Guillain Barre Syndrome (GBS)

An immune-mediated progressive demyelinating polyneuropathy characterised by symmetrical ascending proximal skeletal muscle paralysis.

80% have sensory involvement - often preceded by limb paraesthesia and back pain.
60% have autonomic dysfunction (postural hypotension, sweating, tachycardia, hypertension).
Often preceeding infection - campylobacter, CMV, EBV, mycoplasma all implicated.
Loss of deep tendon reflexes.
Onset over days.
85% make full recovery, although may take several months.
1/3 require ventilatory support.
The more rapid the onset of symptoms the more likely the progression to respiratory failure.
Impending respiratory failure evidenced by difficulty with speech or swallowing.
Inability to cough is a marker of severe respiratory impairment and usually indicates need for intubation.

Management

Immunoglobulin or plasmapheresis.
Same efficacy; IV IG much simpler.
Steroids are of no benefit.
Criteria for ventilation.

  • Bulbar involvement – inability to cough, swallow
  • FVC <1L
  • Autonomic instability
Early trachy if rapid weaning unlikely.

Prognosis

Mortality 5%
Morbidity 10%
Recovery 85%
Poor prognostic features
  • Age >40
  • Rapid onset
  • IPPV
  • Markedly impaired conduction in peripheral nerves
Intensive Care and Anaesthetic implications

Autonomic dysfunction makes cardiovascular instability likely on induction, initiation of ventilation and with postural changes.
Tachycardia due to surgical stimulus may be extreme.
Atropine can cause paradoxical bradycardia.
Hyperkalaemia with suxamethonium – risk can persist for several months post recovery.
NDMRs may be unnecessary and should be used cautiously.
Regional anaesthesia can avoid opiate use and be useful for paraesthesia.
Respiratory support likely to be needed post-op.