Learning objectives

• Describe the etiology and symptoms of Guillain-barré syndrome
• Diagnose and treat Guillain-barré syndrome
• Manage patients with Guillain-barré syndrome presenting for surgery

Background

• Guillain-Barré syndrome (GBS) is an acute demyelinating polyneuropathy typically occurring as an autoimmune response following a gastrointestinal or respiratory infection
• Most common cause of acute, flaccid, neuromuscular paralysis in the United States
• Potentially severely debilitating disorder
• Mortality rate ~10%
• Initial presentation is often misdiagnosed as hysteria

Etiology

• Affects all ages, but a tendency towards young adults and the elderly
• Slightly more prevalent in men
• Children are less severely affected
• Usually occurs within a month of a respiratory or gastrointestinal infection
• Common pathogens causing GBS:
  • Campylobacter jejuni (associated with axonal degeneration in addition to primary demyelination)
  • Epstein Barr virus
  • Mycoplasma pneumonia 
  • Cytomegalovirus

Signs & symptoms

• Clinical signs
  • Acute inflammatory demyelinating polyradiculopathy
  • Acute motor axonal neuropathy
  • Acute motor sensory axonal neuropathy
  • Miller Fisher syndrome (ataxia, areflexia, and ophthalmoplegia, possibly with limb weakness, ptosis, and facial and bulbar palsy)
• Symptoms 
  • Progressive motor weakness, usually ascending from the legs (more proximal than distal)
  • Areflexia
  • Facial palsy and bulbar weakness
  • Ophthalmoplegia
  • Sensory symptoms
  • Severe pain, often affecting the girdle area
  • Weakness of the respiratory musculature leading to respiratory failure
  • Autonomic dysfunction causing under- or overactivity of the sympathetic and parasympathetic systems leading to arrhythmias, fluctuations in blood pressure and pulse, urinary retention, ileus, and excessive sweating

Diagnosis

• Physical findings: Progressive muscle weakness and areflexia
• When GBS is suspected, monitor for arrhythmias and respiratory muscle weakness
• Further investigations:
  • Blood testing: Full blood count, urea and electrolytes, liver and renal function tests, clotting screen, calcium levels, antibody tests, blood cultures, and inflammatory markers
  • Stool cultures
  • ECG
  • Head CT
  • Lumbar puncture and CSF analysis
  • Electrophysiological studies
  • Gadolinium-enhanced MRI of the spinal cord

Treatment

• Supportive therapy
  • Physiotherapy and occupational therapy
  • Counseling
  • Nutritional support
  • Analgesia
  • Thromboembolic prophylaxis
  • Respiratory support
    • Indications for intubation and ventilation:
      • Vital capacity <20 mL/kg
      • Maximal inspiratory pressure (MIP) <30 cmH2O
      • Maximal expiratory pressure (MEP) <40 cmH2O
      • Decrease of >30% in vital capacity, MIP or MEP
• Specific therapy
  • Treatment of choice: IV immunoglobins (0.4 mg/kg daily, 5-6 days)
  • Plasmapheresis, up to 5 exchanges of 250 mL/kg of plasma with 4.5% human albumin solution (more difficult to administer, more side-effects and contraindications)
  • CSF filtration (rarely performed)

Anesthetic considerations

• Preoperative
  • Many patients are ventilated in the ICU
  • Assess bulbar and ventilatory function to predict the need for postoperative ventilation
  • Ileus increases the risks of aspiration
• Induction
  • Rapid sequence induction 
  • Succinylcholine is contraindicated due to potentially fatal hyperkalemia
  • Rocuronium is a suitable alternative
  • Autonomic dysfunction can complicate induction and intubation by resulting in a labile pulse and blood pressure
• Intraoperative
  • Controlled ventilation if respiratory function is impaired
  • Avoid nondepolarizing neuromuscular blockers
  • Consider extubating when fully recovered or once bulbar reflexes have returned
• Postoperative
  • Ventilation is often required
  • Careful monitoring of respiratory function
  • Adequate analgesia

Suggested reading

• Nguyen TP, Taylor RS. Guillain Barre Syndrome. [Updated 2022 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532254/
• Pollard BJ, Kitchen, G. Handbook of Clinical Anaesthesia. Fourth Edition. CRC Press. 2018. 978-1-4987-6289-2.
• Richards KJC, Cohen AT. Guillain‐Barré syndrome. BJA CEPD Reviews. 2003;3(2):46-9.

Clinical updates

Wang et al. (BJA, 2025) describe clinically important failure of quantitative neuromuscular monitoring in patients with prior Guillain-Barré syndrome due to persistent peripheral neuropathy, despite apparent functional recovery. The report shows that standard EMG-based and acceleromyographic monitoring may be unreliable or impossible in GBS survivors, even years after the acute illness, leading to the inability to confirm neuromuscular block depth or reversal despite large doses of sugammadex.