Libby Cyran BSN, RN, CNRNSt. Vincent HospitalIndianapolis, IN

Paralyzed and Painfully Aware: A Discussion on

Guillain-Barré Syndrome

Objectives• Define Guillain-Barré Syndrome and its

classifications• Explain how GBS is diagnosed and treated• Consider potential complications and

nursing management• Discuss recovery and prognosis for GBS

patients• Explore a case study of a GBS survivor

Guillain-Barré Syndrome Defined

• Acute inflammatory polyneuropathy• Autoimmune• Ascending weakness and sensation changes

progressing to possible paralysis • Rare; Affecting 1-2/100,000 each year• Mortality rate = 5%

Pathophysiology• Myelin sheath on

peripheral nerves degenerates as it is attacked by the immune system

• Delays and impairs impulse along the dorsal and ventral nerve roots

• Muscles weaken and possible paralysis can result

Causes• Unknown• Post-infectious immune-mediated-Respiratory or GI

illness 1-3 weeks prior to onset

Campylobacter jejuni

• Post-surgical• Vaccination Significant elevation of GBS in1976-77 Swine Flu

vaccination season

GBS Defined3 Phases

1. Acute-rapidly progressive and potentially fatal (1-3 weeks)

2. Plateau-symptoms stabilize (several days-2 weeks)3. Recovery-remyelination of nerves (4 months-3 years),

sometimes recovery is not complete

Diagnostic EvaluationHistory• 2/3 of patients have experienced a GI or Respiratory

illness in the 3 weeks prior to onset of symptoms• Paresthesia in the legs• Stiffness or pain in legs and back• Dyspnea on exertionPhysical• Ascending weakness of the limbs (symmetrical)• Muscle weakness• Decreased/absent tendon reflexes (knee jerks)

Diagnostic Evaluation

• Lumbar Puncture Low blood cell count Elevated protein

• Nerve Conduction Velocity Decreased conduction

velocity to peripheral nerves

Treatment• No known cure• Plasmapheresis-temporarily reduces circulating

antibodies Daily exchanges for 3-5 days

• High-Dose Immune Globulin therapy-acts as a blocking receptor on the macrophages to prevent antibody attack on the myelin Daily infusions for 5 consecutive days

• Corticosteroids-thought to affect the inflammatory process, given in combination with another therapy. Some studies indicate not an effective treatment..

Complications

1. Weakness/Immobility2. Respiratory Distress3. Autonomic Dysfunction4. Nutrition5. Psychosocial6. Pain

Weakness/Immobility

Effects

• Weakness, depending on severity, leads to limited mobility to complete bedrest

• Skin breakdown, constipation, Deep Vein Thrombosis (DVT) and Pulmonary Emboli (PE)

Interventions

• Teach safety precautions• Frequently turn/reposition• Provide ROM exercises• Recommend physical

therapy referral• Assess for contractures,

edema in LE and constipation

• Provide assistive devices• Apply antiembolism

stockings

Respiratory Distress

Effects

• Decreased vital capacity and depth of respirations due to accessory muscle weakness

• Ineffective cough

Interventions

• Encourage cough/deep breathing

• Elevate HOB• Monitor breath sounds,

depth of respirations and O2 saturation

• Administer oxygen• Avoid opioids and

sedatives, if possible• Intubation

Autonomic Dysfunction

Effects

• Tachycardia and arrhythmias

• Postural hypotension• Temperature instability• Urinary retention

Interventions

• Monitor telemetry• Obtain vital signs frequently• Insert NG tube if paralytic ileus

occurs• Perform In and Out

catheterization to relieve urinary retention

• Monitor fluid and electrolytes

Nutrition

Effects

• Rapid weight loss and muscle atrophy

• Dysphagia due to cranial nerve involvement

Interventions

• Auscultate for bowel sounds; hold enteral feedings if BS are absent

• Assess chewing and swallowing ability

• During rehab, encourage small, frequent meals

• Referral to dietician for evaluation

Psychosocial

Effects

• Anxiety and depression are very common

• Inability to communicate increases anxiety

Interventions

• Build a trusting relationship• Develop a communication

system• Provide explanation and

reassurance• Provide patient call system• Recommend referral to speech

therapy• Refer to social work,

counselor, psychologist

Pain

Effects

• Described as “severe charley horse”

• Often in the extremities and low back

• Worse at night, causing sleep dysfunction

• 1/3 have pain after 2 years

Interventions

• Assess pain frequently• Administer analgesics as

required (Narcotic agents sometimes effective)

• Turn the patient frequently• Provide multiple pain relieving

techniques (massage, distraction, etc.)

Recovery• After the patient reaches

plateau, an aggressive rehab program is needed for optimal recovery

• Outcome can be predicted by age and severity of illness

• 15-25% experience residual weakness

• 1/3 of patient have pain after 2 years

Case Study-Part 1

From Guillain-Barre Syndrome to Happily Every After

• 26 year old, previously healthy female

• January 26, 2011-delivered infant by c-section

• Early February-suffered from the “flu”

• 3 weeks postpartum- tingling finger, pain in neck and weakness in lower extremities, bilaterally

• Late February-diagnosed with GBS and intubated within 24 hours of admission

Case Study-Part 2

• One IVIG dose given and patient continued to decline

• Plasmapheresis• Tracheotomy• PEG Tube

• From Guillain-Barre Syndrome to Happily Ever After

May is Guillain-Barré Awareness Month

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• Souayah, N., A. Nasar, M. Fareed, et al. Guillain-Barré Syndrome after Vaccination in United States: Data From the Centers for Disease Control and Prevention/Food and Drug Administration Vaccine Adverse Event Reporting System (1990-2005). Journal of Neuromuscular Disease 11. 1 (2009): 1-6. Ovid Full Text. Web. 19 Feb. 2015.