Guillain-Barré SyndromeEmergency

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Ascending symmetric weakness + areflexia; post-infection (Campylobacter)

ABCDE

Monitor FVC; airway if bulbar/falling FVC; cardiac monitor (autonomic); early IVIG/PLEX.

Calculators:
  1. Monitor in ICU: Forced vital capacity (FVC) — do NOT wait for desaturation to intubate
  2. LP: albuminocytologic dissociation (↑protein, normal cells) — excludes infection
  3. Treat: IVIG 0.4 g/kg/day ×5 d — start within 2 weeks of weakness onset if unable to walk unaided (may consider up to 4 wk) — OR plasma exchange 12–15 L in 4–5 exchanges over 1–2 wk, within 4 weeks (equal efficacy; EAN/PNS 2023)

Order set

  • FVC serial
  • LP (albuminocytological)
  • Nerve conduction
  • ECG (autonomic)

Escalate / ICU

  • FVC <15–20 mL/kg or falling
  • Bulbar weakness / aspiration risk
  • Autonomic instability → ICU + intubate

Criteria

AdmitAll with progressive weakness
ICUFVC <15–20 mL/kg, bulbar/autonomic involvement
IntubateFalling FVC / bulbar failure / aspiration
VentilateNeuromuscular respiratory failure
DischargePlateaued/improving, FVC safe, swallow safe, rehab

Never

  • Give steroids — they do not work in GBS (EAN/PNS 2023)
  • Sequence PE → IVIg, or switch to the other modality after failure of the first
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
  • FVC <15–20 mL/kg
  • Bulbar/autonomic involvement
  • mEGRIS risk score at admission (respiratory-insufficiency risk); progression >8 weeks → consider A-CIDP
Differentials
  • Myasthenia
  • Botulism
  • Transverse myelitis
  • Tick paralysis
Common mistakes
  • Steroids (ineffective)
  • Waiting for desaturation to intubate
Disposition & follow-up

IVIG/PLEX; ICU if respiratory/autonomic risk.

Discharge package
Medications—
Follow-upNeurology + rehab
Warning symptomsBreathing difficulty, worsening weakness, swallowing problems
💊 Treatment detail — doses & preparation
IVIGimmunoglobulin
Dose1 g/kg/day ×2 d (ITP bleeding, GBS total 2 g/kg over 2–5 d)
Preparation50/100 mL ready bottles; start slow (30 mL/h), escalate per tolerance
MonitorHeadache/aseptic meningitis, renal function, thrombosis; live vaccines after
Plasma exchangedefinitive
DoseAlternate to IVIG: 5 exchanges over 1–2 wk (equal efficacy)
PreparationCentrifugal line, albumin replacement
MonitorFVC/NIF trend — choose ONE modality: PE followed by IVIg NOT recommended; do NOT switch to the other modality after failure of the first (EAN/PNS 2023)
Gabapentinneuropathic analgesia
Dose300 mg OD day 1 → BD day 2 → TDS; titrate to 600–1200 mg TDS — gabapentinoids/TCAs are first-line for GBS neuropathic pain
Preparation100/300/400 mg capsules; taper to stop
MonitorRenal dosing, sedation, oedema
📖 EAN/PNS GBS Guideline 2023Reviewed July 2026

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