Guillain-Barré Syndrome Management

Algorithm Steps

1. ▶

   Start

   Suspected Guillain-Barré Syndrome

   Progressive symmetric weakness with areflexia

   1. ●

      Action

      Confirm Clinical Features

      Brighton criteria for diagnosis

      • Bilateral flaccid weakness
      • Decreased/absent deep tendon reflexes
      • Monophasic illness pattern
      • Disease nadir: 12 hours to 28 days
      • CSF: albuminocytologic dissociation
      1. ◆

         Decision

         Assess Severity

         Can patient walk unaided?

         • GBS Disability Scale
         • 0 = Healthy
         • 1 = Minor symptoms
         • 2 = Walks without support
         • 3 = Walks with support
         • 4 = Bedridden/wheelchair
         • 5 = Requires ventilation
         • 6 = Death
         1. ●

            Action

            Mild GBS (Can Walk)

            Monitor closely, treatment optional

            • Close observation for progression
            • Serial respiratory assessments
            • Immunotherapy if progressing
            • Pain management
            1. ●

               Action

               Cannot Walk Unaided

               Immunotherapy indicated

               • IVIG or PLEX within 2-4 weeks of onset
               • ICU admission if progressing
               • Serial FVC monitoring q4h
               • DVT prophylaxis
               1. ◆

                  Decision

                  Respiratory Status

                  Assess for impending failure

                  • 20/30/40 rule: FVC<20, NIF<-30, MEP<40 = ICU
                  • FVC <15 mL/kg = consider intubation
                  • FVC declining >30%/24h = escalate
                  • Note: 20/30/40 from Lawn 2001 (limited evidence)
                  1. ●

                     Action

                     Mechanical Ventilation

                     Early intubation if criteria met

                     • ~25% of GBS patients require intubation
                     • Avoid succinylcholine (hyperkalemia risk)
                     • Plan for prolonged ventilation (weeks)
                     • Tracheostomy if >2 weeks expected
                     1. ◆

                        Decision

                        Select Immunotherapy

                        IVIG vs Plasma Exchange

                        • Equally effective (Class I evidence)
                        • Treat within 2 weeks (IVIG) or 4 weeks (PLEX)
                        • Do NOT combine sequentially
                        • Steroids NOT effective in GBS
                        1. ●

                           Action

                           IVIG

                           0.4 g/kg/day × 5 days

                           • Total dose: 2 g/kg
                           • Monitor renal function
                           • Risk: headache, aseptic meningitis
                           • Contraindicated: IgA deficiency
                           1. ●

                              Action

                              Supportive Care

                              Essential throughout hospitalization

                              • DVT prophylaxis (LMWH)
                              • Pain management (gabapentin, opioids)
                              • Autonomic monitoring (BP, HR)
                              • Physical/occupational therapy
                              • Nutrition support
                              1. ⚠

                                 Warning

                                 ⚠️ Autonomic Dysfunction

                                 Present in 70% of severe GBS

                                 • Cardiac arrhythmias
                                 • Blood pressure lability
                                 • Urinary retention
                                 • Ileus
                                 • Requires ICU monitoring
                              2. ●

                                 Action

                                 Prognosis Assessment

                                 Modified Erasmus GBS Outcome Score (mEGOS)

                                 • Age, diarrhea, GBS disability score
                                 • ~80% recover to walk independently
                                 • 5% mortality
                                 • Recovery over months to years
                                 1. ✓

                                    Outcome

                                    Recovery Phase

                                    Rehabilitation and follow-up

                                    • Inpatient rehab if needed
                                    • Monitor for treatment-related fluctuations
                                    • Consider CIDP if relapsing >8 weeks
                                 2. ⚠

                                    Warning

                                    Poor Response

                                    Consider additional evaluation

                                    • Second course NOT routinely recommended
                                    • Re-evaluate diagnosis (CIDP?)
                                    • Supportive care, prolonged rehab
                                    • Some advocate repeat IVIG if worsening
                        2. ●

                           Action

                           Plasma Exchange

                           4-5 exchanges over 1-2 weeks

                           • 200-250 mL/kg total volume
                           • Replacement: 5% albumin
                           • May be faster onset than IVIG
                           • Avoid in hemodynamic instability