Guillain-Barre syndrome Management,

Medications and Nursing Considerations

Prehospital and Emergency Department Care
Prehospital care of patients with Guillain-Barr syndrome (GBS) requires careful attention to
airway, breathing, and circulation (ABCs). Administration of oxygen and assisted ventilation
may be indicated, along with establishment of intravenous access. Emergency medical
services personnel should monitor for cardiac arrhythmias and transport expeditiously.
In the emergency department (ED), continuation of ABCs, intravenous treatment, oxygen,
and assisted ventilation may be indicated. Intubation should be performed on patients who
develop any degree of respiratory failure. Clinical indicators for intubation in the ED include
the following:

Hypoxia
Rapidly declining respiratory function
Poor or weak cough
Suspected aspiration
Typically, intubation is indicated when the forced vital capacity (FVC) is less than 15
mL/kg. Declining NIF to -30 cm water should cause concern and very close monitoring.
Patients should be monitored closely for changes in blood pressure, heart rate, and
arrhythmias. Treatment is rarely needed for tachycardia. Atropine is recommended for
symptomatic bradycardia.
Because of the lability of dysautonomia, hypertension is best treated with short-acting
agents, such as a short-acting beta blocker or Nitroprusside. Hypotension from
dysautonomia usually responds to intravenous fluids and supine positioning. Temporary
pacing may be required for patients with second- and third-degree heart block.
Consult a neurologist if any uncertainty exists as to the diagnosis. Consult the ICU team for
evaluation of need for admission to the unit.

Medical Management
Immunomodulatory therapy, such as plasmapheresis or the administration of
intravenous immunoglobulins (IVIGs), is frequently used in patients with Guillain-Barr
syndrome (GBS). The efficacy of plasmapheresis and IVIGs appears to be about equal in
shortening the average duration of disease. Combined treatment has not been shown to
produce a further, statistically significant reduction in disability.
The decision to use immunomodulatory therapy is based on the disease's severity and rate
of progression, as well as on the length of time between the condition's first symptom and
its presentation. Risks, such as thrombotic events associated with IVIG, should be taken
into consideration. Patients with severe, rapidly progressive disease are most likely to
benefit from treatment, with faster functional recovery.

Plasma exchange (plasmapheresis). The liquid portion of part of your blood

(plasma) is removed and separated from your blood cells. The blood cells are then put
back into your body, which manufactures more plasma to make up for what was
removed. Plasmapheresis may work by ridding plasma of certain antibodies that
contribute to the immune system's attack on the peripheral nerves.

Immunoglobulin therapy. Immunoglobulin containing healthy antibodies from blood

donors is given through a vein (intravenously). High doses of immunoglobulin can block
the damaging antibodies that may contribute to Guillain-Barre syndrome.

These treatments are equally effective. Mixing them or administering one after the other is
no more effective than using either method alone.

Medications
Immunomodulatory Agents
Class Summary
These medications are used to improve the clinical and immunologic aspects of GBS. They
may decrease autoantibody production and increase the solubilization and removal of
immune complexes.

Intravenous immunoglobulin (Bivigam, Carimune NF, Gammagard S/D, Gamunex-C,

Hizentra, Octagam, Privigen)

IVIG is derived from fractionated, purified human plasma collected from a large pool of
multiple donors. The product is treated with solvents and detergents to inactivate any
blood-borne virus. IVIG may work via several mechanisms, including the blockage of
macrophage receptors, the inhibition of antibody production, the inhibition of complement
binding, and the neutralization of pathologic antibodies.

Low Molecular Weight Heparin

Class Summary
Low molecular-weight heparin (LMWH) is used in the prophylaxis of deep venous
thrombosis (DVT). The first LMWH to become available in the United States was enoxaparin
(Lovenox). LMWH has been used widely in pregnancy, although clinical trials are not yet
available to demonstrate that it is as safe as unfractionated heparin.
Reversible elevation of hepatic transaminase levels occurs occasionally. Heparin-associated
thrombocytopenia has been observed with LMWH.

Enoxaparin (Lovenox) enhances the inhibition of factor Xa and thrombin by

increasing antithrombin III activity. It also slightly affects thrombin and clotting time
and preferentially increases the inhibition of factor Xa.

This agent has a wide therapeutic window; the prophylactic dose is not adjusted based on
the patient's weight. Enoxaparin is safer and more effective than unfractionated heparin for
prophylaxis of venous thromboembolism. The average duration of treatment is 7-14 days.

Dalteparin (Fragmin) is an LMWH with antithrombotic properties. It enhances the

inhibition of Factor Xa and thrombin by increasing antithrombin. It has a minimal
effect on activated partial thromboplastin time (aPTT).
Tinzaparin - is an LMWH with antithrombotic properties. It enhances the inhibition of
Factor Xa and thrombin by increasing antithrombin. It has a minimal effect on aPTT.

Analgesics
Class Summary
Pain medications may be required in inpatient and outpatient settings. A tiered
pharmacologic approach that starts with nonsteroidal anti-inflammatory drugs (NSAIDs) or
acetaminophen, with narcotic agents added as needed, is usually recommended.

Acetaminophen (Tylenol, AspirinFree Anacin, Cetafen, APAP 500, Mapap Extra

Strength)
Ibuprofen (Motrin, Advil, Neoprofen, Provil)
Indomethacin (Indocin)
Naproxen (Naprosyn, Naprelan, Aleve, Anaprox)
Diclofenac (Voltaren, Cataflam XR, Zipsor, Cambia)
Ketoprofen
Celecoxib (Celebrex)

People with Guillain-Barre syndrome need physical help and therapy before and during
recovery. Your care may include:

Movement of your arms and legs by caregivers before recovery, to help keep your
muscles flexible and strong

Physical therapy during recovery to help you regain strength and proper movement
Training with adaptive devices, such as a wheelchair or braces, to give you mobility and
self-care skills
If the diaphragm is weak, breathing support or even a breathing tube and ventilator
may be needed.
Exercise therapy, to cope with fatigue
Alert!
Corticosteroids
Corticosteroids are not recommended for the treatment of Guillain-Barr syndrome.
Although corticosteroids are often used to reduce inflammation, there is no evidence to suggest they
offer a significant benefit in treating this condition.
A few studies have investigated other medications to treat GBS; however, the trials have been small
and the evidence weak, highlighting the need for further investigation of potential treatment options.

Recovery
Although some people can take months and even years to recover, most people with
Guillain-Barre syndrome experience this general timeline:

After the first signs and symptoms, the condition tends to progressively worsen for
about two weeks
Symptoms reach a plateau within four weeks
Recovery begins, usually lasting six to 12 months, though for some people it could take
as long as three years

Among adults recovering from Guillain-Barre syndrome:

About 80 percent can walk independently six months after diagnosis

About 60 percent fully recover motor strength one year after diagnosis
About 5 to 10 percent have very delayed and incomplete recovery

Children, who rarely develop Guillain-Barre syndrome, generally recover more completely
than adults.

Coping and support

A diagnosis of Guillain-Barre syndrome can be emotionally difficult. Although most people
eventually recover fully, the condition is generally painful and requires hospitalization and
months of rehabilitation. You must adjust to limited mobility and fatigue.
To manage the stress of recovery from Guillain-Barre syndrome, consider these
suggestions:

Maintain a strong support system of friends and family

Contact a support group, for yourself or for family members
Discuss your feelings and concerns with a counselor

Nursing Interventions for Guillain-Barre Syndrome

1. Monitor respiratory status through
vital capacity measurements, rate and
depth of respirations, and breath
sounds.
2. Monitor level of muscle weakness as it
ascends toward respiratory muscles.
Watch for breathlessness while talking
which is a sign of respiratory fatigue.
3. Monitor the patient for signs of
impending respiratory failure.
4. Monitor gag reflex and swallowing
ability.
5. Position patient with the head of bed
elevated to provide for maximum
chest excursion.

6. Avoid giving opioids and sedatives that

may depress respirations.
7. Position patient correctly and provide
range-of-motion exercises.
8. Provide good body alignment, rangeof-motion exercises, and change of
position to prevent complications such
as contractures, pressure sores, and
dependent edema.
9. Ensure adequate nutrition without the
risk of aspiration.
10. Encourage physical and occupational
therapy exercises to help the patient
regain strength during rehabilitation
phase.

11. Provide assistive devices as needed

(cane or wheelchair) to maximize
independence and activity.
12. If verbal communication is possible,
discuss the patients fears and
concerns.
13. Provide choices in care to give the
patient a sense of control.
14. Teach patient about breathing
exercises or use of an incentive
spirometer to reestablish normal
breathing patterns.

15. Instruct patient to wear good

supportive and protective shoes while
out of bed to prevent injuries due to
weakness and paresthesia.
16. Instruct patient to check feet routinely
for injuries because trauma may go
unnoticed due to sensory changes.
17. Urge the patient to maintain normal
weight because additional weight will
further stress monitor function.
18. Encourage scheduled rest periods to
avoid fatigue.

Nurses Note:
Knowing when to intubate
Patients require intubation if they meet
these three criteria:
* FVC < 20 mL/kg
* maximum inspiratory pressure < 30 cm
H2O
* maximum expiratory pressure < 40 cm
H2O.

Patients probably require intubation if

they meet at least four of these six
criteria:
* symptoms began less than 7 days ago
* can't lift elbows off bed
* can't lift head off bed
* can't stand up
* can't cough effectively
* liver enzyme levels are elevated.

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