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Guillain-Barre syndrome

. 79-year-old male was a patient of 1.HTN 2.GBS s/p 7 times plasmapheresis. Brief history. Septic shock was noted on 7/20 at our ER, and hemodynamics was stable under ABX used.Cardiac echo(7/26) : vegetation on MV and IE was diagnosis and treated by medicationCardiac echo(8/11): progressive IE ( vegetation on RCC

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Guillain-Barre syndrome

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    1. Guillain-Barre syndrome Ri ???

    3. Brief history Septic shock was noted on 7/20 at our ER, and hemodynamics was stable under ABX used. Cardiac echo(7/26) : vegetation on MV and IE was diagnosis and treated by medication Cardiac echo(8/11): progressive IE ( vegetation on RCC&NCC of aortic valve , destructive LCC of aortic valve)

    4. Brief history Acute onset dyspnea , CXR : pulmonary effusion on 8/19 Desaturation on 8/24 , intubation Persisted pleural effusion and decreasing urine output was noted OP method : AVR with Biocor tissure valve on 8/28

    5. Past history 1. GBS s/p 7 times plasmapheresis (initial presentation: ascending numbness form bilateral feet and bilateral leg weakness) 2. HTN

    6. Post OP status Hemodynamic : BP: 130/70 HR:88 CVP: 6 PAP:28/12 C.O: 5.35 l/min C.I: 2.97 under Isuprel: 0.0024*1 = 0.0024ug/Kg/min NTG: 0.12*8=0.96 ug/Kg/min Dopamine: 0.39*20=7.8ug/Kg/min Isuprel, NTG stop on 8/30 Dopamine stop on 9/10

    7. Post OP status Infection: No fever was noted since8/28 No leukocytosis or leukopenia was noted CRP : 8 CXR : clear ABX: teicoplanin for B/C coagulase neg. staphylococci kefadin for S/C pseudomonas aeruginosa 6. Teicoplanin related neutropenic fever on 9/22 -- change ABX to maxipime

    8. NE on 8/30 Isocoric pupil (3/3mm) , LR :+/+ EOM : full and free Mild bilateral facial weakness Suction reflex : good MP of Upper limb :2-3 MP of Lower limb :1-2 DTR : all negative Plantar reflex : flexion

    9. Post OP status Respiratory system: 8/28-29: ACMV, Vt:780, RR:10/12, PS/PEEP: 0/3, FiO2:0.6 ,pH:7.47 ,PCO2 42.7 ,PO2:100 , HCO3:31.2 8/30-9/14: SIMV+PS, Vt:780, RR:15/4, PS/PEEP: 12/3, FiO2:0.4 ,pH:7.4 ,PCO2 34 ,PO2:122 , HCO3:25.8 9/14 : extubation byself but re-on on the same day

    10. Weaning parameter 9/3 : Vt:251 , RR 29 , VE:7.3L/min , Pimax:-20 , Pemax: 10 , RSBI: 115 9/18 : Vt:386 , RR 38 , VE:14.7L/min , Pimax:-40 , Pemax: 40 , RSBI: 100 9/29 : Pimax : -30 , Pemax :50

    11. History summary

    12. Acute Inflammatory Demyelinating Polyradiculoneuropathy (AIDP) More commonly called Guillain-Barre syndrome (GBS) Acute demyelinating neuropathy More than half patients describe an antecedent viral infection

    13. Clinical Features Progressive motor weakness involve more than one limb The weakness may be ascending or descending Areflexia Autonomic dysfunction is commonly associated 50% of patients will reach a nadir by 2 weeks Recovery of function usually begin 2-4 weeks after progression stops

    14. Diagnosis CSF examination is less important Electrophysiologic studies are more important for diagnosis

    15. Management Respiratory function must be carefully monitored -- intubation is needed if vital capacity fall rapidly to less than 50% of normal Plasma exchange or IVIG

    16. Question How long the mechanical ventilation may be used in Guillain-Barre syndrome patients ?

    17. POST-INTUBATION PULMONARY FUNCTION TEST IN GUILLAIN–BARRÉ SYNDROME Muscle Nerve 23: 613–616, 2000

    18. Aim : Determine whether postintubation respiratory parameters can predict duration of mechanical ventilation in GBS The records of patients ventilated for neuromuscular respiratory failure due to GBS between 1976 and 1998 were reviewed Daily VC (mL/kg), PImax (cm H2O), and PEmax (cm H2O) were summed to form an integrated pulmonary function (PF) score PF ratio : (PF score immediately prior to intubation)/(day 12 after intubation)

    19. result Overall the median duration of ventilation was 39 days but the median duration of mechanical ventilation was 47 days if patients were not extubated within 3 weeks Other clinical features of these groups were similar

    22. The PF ratio was greater than 1 in all 10 of the patients ventilated for less than 3 weeks PF ratio less than 1 in 19 of the 27 patients ventilated for greater than 3 weeks (P =0.0001) No patient with a PF ratio of less than 1 was weaned within 3 weeks.

    24. The morbidity of Guillain-Barré syndrome admitted to the intensive care unit NEUROLOGY 2003;60:17–21

    25. method A database of 114 patients admitted to the intensive care units of the Mayo Medical Center between 1976 and 1996 with a diagnosis of GBS has been collected Corticosteroids were often used as treatment in patients during the first half of the study (1976–1986) and plasma exchange (PLEX) or IV immunoglobulin (IVIg) were utilized in the latter half of the study period

    28. summary Mechanical ventilation is necessary in 20–30% of patients with Guillain–Barre´ syndrome majority require prolonged respiratory support PF ratio may predict MV time IVIG or plasmaphoresis may be help in our patient Preventing infection is still the most important task

    29. Thanks for your attention

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