 3

Cardiovascular and Autonomic Complications

• Cardiac arrhythmias and blood pressure instability from autonomic nervous system involvement can be life-threatening and require continuous cardiac monitoring. 1, 4
• Autonomic dysfunction contributes significantly to the 3-10% mortality rate despite optimal medical care. 4
• Up to two-thirds of GBS deaths occur during the recovery phase from cardiovascular and respiratory dysfunction. 4
• Life-threatening arrhythmias can be triggered by routine procedures such as tracheal aspiration, potentially causing idioventricular rhythms or cardiac arrest. 5
• Blood pressure instability, heart rate variability, pupillary dysfunction, and bowel/bladder dysfunction are common manifestations of dysautonomia. 3

Major Medical Complications

Infectious Complications

• Pneumonia is the most common major complication, occurring in 54% of ICU-admitted patients. 2
• Two-thirds of ICU patients suffer at least one major complication, with infectious complications being predominant. 2
• Prolonged mechanical ventilation significantly increases the risk of hospital-acquired infections. 2

Neurological Complications

• Posterior reversible encephalopathy syndrome (PRES) is a rare but potentially life-threatening complication that can occur in pediatric patients with GBS, presenting with hypertension, seizures, and altered mental status. 6
• Facial nerve involvement occurs frequently due to the nerve's longest intracranial course and extensive myelin coverage, making it particularly vulnerable to immune-mediated demyelination. 3
• Bilateral facial palsy can be the presenting feature before limb weakness develops. 3

Treatment-Related Complications

• Treatment-related fluctuations (TRFs) occur in 6-10% of patients within 2 months after initial improvement following immunotherapy. 1, 3
• Approximately 5% of patients initially diagnosed with GBS may actually have acute-onset chronic inflammatory demyelinating polyneuropathy (CIDP) if progression continues after 8 weeks or if three or more TRFs occur. 3

Functional and Recovery Complications

Short-Term Disability

• Most patients reach maximum disability within 2 weeks of symptom onset, with rapid progression being characteristic of the disease. 1
• Approximately 20% of patients remain unable to walk independently during the acute phase. 1
• Dysphagia and aspiration risk develop in patients with cranial nerve involvement, requiring swallowing assessment. 3

Long-Term Outcomes

• About 60-80% of patients are able to walk independently 6 months after disease onset, but 20-40% have persistent disability. 1
• Recovery can continue for more than 3 years, with improvement possible even 5 years after onset. 3
• Among ICU-admitted patients, 75% eventually recover independent ambulation over an average 3-year follow-up, with median time to ambulate being 198 days. 2
• Advanced age and severe disease at onset are the most powerful predictors of poor outcome. 3, 2

Psychological and Quality of Life Complications

Mental Health Impact

• Anxiety, depression, and hallucinations are frequent complications that require screening and management. 3
• Patients with complete paralysis maintain intact consciousness, vision, and hearing, making them fully aware of their condition and vulnerable to psychological distress. 3
• The psychosocial impact extends to caregivers, requiring comprehensive support systems. 7

Pain Syndromes

• Back and limb pain affects approximately two-thirds of patients and can be muscular, radicular, or neuropathic in nature. 3
• Neuropathic pain and paresthesias require specific management with gabapentinoids or duloxetine. 3

Critical Monitoring Priorities

All patients with suspected GBS require immediate assessment of respiratory function and autonomic stability, as these determine mortality risk and need for ICU-level care. 3

• Patients with Grade 3-4 disease (severe weakness limiting self-care, dysphagia, facial weakness, respiratory muscle weakness, or rapidly progressive symptoms) require admission to units with capability for rapid ICU transfer. 3, 4
• Serial measurements of vital capacity, negative inspiratory force, and maximum inspiratory/expiratory pressures are mandatory. 3
• Continuous electrocardiographic monitoring and blood pressure monitoring are essential, particularly during the plateau and early recovery phases. 4

Common Pitfalls

• Do not dismiss the diagnosis based on normal CSF protein in the first week, as albumino-cytological dissociation may not be present early in the disease course. 3
• Avoid medications that worsen neuromuscular transmission: β-blockers, IV magnesium, fluoroquinolones, aminoglycosides, and macrolides. 3, 4
• Morbidity is strongly associated with mechanical ventilation and male sex, requiring heightened vigilance in these populations. 2
• Prolonged mechanical ventilation and severe axonal loss do not preclude favorable recovery, so aggressive supportive care should not be prematurely withdrawn. 2