Suggest treatment for Guillain-Barré syndrome

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Posted on Sat, 3 Sep 2016 in Brain and Spine
Question: I am from XXXXXXX My son of 18 years old is in ICU with ventilator support for the last seventeen days in XXXXXXX The day (18/07/2016) he was hospitalised, he was not having any strength in hand and legs. Speech was little bit distorted. Next day he started having breathing problem. Then he was put on ventilator. Doctor ( neurologist) diagnosed that he is having GBS. Next day IVIG administered for five days. Total 140 gram was administered based on his weight. After 12 days also no improvement noticed, neither in hands and legs nor in the breathing. Doctor has started second course of IVIG on 03/08/2016. The dose completed on 07/08/2016. After twenty two days also there is no improvement. Is the line of treatment ok ? How much time it will take to notice first sign of improvement? How much time it will take to come out from ventilator and to fully recover?. Please advice me urgently. Regards. XXXX
doctor
Answered by Dr. Bruno Mascarenhas 1 hour later
Brief Answer:
Treatment Line is OK. Plasmapheresis can be tried

Detailed Answer:
Hi,

Welcome to HealthCareMagic.com I am Dr.J XXXXXXX Anto Bruno Mascarenhas. I have gone through your query with diligence and would like you to know that I am here to help you.

I am sorry that your son has been in ICU in need of ventilator support
Let me answer your questions one by one

Q1 : Is the line of treatment ok ?
A1 : The line of treatment is OK. In addition, we can try plasmapheresis

Q2 : How much time it will take to notice first sign of improvement? How much time it will take to come out from ventilator and to fully recover?. Please advice me urgently. Regards. XXXX
A2 : The time to notice first sign of improvement varies from person to person. Hence we cannot give an accurate answer for this question. Same way, the time taken to come out from ventilator also varies from person to person. Hence, we cannot tell an reply for this question too

In short, Since Immunoglobins have been already given, I would suggest that Plasmapheresis may be tried

Hope you found the answer helpful.

If you need any clarification / have doubts / have additional questions / have follow up questions, then please do not hesitate in asking again. I will be happy to answer your questions.

Best Wishes for Speedy Recovery
Let me know if I can assist you further.
Take care.

-oOo-

PS 1 : After all your doubts have been cleared, kindly (a) Close this Question (b) Rate my Replies and (c) Give your Feedback.

PS 2 : In the future, for continuity of care, I encourage you to contact me directly in HealthCareMagic at http://bit.ly/askdrbruno
Above answer was peer-reviewed by : Dr. Arnab Banerjee
doctor
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Follow up: Dr. Bruno Mascarenhas 13 hours later
I reported that Doctors here diagnosed the disease is as GBS. However it may be something else. I will let you know the symptoms. Previous day till evening he was able to walk normally even carried the shopping bags. In the night during dinner time he complained some weakness in hands. Next day by 10 am he was not having much power on his limbs. He was having problem of swallowing. By 2 pm he could not walk. Could not lift anything. Speech got distorted. He was hospitalized by 5 pm. Next day he was having breathing problem and pit on ventilator. Is it GBS or something else?Please let me know. As he is not responding, disease may be something.
Now Doctors say as IVIG of total 265 grms have been put, if plasmapheresis is done, the serum will get washed out which is opposite to IVIG treatment. Please justify saying plasmapheresis can be tried.
You must have dealt with GBS patients. Based on experience, please tell me other patients have taken how many days to show first sign of improvement. I am expecting some figures.
Improvements will be seen in limbs or respiratory system? Please reply as soon as possible.
doctor
Answered by Dr. Bruno Mascarenhas 18 hours later
Brief Answer:
I have answered questions one by one

Detailed Answer:
Dear Sir

Welcome Back . I will reply to your questions one by one

-oOo-

Q1 : As he is not responding, disease may be something.
A1 : The symptoms you have described are seen in GBS. The following diseases also present with similar symptoms.
1. Myasthenia gravis,
2. Botulism,
3. Poliomyelitis,
4. Toxic neuropathy).
5. Carcinomatous invasion of the nerve roots

I hope that the treating doctors have done a CSF Analysis to confirm the diagnosis. If not done, we have to do it now to confirm the diagnosis

-oOo-


Q2 : Please justify saying plasmapheresis can be tried.
A2 : A course of plasmapheresis usually consists of ~40–50 mL/kg plasma exchange (PE) four to five times over a week. Meta-analysis of randomized clinical trials indicates that treatment reduces the need for mechanical ventilation by nearly half (from 27% to 14% with PE) and increases the likelihood of full recovery at 1 year (from 55% to 68%). So the above studies are in favour of Plasmapheresis.

However, there are many authors who say that

1. Either high-dose intravenous immune globulin (IVIg) or plasmapheresis can be initiated, as they are equally effective for typical GBS.

2. A combination of the two therapies is not significantly better than either alone.

3. IVIg is often the initial therapy chosen because of its ease of administration and good safety record.

4. Anecdotal data has also suggested that IVIg may be preferable to PE for the XXXXXXX and MFS variants of GBS.

5. There is some evidence that GBS autoantibodies are neutralized by anti-idiotypic antibodies present in IVIg preparations, perhaps accounting for the therapeutic effect.

6. The lack of noticeable improvement following a course of IVIg or PE is not an indication to treat with the alternate treatment.

So, your neurologist is right in sticking with IVIG

-oOo-

Q3 : You must have dealt with GBS patients. Based on experience, please tell me other patients have taken how many days to show first sign of improvement. I am expecting some figures.
A3 : We have seen first sign of improvement as early as one week and ask late as six months. It varies from patient to patient and we can't exactly predict how much time will be needed in case of your son. Approximately 85% of patients with GBS achieve a full functional recovery within several months to a year, although minor findings on examination (such as areflexia) may persist and patients often complain of continued symptoms, including fatigue

-oOo-

Q4 : Improvements will be seen in limbs or respiratory system? Please reply as soon as possible.
A4 : Again, this too varies from patient to patient.

Hope you found the answers helpful.

If you need any clarification / have doubts / have additional questions / have follow up questions, then please do not hesitate in asking again. I will be happy to answer your questions.

Best Wishes for Speedy Recovery
Let me know if I can assist you further.
Take care.

-oOo-

PS 1 : After all your doubts have been cleared, kindly (a) Close this Question (b) Rate my Replies and (c) Give your Feedback.

PS 2 : In the future, for continuity of care, I encourage you to contact me directly in HealthCareMagic at http://bit.ly/askdrbruno



Above answer was peer-reviewed by : Dr. Nagamani Ng
doctor
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Follow up: Dr. Bruno Mascarenhas 26 hours later
There is no improvement in limbs yet. As far as ventilator is concerned, self triggering is not there. But if the physiotherapist exerts a little push at chest ribs initiation of breathing has taken place with a different mode of venti. He could sustain for two minutes. Doctors suggested to continue the exercise. Please give me your comments. He is having some secretion. While secretion comes saturation gets reduced. Is it normal? How saturation should be ok. What diet you should suggest. How many times physiotherapy should be done in a day? Do you right now have any patients? Can you provide contact nos of relatives of patients who either have recovered or undergoing treatment?
doctor
Answered by Dr. Bruno Mascarenhas 1 hour later
Brief Answer:
I have answered Questions one by one

Detailed Answer:
Dear Sir

Welcome Back

Let me answer questions one by one

Q1 : There is no improvement in limbs yet. As far as ventilator is concerned, self triggering is not there. But if the physiotherapist exerts a little push at chest ribs initiation of breathing has taken place with a different mode of venti. He could sustain for two minutes. Doctors suggested to continue the exercise. Please give me your comments.
A1 : This will improve gradually

Q2 : He is having some secretion. While secretion comes saturation gets reduced. Is it normal?
A2 : Yes. Saturation will be reduced when there is more secretion

Q3 : How saturation should be ok.
A3 : We have to maintain Saturation of 100 percent by
1. Constant Suctioning
2. Reducing Secretion

Q4 : What diet you should suggest.
A4 : Since I am not the treating doctor, I cannot comment on this. It is for the attending Physician to decide on the diet

Q5 : How many times physiotherapy should be done in a day?
A5 : 2 to 5 times

Q6 : Do you right now have any patients?
A6 : Yes

Q7 : Can you provide contact nos of relatives of patients who either have recovered or undergoing treatment?
A7 : No. We have to respect Privacy of Patients.

Hope you found the answers helpful.

If you need any clarification / have doubts / have additional questions / have follow up questions, then please do not hesitate in asking again. I will be happy to answer your questions.

Best Wishes for Speedy Recovery
Let me know if I can assist you further.
Take care.

-oOo-

PS 1 : After all your doubts have been cleared, kindly (a) Close this Question (b) Rate my Replies and (c) Give your Feedback.

PS 2 : In the future, for continuity of care, I encourage you to contact me directly in HealthCareMagic at http://bit.ly/askdrbruno
Above answer was peer-reviewed by : Dr. Veerisetty Shyamkumar
doctor
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Follow up: Dr. Bruno Mascarenhas 2 days later
Not yet any improvement after twenty eight days. As far as ventilator is concerned, pushing the chest ribs by physiotherapist just after the exhalation with CPAP mode, he is able sustain to initiate breathing of about ten minutes. Does is indicate any improvement? Can the exercise be done when the patient is in PCV-VG mode ? What changes will be shown on the monitor in that case? Now lot of secretion is there. No fever, BP 140/80 heart bit 80-90. What should be done? Presently you have one patient. But in the past you definitely had good number of patients whom you had treated. Can you not provide some range of figures related to first sign of improvement in limbs and ventilator. How much time it took to come out from ventilator? Some statistics? During the treatment, can you provide some input about how you have given counseling to the patients as well as relatives on daily basis. What were the reactions of the relatives.
doctor
Answered by Dr. Bruno Mascarenhas 12 minutes later
Brief Answer:
I will answer questions one by one

Detailed Answer:
Dear Sir

I will answer questions one by one

Q1 : Does is indicate any improvement? Can the exercise be done when the patient is in PCV-VG mode ? What changes will be shown on the monitor in that case? Now lot of secretion is there. No fever, BP 140/80 heart bit 80-90. What should be done?
A1 : All these questions can be answered by the treating physician only. I cannot opine answers for this without examining or following up the patient

Q2 : Presently you have one patient. But in the past you definitely had good number of patients whom you had treated. Can you not provide some range of figures related to first sign of improvement in limbs and ventilator. How much time it took to come out from ventilator? Some statistics?
A2 : I have already answered this. Approximately 85% of patients with GBS achieve a full functional recovery within several months to a year, although minor findings on examination (such as areflexia) may persist and patients often complain of continued symptoms, including fatigue

Q3 : During the treatment, can you provide some input about how you have given counseling to the patients as well as relatives on daily basis. What were the reactions of the relatives.
A3 : Relatives will be in various stages of KR Grief Cycle.

Denial – The first reaction is denial. In this stage individuals believe the diagnosis is somehow mistaken, and cling to a false, preferable reality.

Anger – When the individual recognizes that denial cannot continue, they become frustrated, especially at proximate individuals, individual doctors.. Certain psychological responses of a person undergoing this phase would be: "Why my son? It's not fair!"; "How can this happen to my son?"; '"Who is to blame?"; "Why would this happen?".

Bargaining – The third stage involves the hope that the individual can avoid a cause of grief. Usually, the negotiation for an early recovery is made in exchange for a reformed lifestyle. People facing less serious trauma can bargain or seek compromise.

Depression – "I'm so sad, why bother with anything?"; "My Son is going to be in ventilator for long, so what's the point?"; "why go on?" During the fourth stage, the individual despairs at the recognition of the illness. In this state, the individual may become silent, refuse visitors and spend much of the time mournful and sullen.

Acceptance – "It's going to be okay."; "I can't fight it, I may as well prepare for it."
In this last stage, individuals embrace illness or inevitable future

Our Counselling will be based on Which Stage the Parents are at that time
You are now between Stage III and IV

Hope you found the answers helpful.

If you need any clarification / have doubts / have additional questions / have follow up questions, then please do not hesitate in asking again. I will be happy to answer your questions.

Best Wishes for Speedy Recovery
Let me know if I can assist you further.
Take care.

-oOo-

PS 1 : After all your doubts have been cleared, kindly (a) Close this Question (b) Rate my Replies and (c) Give your Feedback.

PS 2 : In the future, for continuity of care, I encourage you to contact me directly in HealthCareMagic at http://bit.ly/askdrbruno
Above answer was peer-reviewed by : Dr. Prasad
doctor
Answered by
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Dr. Bruno Mascarenhas

Neurologist, Surgical

Practicing since :2000

Answered : 803 Questions

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