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Wednesday, August 29, 2007

Easing the course of Guillan-Barre syndrome

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Easing the course of Guillan-Barre syndrome
Author/s: Treesa L. Worsham
Issue: March, 2000

Patients can rapidly develop a number of life-threatening problems,
including the inabiltly to swallow and breathe. Here you'll find
information about GBS and the nursing care necessary to see patients
safely through the crisis.

In the late '70s, Guillain-Barre syndrome (GBS) was little known,
tied in the public's mind to flu shots, and much feared. The panic
associated with it then is no more, but for those afflicted, the fear
is still very real. That's 'because GBS, which comes on seemingly out
of the blue, is an inflammatory disorder that affects the peripheral
nervous system, causing motor weakness and sensory abnormalities. It
strikes approximately one in 100,000 people each year without regard
to gender, age, or race. [1]

Scientists believe that GBS, also called acute idiopathic
polyneuritis, is an autoimmune disease. What initially causes it
isn't known; however frequent triggers include viral and bacterial

Since GBS can cause respiratory paralysis, it's considered a medical
emergency. In order to act quickly and care for GBS patients most
effectively, nurses need to know how the syndrome progresses, how
it's diagnosed and treated, and what problems these patients will
encounter during their hospital stay.

Signs and symptoms are key to diagnosis

The syndrome--which can develop over hours, days, or weeks--typically
begins with muscle weakness and abnormal sensations, such as tingling
or numbness, in the legs. (The box at right explains the
pathophysiology. ) These symptoms usually ascend symmetrically to the
upper body.

There are no tests specifically for GBS, so diagnosis is based mainly
on the history and physical exam. Patients typically arrive in the ED
complaining of symptoms of two weeks' duration. They may or may not
report a recent infection.

The physical exam will reveal motor, autonomic, and sensory deficits,
which are listed in the box on page 50. Not all of these signs may be
present on the initial exam, however.

To help confirm the diagnosis, a physician may perform a lumbar
puncture. Cerebrospinal fluid in patients with GBS commonly has
elevated protein levels (greater than 400 mg/[L). [2] The doctor may
also order a nerve conduction velocity study to test for slow impulse
transmission- -another finding in GBS. Electromyography, which records
muscle activity, is also helpful; in GBS, the results generally show
that single muscle cells are activated rather than groups of muscle

Once GBS is suspected, hospitalization is a must. The patient's
condition can rapidly deteriorate into paralysis that affects the
respiratory muscles, necessitating intubation and mechanical
ventilation. Depending on the severity of the patient's symptoms (not
all will experience paralysis), he may be admitted to a medical or
neurology floor or to an ICU.

Nine out of 10 patients are at their weakest by the third week after
the onset of symptoms. [3] About 5% die. [4] The other 95% eventually
recover on their own, which normally takes at least a couple of
months. However, there are treatments that can help speed healing.

Treatment leads to faster recuperation
Plasmapheresis and intravenous immune globulin (IVIG) are two of the
more effective therapies for GBS. Plasmapheresis removes plasma from
the blood that may contain antibodies responsible for the attack.
Since it carries its own risks, though, it's generally reserved for
patients who develop major problems, such as the inability to walk.
How often plasmapheresis is done will vary depending on the patient's
condition; but in a typical case, several times over about five days
could be expected. The procedure is done only by a specially trained
nurse or technician.

Although plasmapheresis can decrease the amount of time a patient
must spend on a ventilator and bedridden in the hospital, [5] it has
its drawbacks. It must be started within two weeks of the onset of
symptoms to be effective, and has been associated, rarely, with an
increased rate of relapse. [6] Therefore, patients who've undergone
plasmapheresis should be followed closely after treatment.

An alternative to plasmapheresis is IVIG. Although the exact mode of
action is unknown, it may help GBS patients by binding good
antibodies to the receptor sites on nerve cells and preventing the
bad antibodies from attaching there.

IVIG, such as Gamimune N, is administered as an infusion over several
hours--usually once a day for three to five days. It must be given in
the earlier stages of the syndrome. IVIG can be administered by the
patient's bedside nurse so it's more readily available than

IVIG is more expensive, though. As with plasmapheresis, patients need
to be watched closely after it's administered to them.

Supportive measures keep the patient alive
Other treatment focuses on keeping the patient's body functioning as
he recovers. Even with plasmapheresis or IVIG, the patient may need
mechanical ventilation. It should be initiated when he can no longer
breathe effectively on his own -- usually once pulmonary function
tests show that his vital capacity has dropped to 10 or 12 ml/kg.

If long-term ventilatory support is needed (more than a couple of
weeks), a tracheotomy is usually done; it's generally better
tolerated than endotracheal intubation.

If the patient can't swallow or he's on a ventilator, he'll need to
be fed through a nasointestinal or gastrostomy tube. High-protein,
high-calorie enteral formulas, such as TwoCal HN, are preferred. They
deliver the calories needed to maintain basal metabolic rate and
prevent muscle wasting.

Although total parenteral nutrition is an option, enteral feeding is
preferred if the patient has a functioning gut. That's because if the
GI tract is not used, the junction between intestinal cells widens,
allowing gut bacteria to translocate and possibly cause sepsis.

A watchful eye will help spot complications
Frequent assessment is especially important in GBS; because of the
progressive nature of this disease, a change in cardiovascular,
neurological, or respiratory status can be life-threatening.

Vigilant assessment will also help detect other problems that can
develop, such as urinary tract infection. UTIs are common in GBS
patients, who may develop bladder atony and require an indwelling
(Foley) catheter to prevent urinary retention.

Gastrointestinal dysfunction can also occur. If it does, it's likely
to cause severe constipation. This problem may be alleviated
naturally with fiber or chemically with laxatives or suppositories.

Patients with CI dysfunction are also at risk for paralytic ileus. If
you suspect this--you note abdominal distention or an absence of
bowel sounds, for example--you' ll temporarily stop the feeding and
alert the physician. You may also need to perform gastric

Of course, any patient who's on a ventilator is at risk for
nosocomial pneumonia. Meticulous pulmonary hygiene--which includes
prn suctioning and chest PT to facilitate the removal of secretions--
will help prevent it.

Keeping the patient comfortable
Pain management and comfort measures are also vital. Although your
patient may have extensive paralysis, he isn't numb. On the contrary,
because GBS causes an alteration in nerve function, the patient may
develop paresthesia, deep muscle aches, and muscle stiffness.

To help relieve some of the discomfort, reposition your patient
frequently. That may mean every 30 -- 45 minutes. (This will also
help prevent nosocomial pneumonia.)

You should gently perform range-of-motion exercises approximately
three to six times a day and keep your patient's body in alignment.
Ask the occupational therapist to provide padded foot-boards or bunny
boots to prevent footdrop and supportive wrist splints to prevent

Physical therapy should be initiated early in the course of the
disease and continued throughout recovery to prevent contractures.
You can increase your patient's tolerance to the therapy by
administering an analgesic before each session. Make sure he receives
medication to help reduce neuropathic pain, such as gabapentin
(Neurontin) or a tricyclic antidepressant like amitriptyline
(Elavil). Patients with severe pain may need narcotics.

In order to guard against pressure ulcers, use an air mattress.
Padded heel and elbow protectors may help prevent abrasions from

Communication, education, and support

Keep in mind that your patient is physically, not mentally, impaired.
His hearing is intact and he's probably very anxious about what is
happening to him. Help decrease his fear by talking to him.
Acknowledge him when you enter the room, and explain what you're
doing as you perform his care.

In addition, devise a way for him to communicate. For example, if he
can blink his eyes, teach him to do so in response to Yes/No
questions--once for Yes, twice for No--or in response to large-print
picture cards. These may be available in your speech therapy
department. Or you can obtain them from the Guillain-Barre Syndrome
Foundation International (see the box below for contact information) .

Keep in mind that mechanically ventilated patients may fear that the
ventilator will become disconnected or malfunction. Be sure to
explain the built-in safeguards that will prevent that from happening.

Don't forget the family members, who are probably stressed and
anxious as well. Offer them counseling services from your pastoral
care or social work departments. Also encourage them to openly
discuss their concerns with you and join a support group.

You can help them gain a sense of control by encouraging them to
participate in their loved one's care. They can learn to perform
passive range-of-motion exercises and perhaps provide bolus feedings
through the gastrostomy tube. As the patient recovers, encourage him,
too, to take an active role in his care.

Patients are generally discharged from the hospital once they are
medically stable. They'll need physical and, possibly, occupational
therapy to regain their lost motor function. Whether rehab is done at
an inpatient center or on an outpatient basis, make sure patients
understand it can be a lengthy process that can take up to two years.

Explain that the extent of residual weakness from GBS varies.
Generally speaking, only 20% of patients still have weakness at one
year and only 5% have severe permanent disability. [5] Only about 3%
of patients will ever experience a relapse of symptoms after the
initial episode. [3]

GBS often leads to an extensive and trying hospital stay. Providing
patients and their families with education, support, and the best
nursing care possible will help them cope with the stress and chaos
this disorder brings into their lives.

TREESA L. WORSHAM is an acute care nurse practitioner at the Stern
Cardiovascular Center in Memphis.


(1.) Diseases of the peripheral nerves. (1997). In R. D. Adams, M.
Victor, & A. H. Ropper (Eds.), Principles of neurology (pp. 1302 -
1369). New York: McGraw-Hill.

(2.) Bacher, I., Braunwald. E., et al. (Eds.). (1994). Harrison's
principles of internal medicine (13th ed.). New York: McGraw-Hill.

(3.) National Institutes of Health. "Guillain-Barre Syndrome."
http://www.ninds. /Disorder/ guillain/ guillain. htm (11
Nov. 1999).

(4.) Peripheral nerve disorders. (1997). In The Merck manual of
medical information (Home edition) (pp. 330 - 344). Whitehouse
Station, NJ: Merck & Co. Inc.

(5.) Pascuzzi, R. M., & Fleck. J. D. (1997). Acute peripheral
neuropathy in adults: Guillain-Barre syndrome and related disorders.
Neurol. Clin., 15(3), 529.

(6.) Parry, G. J. (1993). Guillain-Barre syndrome. New York: Thieme
Medical Publishers. Inc.

How GBS weakens the body
The peripheral nervous system is composed of 31 pairs of spinal
nerves, 12 pairs of cranial nerves, and various plexuses and ganglia.
Each nerve cell, or neuron, is composed of several parts, including
the axon. Responsible for transmitting nerve impulses, axons are
wrapped in segments of insulation called the myelin sheath, which is
composed of Schwann cells.

In GBS, antibodies attack the Schwann cells, causing the sheath to
break down--a process called demyelination- -and the uninsulated
portion of the nerve to become inflamed. Nerve conduction is,
interrupted, causing the classic signs of muscle weakness, tingling,
and numbness, which begin in the legs or feet and work their way

It's possible that the signals to and from the legs are most
vulnerable to interruption because they have to travel the longest
distance. Perhaps that's why symptoms appear there first, and
progress upward.

The demyelination is self-limiting. Once it stops, the Schwann cells
rebuild the lost insulation. Remyelination, and therefore recovery,
occurs in reverse; it starts at the top of the body and proceeds

Clinical signs of GBS


Upper and lower limb weakness

Complete or partial absence of reflexes

Decreased pulmonary function


Cardiac dysrhythmias

Increased or decreased heart rate

Increased or decreased blood pressure

Paroxysmal hypertension

Bladder atony



Impaired response to light touch and pin prick

Decreased proprioception


* Guillain-Barre syndrome

* autoimmune disease

* peripheral nervous system

* paralysis

* respiratory failure

* lumbar puncture

* nerve condution velocity study

* electromyography

* plasmapheresis

* intravenous immune globulin (IVIG)

* mechanical ventilation

* enternal nutrition

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