ICU · neurocritical-care

Guillain-Barre Syndrome — Comprehensive ICU Management

Also known as Guillain-Barre syndrome · GBS · Acute inflammatory demyelinating polyneuropathy · AIDP · Acute motor axonal neuropathy · AMAN · Miller-Fisher syndrome · MFS · Acute flaccid paralysis · Ascending paralysis · Neuromuscular respiratory failure

Guillain-Barre syndrome (GBS) — acute immune-mediated polyradiculoneuropathy causing rapidly progressive (hours to 4 weeks) ascending flaccid paralysis + areflexia ± autonomic dysfunction ± respiratory failure ± cranial nerve involvement. ICU admission for: respiratory failure (20-30% of cases develop the severe generalised manifestation with respiratory failure), severe autonomic dysfunction (arrhythmia, BP swings), bulbar weakness (aspiration risk), or severe weakness (unable to walk unaided). Variants: AIDP (demyelinating, commonest in the West), AMAN/AMSAN (axonal — Campylobacter jejuni), Miller-Fisher (ophthalmoplegia + ataxia + areflexia + GQ1b antibody), Bickerstaff brainstem encephalitis. Diagnostic: Brighton criteria (progressive weakness, areflexia, CSF albuminocytologic dissociation, NCS abnormalities). Treatment: IVIG (0.4 g/kg/day for 5 days) OR plasma exchange (12-15 L in four to five exchanges over 1-2 weeks) — equally effective, no benefit from combining, corticosteroids are INEFFECTIVE. ICU management: serial FVC and respiratory-pressure monitoring (progression to respiratory failure is associated with vital capacity <20 mL/kg, maximal inspiratory pressure <30 cmH2O, maximal expiratory pressure <40 cmH2O, or a >30% decline), autonomic monitoring (ECG, BP — watch for sudden asystole from vagal hypertonia), DVT prophylaxis, pain management (neuropathic pain common — gabapentinoids, TCAs or carbamazepine per EAN/PNS), early physiotherapy. Prognosis: 3-10% die and 20% are still unable to walk after 6 months. Erasmus GBS Respiratory Insufficiency Score (EGRIS, 0-7) stratifies the risk of artificial ventilation.

high26 referencesUpdated 26 July 202623 min readSource-verified · Sept 2026

Checked against its sources on 2 Sept 2026

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Red flags

FVC <20 mL/kg, maximal inspiratory pressure <30 cmH2O, maximal expiratory pressure <40 cmH2O, or a fall of >30% in any of these measures predicts progression to respiratory failure — prepare for elective intubation (do not wait for the emergency)
Bulbar weakness (dysphagia, poor cough, pooled secretions) plus declining respiratory function = VERY HIGH intubation risk — intubate early before aspiration
Autonomic dysfunction can cause SUDDEN DEATH from asystole (vagal hypertonia) — continuous ECG monitoring for ALL GBS ICU patients — have atropine + external pacemaker ready
Blood pressure swings are BRISK and UNPREDICTABLE in GBS — use short-acting, titratable agents — avoid long-acting antihypertensives
CSF: albuminocytologic dissociation (elevated protein with a normal cell count). Mild pleocytosis (5 to 50 cells/µL) occurs in about 15% — none of 494 patients in the Brighton validation series had more than 50 cells/µL, so marked pleocytosis should prompt reconsideration of the diagnosis (HIV-associated GBS, lymphoma, leptomeningeal disease)
Campylobacter jejuni infection (preceding diarrhoeal illness) is linked to the axonal AMAN variant via molecular mimicry
DO NOT give corticosteroids — they do NOT hasten recovery in GBS (Cochrane meta-analysis; oral steroids may delay recovery)
IVIG and plasma exchange are EQUALLY effective — do NOT combine (the Lancet 1997 international trial found PE followed immediately by IVIg conferred no advantage)

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Practise this topic8 MCQs with explanations

Target exams

CICMFFICMEDIC

Red flags

FVC <20 mL/kg, maximal inspiratory pressure <30 cmH2O, maximal expiratory pressure <40 cmH2O, or a fall of >30% in any of these measures predicts progression to respiratory failure — prepare for elective intubation (do not wait for the emergency)
Bulbar weakness (dysphagia, poor cough, pooled secretions) plus declining respiratory function = VERY HIGH intubation risk — intubate early before aspiration
Autonomic dysfunction can cause SUDDEN DEATH from asystole (vagal hypertonia) — continuous ECG monitoring for ALL GBS ICU patients — have atropine + external pacemaker ready
Blood pressure swings are BRISK and UNPREDICTABLE in GBS — use short-acting, titratable agents — avoid long-acting antihypertensives
CSF: albuminocytologic dissociation (elevated protein with a normal cell count). Mild pleocytosis (5 to 50 cells/µL) occurs in about 15% — none of 494 patients in the Brighton validation series had more than 50 cells/µL, so marked pleocytosis should prompt reconsideration of the diagnosis (HIV-associated GBS, lymphoma, leptomeningeal disease)
Campylobacter jejuni infection (preceding diarrhoeal illness) is linked to the axonal AMAN variant via molecular mimicry
DO NOT give corticosteroids — they do NOT hasten recovery in GBS (Cochrane meta-analysis; oral steroids may delay recovery)
IVIG and plasma exchange are EQUALLY effective — do NOT combine (the Lancet 1997 international trial found PE followed immediately by IVIg conferred no advantage)

Meet the patient

A 34-year-old man develops ascending leg then arm weakness over four days after a diarrhoeal illness. Reflexes are absent. His FVC falls from 28 to 16 mL/kg over 12 hours; NIF is −28 cmH2O. CSF protein is 1.1 g/L with 4 cells. He needs intubation for progressive weakness and a weak cough — a vital capacity already under 20 mL/kg and falling fast sits exactly on the thresholds that predict progression to respiratory failure, and the falling trajectory compounds the risk.^[17]^[12]

The two questions that decide his next hour are the two that decide every GBS: is the diaphragm failing? (the serial vital capacity and respiratory pressures answer it) and is the heart stable? (the monitor answers it). Intubate on the trajectory, start IVIG or plasma exchange within the treatment window, and keep atropine within reach — the silent killer in GBS is asystole from vagal hypertonia.^[1]^[14]

The one-paragraph exam answer

Guillain-Barre syndrome (GBS) is an acute, immune-mediated polyradiculoneuropathy presenting with rapidly progressive (within 4 weeks) ascending flaccid paralysis plus areflexia plus or minus autonomic dysfunction, cranial-nerve (bulbar or facial) involvement, and respiratory failure (20 to 30 per cent of cases). Triggered by a preceding infection (most importantly Campylobacter jejuni; also CMV, EBV, Mycoplasma, Zika). Variants: AIDP (demyelinating — the commonest in Western populations), AMAN or AMSAN (axonal — C. jejuni-associated), Miller-Fisher (ophthalmoplegia plus ataxia plus areflexia; anti-GQ1b positive in 18 of 19 typical cases). Diagnosis: Brighton criteria. Treatment: IVIG 0.4 g/kg for 5 days (within 2 weeks of onset, also advised up to 4 weeks, if unable to walk unaided) OR plasma exchange 12 to 15 L in four to five exchanges over 1 to 2 weeks (within 4 weeks) — equally effective, never combined, never corticosteroids. Intubate on the trajectory (vital capacity under 20 mL/kg, maximal inspiratory pressure under 30 cmH2O, maximal expiratory pressure under 40 cmH2O, or a fall over 30 per cent); avoid suxamethonium. 3 to 10 per cent die and 20 per cent are still unable to walk after 6 months.^[1]^[17]^[21]^[15]

References26Show

[1]van Doorn PA, Van den Bergh PYK, Hadden RDM, et al. European Academy of Neurology/Peripheral Nerve Society Guideline on diagnosis and treatment of Guillain-Barré syndrome Eur J Neurol, 2023.PMID 37814552
[2]van der Meché FG, Schmitz PI, et al. A randomized trial comparing intravenous immune globulin and plasma exchange in Guillain-Barré syndrome. Dutch Guillain-Barré Study Group N Engl J Med, 1992.PMID 1552913
[3]Plasma Exchange/Sandoglobulin Guillain-Barré Syndrome Trial Group Randomised trial of plasma exchange, intravenous immunoglobulin, and combined treatments in Guillain-Barré syndrome Lancet, 1997.PMID 9014908
[4]Hughes RA, Swan AV, van Doorn PA Intravenous immunoglobulin for Guillain-Barré syndrome Cochrane Database Syst Rev, 2014.PMID 25238327
[5]Chevret S, Hughes RA, Annane D Plasma exchange for Guillain-Barré syndrome Cochrane Database Syst Rev, 2017.PMID 28241090
[6]Hughes RA, Brassington R, Gunn AA, et al. Corticosteroids for Guillain-Barré syndrome Cochrane Database Syst Rev, 2016.PMID 27775812
[7]van Koningsveld R, Schmitz PIM, van der Meché FGA, et al. Effect of methylprednisolone when added to standard treatment with intravenous immunoglobulin for Guillain-Barré syndrome: randomised trial Lancet, 2004.PMID 14738791
[8]Walgaard C, Jacobs BC, Lingsma HF, et al. Second intravenous immunoglobulin dose in patients with Guillain-Barré syndrome with poor prognosis (SID-GBS): a double-blind, randomised, placebo-controlled trial Lancet Neurol, 2021.PMID 33743237
[9]Walgaard C, Lingsma HF, Ruts L, et al. Prediction of respiratory insufficiency in Guillain-Barré syndrome Ann Neurol, 2010.PMID 20517939
[10]Doets AY, Walgaard C, Lingsma HF, et al. International Validation of the Erasmus Guillain-Barré Syndrome Respiratory Insufficiency Score Ann Neurol, 2022.PMID 35106830
[11]van Koningsveld R, Steyerberg EW, Hughes RA, et al. A clinical prognostic scoring system for Guillain-Barré syndrome Lancet Neurol, 2007.PMID 17537676
[12]Fokke C, van den Berg B, Drenthen J, et al. Diagnosis of Guillain-Barré syndrome and validation of Brighton criteria Brain, 2014.PMID 24163275
[13]Willison HJ, Jacobs BC, van Doorn PA Guillain-Barré syndrome Lancet, 2016.PMID 26948435
[14]van den Berg B, Walgaard C, Drenthen J, et al. Guillain-Barré syndrome: pathogenesis, diagnosis, treatment and prognosis Nat Rev Neurol, 2014.PMID 25023340
[15]van Doorn PA, Ruts L, Jacobs BC Clinical features, pathogenesis, and treatment of Guillain-Barré syndrome Lancet Neurol, 2008.PMID 18848313
[16]Shang P, Zhu M, Baker M, et al. Mechanical ventilation in Guillain-Barré syndrome Expert Rev Clin Immunol, 2020.PMID 33112177
[17]Lawn ND, Fletcher DD, Henderson RD, et al. Anticipating mechanical ventilation in Guillain-Barré syndrome Arch Neurol, 2001.PMID 11405803
[18]Sharshar T, Chevret S, Bourdain F, et al. Early predictors of mechanical ventilation in Guillain-Barré syndrome Crit Care Med, 2003.PMID 12545029
[19]Lawn ND, Wijdicks EF Tracheostomy in Guillain-Barré syndrome Muscle Nerve, 1999.PMID 10417787
[20]Wijdicks EF, Roy TK BiPAP in early guillain-barré syndrome may fail Can J Neurol Sci, 2006.PMID 16583732
[21]Chiba A, Kusunoki S, Obata H, et al. Serum anti-GQ1b IgG antibody is associated with ophthalmoplegia in Miller Fisher syndrome and Guillain-Barré syndrome: clinical and immunohistochemical studies Neurology, 1993.PMID 8413947
[22]Hor JY Cardiac arrhythmia after succinylcholine administration in a patient with Guillain-Barré syndrome--a case report Middle East J Anaesthesiol, 2010.PMID 21526679
[23]Reilly M, Hutchinson M Suxamethonium is contraindicated in the Guillain-Barré syndrome J Neurol Neurosurg Psychiatry, 1991.PMID 1800653
[24]Tran DTT, Newton EK, Mount VAM, et al. Rocuronium versus succinylcholine for rapid sequence induction intubation Cochrane Database Syst Rev, 2015.PMID 26512948
[25]Ruts L, Drenthen J, Jacobs BC, et al. Distinguishing acute-onset CIDP from fluctuating Guillain-Barre syndrome: a prospective study Neurology, 2010.PMID 20427754
[26]Cui H, He G, Yang S, et al. Inappropriate Antidiuretic Hormone Secretion and Cerebral Salt-Wasting Syndromes in Neurological Patients Front Neurosci, 2019.PMID 31780881