The CICM examiners love GBS. Their love is probably proportional to the importance of this condition for the intensivist, as a GBS patient often makes the ICU their home for some considerable number of weeks. Some of the GBS-flavoured questions from the exam in recent past have included the following:
Not only does GBS appear in SAQs but it inevitably finds its way into the hot cases. If there's a GBS at the hospital where the exam is being held, you bet your arse they're going in front of the candidates. Locally, chapters of interest include Approach to the ICU patient with generalised weakness and Features that distinguish Guillain-Barre syndrome from critical illness polyneuromyopathy. Distally, a LITFL article on GBS offers an extensive and well-referenced revision resource.
From Shahrizaila et al (2021):
Laboratory findings
Electrolphysiology
Imaging
Features suggestive of poor prognosis in GBS:
Overall, the mortality in GBS patients admitted to ICU is around 25% according to Oh's Manual
These patients are often referred to the ICU for "monitoring in case of deterioration". Of course, the same could be said of all the patients in the hospital (they could all deteriorate!) and it would be unusual for the intensivist to admit the patient to the ICU just because a diagnosis of GBS has been established. Of the total number of GBS patients admitted to hospital, there is a large proportion who never require ICU admission. For example, Barnes & Herkes (2019) reported a 13% ICU admission rate in a cohort from Concord Hospital in Sydney, which is a mixed ICU/HDU environment, i.e. it would be unexpected for them to be especially reluctant to accept "soft" patients. They would not have allowed borderline cases to languish in the general medical wards.
So, what criteria can you use to decided whether a patient needs to come to the ICU for ongoing monitoring? This is a decision which is not made on the basis of deteriorating lung function alone, but deteriorating lung function certainly seems to have become the focus of attention. Specifically, spirometry data has somehow risen into a position of prominence. The "20/30/40 rule" is often quoted, which consists of:
This 20/30/40 rule, which everybody seems to uncritically apply, has come from a paper by Lawn et al (2001), which was a single centre retrospective study reporting on a historical period spanning from 1976 to 1996. It has already been publically dismembered by Josh Farkas, and nothing else about it can be usefully said, other than it should not be used as the sole trigger for intubation in GBS. However, to abandon the mindless application of this rule does not mean to completely ignore spirometry data. One should make their decision on the basis of a multifaceted assessment which takes into account all of the angles of this complex situation.
So, in summary, the following factors would need to be considered:
When do we offer them a tracheostomy? Nobody knows, is the short answer, but it appears as if there is no point in rushing into anything.
Some experts hold that if the pulmonary function tests fail to improve with treatment and two weeks of intubation has passed without change, a tracheostomy should be offered. Patients showing subtle improvement might be able to wait for another week. This is consistent with observational data which suggest that most patients with GBS seem to get a tracheostomy after about 12 days of ventilation, which is roughly the period of time required to trial plasmapheresis or immunoglobulin and to become disappointed with their effects. By twelve days, the intensivist will have come to the conclusion that we are in this for the long haul, and a tracheostomy is inevitable.
Early tracheostomy, on the other hand, does not seem to have much of a mortality benefit. One might expect to find it, as many GBS patients cannot be successfully extubated; for example in one small but representative study of 44 patients, Nguyen et al (2006) were only able to successfully extubate 14. Surely, one might say, it is pointless to wait, as most of these people cannot be weaned quickly. Yes, this may be true, but an early tracheostomy ritual does not seem to ward against major complications of ICU stay, and does not seem to improve mortality. Early small-scale studies seemed to suggest that a late tracheostomy was associated with more chances of a ventilator associated pneumonia (Ali et al, 2006), but the larger the studies get, the smaller this effect seems to become. In their observational study of 654 tracheostomised GBS patients, Naoki et al (2020) were not able to find any outcome difference between patients who had a tracheostomy within the first 7 days of their stay, vs. those who had a tracheostomy after the obligatory two-week wait.
In summary:
Question 22 from the first paper of 2020 specifically asked about the different factors which predispose these patients to frequent infections, and how you would go about minimising that risk. The answer to that question is duplicated here to facilitate revision:
Infectious consequences | Contributing factors |
VAP |
|
Sinusitis |
|
Hospital-acquired pneumonia |
|
Pressure area infections |
|
Line-related sepsis |
|
Urinary tract infection |
|
Increased predisposition to infection |
|
Resistant organisms |
|
With this exercise behind us, we can easily recombine the contributing factors into a structured list of interventions designed to address them:
Factor | Intervention |
Prolonged intubation |
|
Gram-negative colonisation of the lower airway |
|
Poor oral hygiene |
|
Weak cough |
|
Prolonged NGT dwell-time |
|
Impaired airway defence reflexes |
|
Prostration and basal atelectasis |
|
Prolonged immobility |
|
Prolonged need for parenteral medications |
|
Long term IDC |
|
Immunosuppressant therapies |
|
Malnutrition |
|
Resistant organisms |
|
Cross-contamination with MROs |
|
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