Management of Guillain-Barrè Syndrome

In this article, we will discuss the Management of Guillain-Barrè Syndrome. So, let’s get started.

Management

Ideally, all patients of GBS should be hospitalised for observation and subsequent management depending on the situation. Patients should preferably be treated in ICU.

1. Supportive treatment: Careful observation of cardiopulmonary function, prevention of complications (respiratory and autonomic) in ICU provides best chance for favourable outcome. Respiratory and bulbar functions, the ability to cough, heart
rate and BP must be closely monitored in ICU. Look for the signs of muscle paralysis and impending respiratory failure. Monitor FVC and negative inspiratory pressure every 4 hourly while awake. Rapidly declining FVC (<15 ml/kg and mean inspiratory fore reaches 40 mmHg) is an indication for intubation and ventilatory support.

Continuous suction may be done to remove the secretions to prevent atelectasis. The treatment includes:

• BP monitoring and frequent ECGs may allow early detection of life-threatening situations that require prompt treatment.
• Nutritional support to be provided in the form of high caloric protein diet or by beginning enteral feeding as early as possible.
• If hypotension present, use volume
expanders and vasopressors
• Subcutaneous heparin or low molec-
ular-weight heparin together with
thromboembolic deterrent stockings
may be advised routinely in patients
Immobilised for more than 2 weeks to
lower the risk of thromboembolism
• Culture of secretions, frequent blood
and urine cultures must be done for
carly detection of infection and prompt treatment
• Chest physiotherapy and frequent aspiration of the secretions to prevent chest infection and atelectasis.
• Care of skin, eyes, mouth, bowel and bladder is an essential aspect of supportive therapy.
• Frequent change of posture to be done to prevent bedsores. Physical therapy is started early because it prevents contractures, joint immoblisation and venous stasis.

2. Specific therapy:

i. High dose corticosteroids: They were earlier recommended for their potentvanti-inflammatory and immunosuppressive effects. Based on chemical trials, it is now advocated that steroids play no role in GBS management.

ii. Plasmapheresis: Therapeutic plasmapheresis is recommended for few days for patients with moderate to severe GBS. The schedule entails a series of 5 exchanges (40-50 ml/kg) with a continuous flow machine over a week using saline and albumin as replacement fluid. Patients with mild disease may benefit from 2 exchanges on alternate days.

Plasmapheresis removes several factors such as antimyelin antibodies, cytokines, complement components and other inflammatory mediators of GBS.

iii. Liquorpheresis (CSF filtration): Itis a new technique developed to purify CSF from pathological factors responsible for GBS.

iv. Intravenous immunoglobulin: High dose intravenous immunoglobulin (IVIG) has an equivalent benefit similar to plasmapheresis in GBS. Both treatment modalities (plasmapheresis and IVIG) being equally effective, hence, there is no added advantage to use them together. However, IVIG is often
initial therapy chosen because of its
ease administration and good safety
record.

There is some evidence that GBS auto-antibodies are neutralised by anti-idiotypic antibodies present in
IVIG accounting for beneficial effect
The dose of IVIG is 400mg/kg/day for
5 days or 0.5g/kg/day for 4 days (a
total of 2g/kg of body weight).

Prognosis

About 3% of patients with GBS die, mostly due to complications of ventilatory support; but some may die suddenly due to autonomic failure. Those who survive (85%) recover remarkably within several months to a year but all cases do not recover fully, i.e. areflexia may persist. Several survivors fail to achieve the previous level of activity. About 5-10% of cases may have one or more late relapses 5 such cases are then classified as chronic inflammatory demyelinating polyneuropathy (CIDP).

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