Gullian Barrè Syndrome (GBS) is an immune-mediated condition that can cause respiratory failure in 20% of cases. A 15-year old female patient presented with progressive weakness, inability to walk, and respiratory failure due to GBS. She required long-term ventilation and care over 9 months in the ICU for recovery. Her recovery was slow but she showed gradual improvements like returning speech, swallowing, and some spontaneous breathing over several months. Managing GBS patients in resource-poor settings presents challenges due to lack of medications, equipment, and support specialties, but dedicated care can improve outcomes.

1. DR. Irene AKHIDENO FMCA
Egyptian African Critical Care Summit 2017
10 Jan 2017
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3.  Gullian Barrè Syndrome (GBS) is a heterogeneous group of immune-
mediated conditions
 Variants: Incidence of 1-2/100000/year.
 Prior history of infection(respiratory or GIT)
 Require ventilatory support in 20% of cases.
 Active treatment :
◦ Plasmapheresis
◦ intravenous immunoglobulin
 Supportive therapy and multidisciplinary approach is very important.
 80% :full recovery
 16%: neurological deficit
 4%: mortality
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4.  15 year old female
 Prior history of vomiting
 Progressive history of neck pain and stiffness
 Inability to walk, weakness in both hands (global hypotonia)
 Diminishing speech
 Bulbar palsy and respiratory failure
 On admission: SpO2 of 71%, RR: 36 cycles/min, ETCO2 of 75mmHg.
 SIMV mode with an FiO2 of initially 100%, then stabilised at 60%.
 NG Tube feeding was passed as bowel sounds remained active.
 ??Administration of Immunoglobulin G
 Exchange blood transfusion for which only a unit was provided, also due
to cost.
 Care of the immobilized was instituted with passive physiotherapy,
administration of DVT prophylaxis.
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5.  At 2weeks on admission in the ICU:
 Tracheostomy : following consent
 Pressure ulcers on the pinna, occiput, scapula, sacrum,
elbows and both malleoli
◦ Despite 2hrly patient turning
◦ Air or ripple mattress in use.
◦ Wound dressing with povidone iodine and honey was
instituted.
◦ Air ripple mattresses were made available by the 3rd month,
as the pressure sores were getting larger, this remarkably
improved healing of the pressure sores without formation
of any new ones.
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6.  2 weeks in ICU, some spontaneous respiratory efforts,
 FiO2 reduced to 30%
◦ SpO2 > 97%
◦ ETCO2 within the 35-45mmHg range.
◦ The programmed respiratory rate was adjusted to
encourage her own spontaneous efforts to 6.
 34th day in the ICU, her speech had returned and was audible
though not sustained due to early exhaustion but
progressively improved.
 77th day, she had good swallowing reflex ,had stopped
drooling saliva however there was no gag or cough reflex.
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7.  At 5th month :
◦ move the neck from side to side,
◦ Return of the gag reflex
◦ feeding was increased to 4hrly due to increase in appetite.
 She was also noticed to be depressed,
◦ Escitalopram 5mg daily.
◦ Non-pharmacological methods were also employed such as
reassurance and divertional therapy( music, cartoons and movies).
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8.  By the 6th month,
◦ improved spontaneous respiratory efforts ,
◦ ventilatory mode was changed to Adaptive Support Ventilation
(ASV) as a better weaning mode and assessment of her respiratory
dynamics.
 FiO2 of 30%..
 She maintained good saturation > 97% ,
 Endtidal CO2 range of 35 – 45mmHg,
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9.  By the 8th month,
◦ cough reflex had returned,
◦ fasciculations were noticed in the muscles of the lower limbs as
physiotherapy was twice daily
◦ Commenced feeding by mouth
◦ Celebrated her 16th birthday
 9th month:
 Attempted switch to spontaneous mode
◦ Good tidal volume for 48hours
◦ However by 72 hours gradual drop in tidal volume,SpO2 and rising
ETCO2 necessitating return to ASV mode.
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10. Current status as at 9month on admission:
 She’s still in the ICU,
 Mechanically ventilated on ASV mode at 40% Min Vol
 Good oxygenation
 Stronger cough reflex .
 There is still no recovery of motor activity in all in the limbs.
 Enjoying her favourite meal ,noodles, by mouth
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12.  Finance: no health insurance coverage
 Intravenous Immunoglobulin G: expensive, unavailable
 Equipment: Arterial blood gas analyser, financial burden of frequent
payment for ABG sample analysis.
 Pressure sores: these were obvious by 2 weeks on admission ,
despite frequent turning, the availability of the ripple mattress by
the 3rd month greatly improved the healing of these ulcers as they
would have been a nidus for infection and a cause of anaemia
 Depression: fear of never walking, going back to school, leaving the
hospital alive. Issues of abandonment by her parents as they had to
source for funds outside the hospital. No child psychologist in the
hospital so she’s only seen by the mental health physicians.
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13.  Recurrent urinary tract infection: necessitated fortnight changing of
urethral catheter to mitigate this
 Anaemia: blood loss from the pressure sores during dressing and
nutritional anaemia. Feeds were fortified with blended crayfish to
improve protein content
 Hypothermia: loss of subcutaneous fat
 Future: Home care /palliative care with neurological deficit
 ??? WAY FORWARD
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14.  ICU staff :
◦ Zeal
◦ Humane
◦ Dedication
 The versatile and rugged ventilator that has been
functional non-stop for over 9 months has contributed
immensely in the management of this patient
 A compassionate and patient driven hospital management
that has taken over the financial responsibility by waiving
fees for medications, consumables and investigations.
 Donations from well meaning hospital staff and Nigerians
towards her care.
 Patient gradual improvement: A first for us
 An appreciative and intelligent patient with a zeal to live.
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15.  GBS as with other related polyneuropathies
◦ that present with respiratory failure are a challenge to
manage in resource poor settings due to unavailability of
medication, equipments and all support specialties.
 Prognosis is usually good
 Recovery is very slow.
 A dedicated and multidisciplinary ICU team, acute phase
therapy, a versatile and rugged ventilator is vital in improving
outcome.
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17. THANK YOU
-SHUKRAN
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