Guillain-Barré Syndrome With Autonomic Instability and Limited ICU Capacity
A 47-year-old man presents with 5 days of symmetrical ascending weakness, now unable to walk, and 1 day of nasal regurgitation and dysphagia. He had watery diarrhea 2 weeks ago. Examination shows areflexia, mild facial diplegia, forced vital capacity 1.8 L (predicted 4.2 L), and maximal inspiratory pressure -25 cmH2O; oxygen saturation is 96% on room air. Blood pressure fluctuates between 180/110 and 85/50 mmHg, and heart rate between 45 and 130/min. Creatinine is 160 µmol/L, glucose 11 mmol/L, platelets 250,000/µL. CSF shows protein 85 mg/dL and 3 cells/µL. The ICU has one available bed and no plasma exchange machine on site; IVIG is stocked.
1. What respiratory and autonomic monitoring does he need, and when would you intubate?
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Diagnosis and respiratory risk: Guillain-Barré syndrome with bulbar and autonomic involvement. The 20/30/40 rule flags impending respiratory failure: vital capacity below 20 mL/kg, maximal inspiratory pressure weaker than -30 cmH2O, and maximal expiratory pressure below 40 cmH2O. His VC is 1.8 L; if he weighs about 80 kg, that is 22.5 mL/kg but falling, and his MIP of -25 is already abnormal. Bulbar dysfunction with nasal regurgitation and rapid progression are independent indications for elective intubation before aspiration or crash intubation. Monitor VC, MIP, swallowing, and single-breath count every 2-4 hours; do not rely on oxygen saturation, which can be normal until collapse.
Autonomic monitoring: continuous ECG and blood pressure; avoid vagal triggers such as suctioning without preoxygenation, treat marked hypertension with short-acting agents, and avoid sudden standing.
2. Which immunotherapy would you choose given the renal dysfunction and unavailable plasma exchange, and what would you avoid?
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Immunotherapy: IVIG 0.4 g/kg/day for 5 days is appropriate and stocked. Because creatinine is 160 µmol/L and he has diabetes, use slower infusion rates, ensure hydration, check IgA before IVIG, and monitor for thrombosis and renal worsening. Plasma exchange is equally effective and may be preferred in severe rapid disease, but no machine is on site and transfer is risky with autonomic instability. Do not combine IVIG and plasma exchange routinely.
Avoid: corticosteroids are not effective for GBS and may worsen hyperglycemia and infection. Avoid succinylcholine if intubation is needed because of hyperkalemia risk. Supportive care: DVT prophylaxis, pressure-area care, bowel regimen, pain control with gabapentin or carbamazepine, nutrition, and eye care for facial weakness. Watch for ileus and urinary retention. Prognosis: nadir is usually by 4 weeks; monitor for treatment-related fluctuations.