9 Sep 2025

The Numb Traveler: From Feet to Breath

1) Diagnosis

  • Primary: Guillain-Barré Syndrome (GBS), Acute Inflammatory Demyelinating Polyradiculoneuropathy (AIDP subtype).
  • Secondary: Acute respiratory failure requiring mechanical ventilation.

2) History of Present Illness (HPI)

  • Chief complaint: Progressive weakness in both legs for 5 days, spreading to arms within 3 days.
  • Progression: Began distally (feet) → thighs → arms. By Day 4, unable to walk without support.
  • Associated symptoms: Tingling in feet, back pain, difficulty swallowing, facial weakness.
  • Negative history: No bladder/bowel involvement, no trauma, no seizures, no recent vaccination.

3) Past Medical History

  • Hypertension on Amlodipine 5 mg OD (Ca-channel blocker, no neuromuscular effect).
  • No past surgeries or ICU admission.
  • Recent viral illness (flu-like fever, cough 2 weeks prior).

4) Physical Examination

  • General: Conscious, oriented, anxious, no pallor/cyanosis.
  • Motor: Symmetric flaccid weakness → UL 3/5, LL 2/5.
  • Reflexes: Absent DTRs.
  • Sensory: Mild distal paresthesias, no objective sensory loss.
  • Cranial Nerves: Bilateral facial weakness, gag reflex reduced.
  • Respiratory: Shallow breaths, paradoxical abdominal breathing.
  • CVS/Abdomen: Normal.

5) Vitals on Admission

  • HR: 92/min, BP: 138/82 mmHg, RR: 28/min (shallow), Temp: 37.2 °C, SpO₂: 91% (RA), 97% (O₂ mask)
  • GCS: 15/15

6) Echocardiography (ECHO)

  • LV EF: 60% (normal), No valvular lesion, RV/LA: Normal, No pericardial effusion

7) Investigations

Baseline (Day 0):

  • CBC: Hb 13.2, WBC 8.4k, Plt 2.1 lakh → rules out infection, baseline for IVIG
  • RFT: Urea 32, Cr 0.8 → important before IVIG (nephrotoxicity risk)
  • Electrolytes: Na 138, K 4.1, Mg 1.8 → arrhythmia prevention, weakness mimic
  • LFT: Normal → safe for IVIG
  • ABG: pH 7.34, pCO₂ 48 → early type II RF
  • CSF: Protein 120 mg/dL, Cells 2/mm³ → Albuminocytologic dissociation
  • NCS: Demyelinating polyneuropathy
  • CRP: 10 mg/L → mild inflammation
  • Troponin/BNP: Normal → rules out cardiac cause
  • Thyroid panel: Normal → rules out thyrotoxic neuropathy

Follow-up Trends:

Day FVC (mL/kg)ABG (pCO₂)NaKNotes
D014481384.1NIV standby
D112521393.8Elective intubation
D212501383.9On ventilator
D413471403.9IVIG completed
D616441414.0Weaning trials
D718491424.1Extubated

8) Imaging

  • CXR (Day 0): Clear lungs.
  • CXR (Day 3): Mild basal atelectasis → chest physiotherapy given.
  • CT Brain: Normal.

9) ECG & RBS

  • ECG: Sinus rhythm, normal PR/QRS. (Important: rule out arrhythmias due to autonomic dysfunction).
  • RBS: 104 mg/dL.

10) Emergency Stabilization (Day 0)

  • Airway & Breathing: The patient was supported with oxygen via face mask at 5 L/min, maintaining adequate oxygen saturation.
  • Circulation: Two peripheral IV lines were secured for reliable drug administration and fluid access, with continuous cardiac monitoring initiated due to the risk of autonomic instability in Guillain-Barré syndrome.
  • Pharmacotherapy:
    • IVIG 0.4 g/kg/day for 5 days – initiated as first-line immunotherapy, aimed at halting immunemediated nerve injury and accelerating recovery.
    • Pantoprazole 40 mg IV once daily – given for stress ulcer prophylaxis, reducing the risk of gastrointestinal bleeding during critical illness.
    • Enoxaparin 40 mg SC once daily – administered for deep vein thrombosis (DVT) prophylaxis, given the patient’s prolonged immobility in the ICU.
    • Gabapentin 300 mg at bedtime – prescribed for neuropathic pain management, addressing dysesthesias and improving comfort.

11) Day-by-Day ICU Care

  • On admission, the patient was started on O₂ supplementation via face mask at 5 L/min, leading to a noticeable improvement in SpO₂ levels. An arterial blood gas (ABG) analysis revealed type II respiratory failure, for which the patient was kept under close monitoring in the ICU. Intravenous immunoglobulin (IVIG) therapy was initiated at 0.4 g/kg/day, as per standard GBS management protocols. For supportive care, Pantoprazole was administered for stress ulcer prophylaxis, Enoxaparin for venous thromboembolism prevention, and Gabapentin for neuropathic pain control. A comprehensive baseline laboratory panel was obtained, along with cerebrospinal fluid (CSF) analysis and nerve conduction studies (NCS) to confirm the diagnosis and establish the extent of neuromuscular involvement.
  • On Day 1 of ICU stay, the patient demonstrated progressive limb weakness with involvement of both upper and lower extremities (UL 2/5, LL 1/5), along with bulbar symptoms. Serial spirometry revealed a further decline in forced vital capacity (FVC) to 12 mL/kg, warranting elective intubation to secure the airway and prevent impending respiratory failure. The patient was placed on volume controlled mechanical ventilation (tidal volume 8 mL/kg, respiratory rate 14/min, FiO₂ 40%, PEEP 5 cm H₂O). IVIG therapy (0.4 g/kg/day) was continued (Day 2/5), while midazolam infusion (1 mg/hr) and fentanyl infusion (25 mcg/hr) were initiated for light sedation and analgesia. Pantoprazole and enoxaparin were maintained as part of prophylactic measures. Laboratory evaluation showed normal renal function and electrolytes, ensuring safe continuation of IVIG. A repeat ABG revealed worsening hypercapnia (pH 7.32, pCO₂ 52 mmHg), confirming the indication for mechanical ventilation. Chest X-ray confirmed appropriate ET tube placement with clear lung fields. The patient was kept under continuous cardiac and hemodynamic monitoring due to the risk of autonomic dysfunction associated with Guillain Barré syndrome.
  • On Day 2 of ICU stay, the patient remained on mechanical ventilation (VCV: TV 8 mL/kg, RR 14/min, FiO₂ 40%, PEEP 5 cm H₂O) with stable oxygenation (SpO₂ 96%). IVIG therapy (0.4 g/kg/day, Day 3/5) was continued without infusion-related adverse events. Sedation was maintained with midazolam 1 mg/hr and fentanyl 25 mcg/hr, with daily sedation interruption for neurological assessment. On examination, muscle power remained UL 2/5 and LL 1/5, with absent deep tendon reflexes; cranial nerve exam showed mild facial weakness but no new bulbar deterioration. Hemodynamic status was stable (BP 118/76 mmHg, HR 84/min) with no arrhythmias, though close monitoring continued for possible autonomic instability.
    • Laboratory investigations revealed:
      • CBC: Hb 12.6 g/dL, WBC 8,400/µL, Platelets 2.1 lakh/µL → no infection or hematological abnormality.
      • RFT: Urea 32 mg/dL, Creatinine 0.9 mg/dL → normal, safe to continue IVIG.
      • Electrolytes: Na 138 mEq/L, K 4.2 mEq/L, Mg 1.9 mg/dL, Ca 9.0 mg/dL → within range, reducing arrhythmia risk.
      • ABG: pH 7.36, pCO₂ 46 mmHg, HCO₃⁻ 24 → compensated Type II RF with adequate ventilation
    • Pantoprazole IV OD was continued for stress ulcer prophylaxis, and Enoxaparin 40 mg SC OD for DVT prophylaxis. Gabapentin 300 mg PO TDS was given via Ryle’s tube for neuropathic pain. Chest physiotherapy and passive limb physiotherapy were initiated to prevent atelectasis and contractures. Nutritional support was provided via Ryle’s tube feeding with a high-protein formula (1 kcal/mL, 150 mL every 3 hrs), tailored to caloric needs.
    • The patient’s condition remained stable but critically ill, with the plan to continue IVIG, monitor ABG trends, and watch closely for complications such as ventilator-associated pneumonia and dysautonomia.
  • On Day 3 of ICU stay, the patient remained intubated and mechanically ventilated (VCV: TV 8 mL/kg, RR 14/min, FiO₂ 35%, PEEP 5 cm H₂O) with good oxygenation (SpO₂ 97%) and improved gas exchange. IVIG therapy (0.4 g/kg/day, Day 4/5) was continued as per protocol. Sedation was maintained with midazolam 1 mg/hr and fentanyl 25 mcg/hr, with another daily sedation hold performed to evaluate neurological status. On examination, muscle strength remained UL 2/5, LL 1/5, with areflexia. Cranial nerves showed persistent mild facial weakness and weak gag reflex, though there was no deterioration.
    • Vitals were stable (BP 122/80 mmHg, HR 82/min, afebrile, urine output 1.2 mL/kg/hr). Continuous ECG monitoring showed no arrhythmias; autonomic function remained preserved.
    • Laboratory results:
      • CBC: Hb 12.5 g/dL, WBC 9,200/µL, Plt 2.0 lakh/µL → mild leukocytosis, no clinical infection.
      • RFT: Urea 34 mg/dL, Creatinine 0.9 mg/dL → stable.
      • Electrolytes: Na 137 mEq/L, K 4.0 mEq/L, Mg 2.0 mg/dL, Ca 8.9 mg/dL → normal.
      • ABG: pH 7.39, pCO₂ 42 mmHg, HCO₃⁻ 25, PaO₂ 96 → well-ventilated, compensated.
      • CRP mildly elevated (12 mg/L), interpreted as post-IVIG inflammatory response, not sepsis.
    • Medications:
      • Pantoprazole IV OD, Enoxaparin 40 mg SC OD, Gabapentin 300 mg TDS via Ryle’s, IVIG infusion. Antibiotics were withheld, as there were no infection signs.
    • Supportive care:
      • Nutritional therapy was optimized to 30 kcal/kg/day with 1.5 g/kg/day protein through
      • Ryle’s tube (polymeric formula). Physiotherapy continued with passive ROM, limb positioning, and incentive spirometry (assisted). Eye care (lubricating drops Q6H) and oral care with chlorhexidine were maintained to prevent ICU infections.
      • The patient remained hemodynamically stable with improving ABG, continuing to require ventilatory support. The plan included completing IVIG course (Day 5/5), daily neurological monitoring, prevention of VAP, and preparation for tracheostomy if prolonged ventilation was anticipated.
  • On Day 4–5 of ICU stay, the patient demonstrated neurological improvement, with facial weakness showing partial recovery and upper limb muscle power improving to 3/5. The ventilatory strategy was modified, shifting from controlled ventilation to pressure support ventilation (PSV) with FiO₂ reduced to 30%, which was well tolerated. IVIG therapy was completed on Day 5, marking the end of the standard 5-day course. For better control of dysesthetic symptoms, Gabapentin was escalated to 300 mg twice daily. Nutritional support was maintained with Ryle’s tube feeding using Osmolite 200 mL every 4 hours, ensuring adequate caloric and protein intake. Arterial blood gas analysis (pH 7.40, pCO₂ 42 mmHg) indicated stable ventilation, and renal function tests remained within normal limits, effectively ruling out IVIG-associated nephrotoxicity. Overall, the patient showed steady progress with improving neurological function and stable systemic parameters.
  • On Day 6 of ICU stay, the patient continued to show gradual neurological recovery, with upper limb power maintained at 3/5, lower limb power at 2/5, and notable improvement in bulbar weakness. Given stable gas exchange and improved airway protection, the patient was successfully extubated and transitioned to non-invasive ventilation with BiPAP support (IPAP 12, EPAP 6). Nebulization therapy was continued for airway clearance and lung recruitment. Physiotherapy was intensified, incorporating both respiratory muscle training and limb mobilization exercises, to enhance recovery and prevent complications of immobility. Arterial blood gas analysis (pH 7.42, pCO₂ 39 mmHg) confirmed adequate ventilation and oxygenation following extubation. The patient remained hemodynamically stable with encouraging signs of functional improvement.
  • On Day 7 of ICU stay, the patient was breathing comfortably on nasal cannula oxygen at 2 L/min, maintaining stable oxygenation without ventilatory support. Neurological examination revealed further improvement, with upper limb power 4/5 and lower limb power 3/5, though deep tendon reflexes remained absent. Gabapentin 300 mg at bedtime was continued for neuropathic pain control, and oral multivitamin supplementation was initiated to support neuromuscular recovery. Physiotherapy sessions were intensified, focusing on both limb strengthening and respiratory exercises. With improved mobility and reduced risk of stasis, Enoxaparin was discontinued, and graduated compression stockings were applied for continued venous thromboembolism prophylaxis. Arterial blood gas analysis was within normal limits, confirming satisfactory respiratory function off ventilatory support. Overall, the patient demonstrated steady neurological and functional recovery with supportive measures.

12) Discharge Medications and Instructions:

  • Gabapentin 300 mg at bedtime – for ongoing control of neuropathic pain.
  • Oral Multivitamin B-complex once daily – to support neuromuscular recovery and overall nutritional balance.
  • Physiotherapy with incentive spirometry – advised as a structured rehabilitation program to enhance limb strength, prevent contractures, and promote respiratory muscle recovery.
  • Graduated compression stockings – continued as prophylaxis against venous thromboembolism in the setting of reduced mobility.
  • The patient was instructed to follow up regularly for neurological assessment, physiotherapy supervision, and monitoring of recovery milestones.

13) Key Notes / Clinical Pearls

  1. Elective intubation if FVC <15 mL/kg → prevents sudden crash.
  2. IVIG & Plasmapheresis equally effective (IVIG preferred in ICU).
  3. CSF hallmark: Albuminocytologic dissociation.
  4. Steroids have no role in GBS.
  5. Autonomic instability (arrhythmia, BP swings) can be fatal → ICU monitoring essential.

14) Case Storytelling (Narrative)

“She was a 34-year-old mother who walked in with tingling legs. Within 4 days, her smile faded, her voice weakened, and she could no longer lift her arms. By Day 1, her breath slowed — she was intubated before her body collapsed. Machines breathed for her while IVIG calmed her overactive immune system. Slowly, her voice returned, her hands lifted, her smile came back. On Day 7, she looked at her child and whispered, ‘I will walk again.’”

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