Autonomic Failure After Guillain-Barr Syndrome

FIGURE 23.1 Marked dilated colonic loops on abdominal X-ray (A) and confirmed on abdominal CT scan (B).

The treatment of patients with adynamic ileus is mostly parenteral nutrition for several weeks, rectal and oral suction tubes, and in more severe cases, a therapeutic decompressive colonoscopy. The use of erythromycin might be considered if patients have gastroparesis, but its side effects (cardiac arrhythmias) in patients with severe dysautonomia may make it a less favorable choice. We discourage the use of metoclopramide as promotility agent, because it has been associated with the occurrence of asystole in GBS.

In our patient, being on a mechanical ventilator made the use of multiple doses of intravenous morphine much safer, and blood pressure could be controlled within the set goal of systolic blood pressures of 100–140 mmHg. The nursing staff was particularly careful with tracheal suctions trying to avoid multiple passages and straining that could lead to bradycardia and hypotension. The blood pressure swings became less apparent in the following weeks with gradual disappearance over time.

Acute autonomic failure in GBS usually resolves before the patient starts to improve motor function. Marked orthostatic hypotension may persist during the recovery phase. Whether this is due to persistent autonomic failure or a result of long-standing bed rest is undetermined.

KEY POINTS TO REMEMBER REGARDING AUTONOMIC FAILURE IN GUILLAIN-BARR SYNDROME

Acute autonomic failure is common in severe presentations of GBS. Marked blood pressure fluctuations or sustained hypertension are the most concerning manifestations.
Hypertensive surges can be treated with morphine, clonidine, or if necessary, an infusion of a calcium channel blocker, such as nicardipine.
Vagal spells may lead to prolonged episodes of asystole, and a transcutaneous pacemaker might be needed.
Every bedridden patient with severe GBS is at risk of developing severe adynamic ileus, and treatment may require a period of parenteral nutrition or colonoscopic decompression.

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