Suspected Guillain-Barré syndrome (adult or child)
Progressive, fairly symmetric limb weakness with reduced or absent reflexes
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NeurologyEmergency
Guillain-Barré Syndrome Management
Guillain-Barré Syndrome Management: Suspected Guillain-Barré syndrome (adult or child) → Red flags: rule out another diagnosis first → Confirm clinical ...
Pathway Overview
20 steps
Algorithm Steps
20 total
01Start 02Warning Red flags: rule out another diagnosis first
Sensory level or early sphincter loss: urgent spinal MRI
- Sensory level, extensor plantars, or severe bladder or bowel dysfunction at onset: urgent spinal MRI (cord compression, myelitis)
- Marked persistent asymmetry, fever at onset, reduced consciousness, or CSF cells >50/µL: GBS less likely; rethink
- Look for a tick in scalp and skin folds (tick paralysis). Also consider botulism, myasthenia gravis, low potassium
03Action Confirm clinical features
Diagnosis is clinical; CSF and nerve conduction support it
- Bilateral flaccid limb weakness
- Reduced or absent reflexes in weak limbs
- Progression over days to 4 weeks (usually under 2 weeks), then plateau
- CSF: raised protein, white cells usually <5/µL
- Normal CSF protein or normal nerve conduction in week 1 does not exclude GBS
- Blood count, glucose, electrolytes, renal and liver function
04Action Assess respiratory risk now and repeat
FVC and single breath count 3 to 6 times a day; 4-hourly while declining
- mEGRIS at admission estimates the risk of ventilation
- High risk: onset to admission <7 days, bulbar weakness, weak cough, neck flexion weakness, cannot stand
- Facial weakness makes FVC unreliable; SpO2 falls late
- Measure MIP and MEP if available
- No ICU on site: arrange early transfer if any high-risk feature
05Decision Respiratory or bulbar failure imminent?
FVC ≤20 mL/kg, FVC fall >30% in 24 h, SBC <20, MIP or MEP <40 cmH2O (absolute), weak cough or aspiration, rising PaCO2
- FVC ≤20 mL/kg, or fall >30% in 24 h
- Single breath count <20
- MIP or MEP below 40 cmH2O (absolute value)
- Bulbar weakness with weak cough or aspiration
- Rising PaCO2, hypoxaemia, or breathless when talking
- If Yes
06Action Yes, failure imminent: ICU now; plan early elective intubation
Do not use suxamethonium (severe hyperkalaemia, cardiac arrest). Expect BP and HR swings.
- Elective intubation if FVC ≤20 mL/kg, MIP or MEP below 40 cmH2O (absolute), FVC fall ≥50% in <24 h, or bulbar failure with aspiration
- SBC <20 or FVC fall >30% in 24 h alone: ICU transfer and close monitoring; FVC ≤10 mL/kg: ventilation almost inevitable
- NIV is not suitable with bulbar weakness or weak cough
- Induction: agents less likely to cause hypotension; atropine ready
- Expect prolonged ventilation; consider tracheostomy if still ventilated after 2 weeks with failed weaning
- Start immunotherapy (next step)
07Decision IVIg suitable and available?
IVIg and plasma exchange are equally effective. IVIg is easier and usual first choice, including children and pregnancy. No corticosteroids.
- Do not give plasma exchange followed straight away by IVIg
- Do not give corticosteroids (oral steroids may harm)
- Do not give a routine second IVIg course for a poor prognosis
- Children: involve a paediatric neurologist
- If Yes
08Warning Yes, IVIg: check these risks first
IgA deficiency with anti-IgA antibodies: do not give IVIg; use plasma exchange
- IgA deficiency with anti-IgA antibodies: IVIg contraindicated (anaphylaxis); use plasma exchange
- AKI risk (renal impairment, diabetes, hypovolaemia, age >65, nephrotoxic drugs): hydrate first, slowest practicable rate, check creatinine
- Thrombosis risk (older age, obesity, vascular disease, prior thrombosis, immobility): hydrate, slowest practicable rate
09Action IVIg 0.4 g/kg/day for 5 days (total 2 g/kg)
Same regimen in children. Children and pregnancy: dose on actual body weight. Australia: BloodSTAR authorisation needed.
- Adults: dose on adjusted body weight (BloodSTAR default from 1 Jul 2026); use actual weight if it is lower, and in under 18 y, under 152 cm or pregnancy
- Watch for headache, aseptic meningitis, haemolysis, fluid overload
- Monitor creatinine and fluid balance; avoid loop diuretics
- 2-day regimens: more treatment-related fluctuations in children
10Warning Autonomic dysfunction: monitor and treat with care
Common in severe GBS: arrhythmia, BP swings, ileus, urinary retention
- Continuous ECG, BP and HR monitoring; ICU if arrhythmia or marked BP swings
- Suction, turning or intubation can trigger severe bradycardia or asystole: have atropine ready
- Avoid antihypertensives and antiarrhythmics unless essential; use tricyclics with care
11Action Supportive care throughout the admission
Swallow screen before oral intake; nil by mouth and NG feeding if unsafe
- VTE prophylaxis (LMWH) while immobile, unless bleeding risk
- Pain: gabapentin or pregabalin first; carbamazepine next; opioids with care (ileus, breathing)
- Eye care in facial palsy; pressure care; bladder and bowel care
- Physiotherapy, OT and speech therapy from the acute phase
- Patients are usually fully conscious: explain procedures; screen for anxiety and depression
12Action Assess prognosis and response
mEGOS: age, preceding diarrhoea, MRC sum score (admission or day 7)
- About 80% walk independently at 6 months
- Mortality 3-10%, often from late cardiac or respiratory complications
- About 40% do not improve in the first 4 weeks after treatment
- Keep monitoring after ICU discharge
13Decision Improving or stable (treated or observed)?
Compare GBS-DS and MRC sum score with values at start of treatment or observation
- If Yes
14Outcome Improving: recovery and rehabilitation
Rehabilitation; recovery can continue for more than a year
- Inpatient rehabilitation when needed; therapy for more than 6 months if limits persist
- Watch for worsening again after improvement (treatment-related fluctuation)
- Worsening after 8 weeks or 3 or more fluctuations: think of acute-onset CIDP
If No15Outcome Not improving or worsening again: neurologist review
Observed, not treated, and now cannot walk unaided or high-risk: start IVIg or plasma exchange. Treated, no improvement: continue supportive care.
- Treated, no response: a routine second course or a switch of treatment is not advised
- Treatment-related fluctuation (worsening within 8 weeks after improvement): consider repeat IVIg or plasma exchange; Australia: second IVIg dose only on neurologist advice
- Re-check the diagnosis: acute-onset CIDP if worsening after 8 weeks or 3 or more fluctuations
- Continue supportive care and rehabilitation
If No16Action No, IVIg unsuitable: plasma exchange, 4-5 exchanges over 1-2 weeks
Total about 12-15 L plasma (200-250 mL/kg). GBS-DS 2: 2 exchanges. Severe autonomic instability: relative contraindication.
- Start within 4 weeks of onset, as soon as possible
- Needs an apheresis service and good venous access; if neither IVIg nor apheresis is available, transfer urgently
- Continuous-flow machines cause smaller volume shifts
- Less suitable for young children
- Path rejoins step 10Shared downstream outcome
If No17Decision No imminent failure: unable to walk 10 m unaided (GBS-DS 3-5)?
GBS disability scale (GBS-DS) grade 3 or more = cannot walk 10 m unaided
- GBS-DS 0: healthy
- GBS-DS 1: minor symptoms, can run
- GBS-DS 2: walks 10 m unaided, cannot run
- GBS-DS 3: walks 10 m with help
- GBS-DS 4: bedbound or chairbound
- GBS-DS 5: needs ventilation
- GBS-DS 6: dead
- If Yes
18Action Start immunotherapy as soon as possible
Cannot walk unaided (GBS-DS 3-5), or high-risk mild GBS
- IVIg: within 2 weeks of onset (also reasonable at 2-4 weeks)
- Plasma exchange: within 4 weeks of onset
- ICU if rapid progression, bulbar weakness, autonomic instability or high mEGRIS
- Continue respiratory checks 4-hourly while declining
- Path rejoins step 07Shared downstream outcome
If No19Decision Walks unaided (GBS-DS 1-2): any high-risk feature?
Any of these present: start immunotherapy as soon as possible (step above). None: observe.
- Fast deterioration or a high mEGRIS
- Swallowing difficulty or autonomic signs
- Arm weakness or cranial nerve involvement (GBS-DS 2, within 2 weeks)
- Pure Miller Fisher syndrome: usually no treatment, monitor closely
- If Yes
- Path rejoins step 18Shared downstream outcome
If No20Action No high-risk feature: observe, no immunotherapy
Stable GBS-DS 1 in weeks 0-2, or stable GBS-DS 1-2 in weeks 2-4: immunotherapy is not advised
- Reassess strength, walking, FVC and swallowing often
- Start immunotherapy if the patient can no longer walk unaided or a high-risk feature develops
- Supportive care as below
- Path rejoins step 11Shared downstream outcome
Guideline Source
European Academy of Neurology/Peripheral Nerve Society Guideline on diagnosis and treatment of Guillain-Barré syndrome (van Doorn et al, 2023)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Children: IVIg is usual first line; involve paediatric neurology. Adjusted body weight dosing does not apply under 18 years.
- Severe GBS needs ICU and apheresis access; transfer early if these are not on site.
- Variants (Miller Fisher, Bickerstaff, pharyngeal-cervical-brachial) are covered only briefly.
- Autonomic and ICU care are summarised; follow local ICU protocols.
Contraindicated Populations
Suspected spinal cord compression, myelitis or tick paralysis: pathway does not apply until excludedIgA deficiency with anti-IgA antibodies: IVIg contraindicatedChildren: paediatric neurology inputPregnancy: obstetric input; IVIg or plasma exchange both usable
Applicable Regions
AUEUUSglobal
AU: IVIg needs authorisation in BloodSTAR under the National Blood Authority Ig Criteria (GBS, v3.3, 2026). Adjusted body weight dosing is the BloodSTAR default from 1 Jul 2026. Tick paralysis (Ixodes holocyclus) mimics GBS: search for a tick.
EU: EAN/PNS 2023 guideline (published jointly in Eur J Neurol and J Peripher Nerv Syst, doi 10.1111/jns.12594).
US: IVIg and plasma exchange are both standard first-line treatments.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Guillain-Barré Syndrome Management?
The Guillain-Barré Syndrome Management is a emergency clinical algorithm for Neurology. It provides a structured decision tree to guide clinical decision-making, based on European Academy of Neurology/Peripheral Nerve Society Guideline on diagnosis and treatment of Guillain-Barré syndrome (van Doorn et al, 2023).
What guideline is the Guillain-Barré Syndrome Management based on?
This algorithm is based on European Academy of Neurology/Peripheral Nerve Society Guideline on diagnosis and treatment of Guillain-Barré syndrome (van Doorn et al, 2023) (DOI: 10.1111/ene.16073).
What are the limitations of the Guillain-Barré Syndrome Management?
Known limitations include: Children: IVIg is usual first line; involve paediatric neurology. Adjusted body weight dosing does not apply under 18 years.; Severe GBS needs ICU and apheresis access; transfer early if these are not on site.; Variants (Miller Fisher, Bickerstaff, pharyngeal-cervical-brachial) are covered only briefly.; Autonomic and ICU care are summarised; follow local ICU protocols.. Individual patient factors may require deviation from these recommendations.
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