Treating Guillain-Barre syndrome

If you suspect that your patient may have Guillain-Barre syndrome (GBS), your first step is to admit the patient for close observation to watch for disease progression.

Patients with minor findings can progress rapidly, so don’t discharge them unless their clinical picture is clear and improving. Patients can deteriorate quickly with a sudden loss of respiratory control, abrupt swings in vital signs, aspiration, and cardiovascular complications.

Admit the patient to an intensive care unit (ICU) if you are concerned about respiratory effort, dysautonomia, lower cranial nerve dysfunction (which presents as difficulty swallowing or coughing), or if the patient shows signs of aspiration.

Up to one-third of GBS patients will require ICU admission. Older patients and patients who show rapid deterioration are more likely to require ICU admission and respiratory support.

With GBS, the patient should be closely monitored with these tests and checks:

• Neurological checks
• Oxygenation monitoring
• Pulmonary function evaluation
• Vital sign checks

Make sure to order frequent neurological and vital sign checks for your patients with GBS, as well as frequent evaluation of respiratory effort. Blood pressure can fluctuate in patients with GBS, so you must be careful not to overtreat! Overaggressive management can result in profound hypotension, hypertension, or dysrhythmia.

Monitor the patient’s oxygenation, cardiac function, and vital signs. Consult respiratory support teams to perform serial bedside pulmonary function evaluations and pulmonary hygiene procedures.

As well, watch for signs and symptoms of atelectasis, pneumonia, urinary tract infection, and sepsis in your GBS patients.

Consider the standard consultation services and referrals for your patients with GBS:

• Neurology
• Nutritional support
• Rehabilitative therapy
• Speech therapy
• Psychiatric services

Make sure to consult with a neurologist and initiate nutritional support and rehabilitative therapy early. It is also recommended to consult with a speech therapist who can assess swallowing capabilities and aspiration risk. Parenteral nutrition may be necessary, and it’s important to aggressively support adequate caloric intake. Special diets may be necessary to avoid aspiration when patients are taking their food enterally.

As well, initiate physical and occupational therapy for patients with GBS. But if it is early in the disorder—or if the patient has a severe presentation of the disease—do not send them away from the unit for therapy. Rapid decline, particularly in respiration, could result in a disaster. For patients in the ICU, therapy should be conducted at the bedside.

Patients with GBS will benefit from working on range of motion (ROM) and voluntary movement. Physiotherapy and occupational therapy can help mitigate certain complications of immobilization such as decubiti, atelectasis, pneumonia, contractures, and deep vein thrombosis (DVT). However, be aware that swings in vital signs can occur with changes in the patient’s position.

Patients with GBS may also suffer psychological symptoms at the peak of their illness. Provide your patients with emotional support and consult psychiatric services accordingly.

Five additional treatments should be considered in the treatment of GBS:

1. Deep vein thrombosis (DVT) prophylaxis
2. Bowel and bladder function support
3. Intravenous immunoglobulin (IVIG) treatment
4. Plasma exchange
5. Immune modulators

Paralysis increases the risk of blood clots, which can occur in 5–20% of patients with GBS. For this reason, it is important to initiate DVT prophylaxis early.

Bowel and bladder function need to be monitored and supported in patients with GBS, since immobilization and medication may contribute to retention.

As well, treatment with intravenous immunoglobulins (IVIGs) should be initiated early as it is fairly effective in reducing the duration of GBS by as much as 50%. A ten-day course of plasma exchange has shown similar results. Intravenous immunoglobulins are generally considered easier and safer to administer than plasma exchange. Interestingly, a combination of the two therapies is not more beneficial than either one therapy alone.

Other immune modulators such as eculizumab (a complement inhibitor) have shown some promise for GBS treatment. Notably, steroid medications are not efficacious. Steroid medications can precipitate significant complications and are not currently recommended for treatment.

Multiple novel treatment regimens for GBS are currently under study. These include immunoadsorption (a form of plasma purification) and other complement inhibitors. However, none have been proven to be efficacious at this time.