just that am in the ICU and the intensivist and the neurologist are at loggerheads regarding further management at this point.
Wouldn't it be just fantastic if the intensivist WAS a neurologist? Woah.
Plasmapheresis after IVIG is messy, but it is done. It probably isn't as simplistic as "washing out the IVIg", but there likely is some attenuation of the effect. Before repeating IVIg, I'd want to get repeat protein, IgG levels, and make sure the renal function was OK. You can hurt people (thromboemoblism, renal failure) by stacking the doses too close to each other. There is very little evidence for increasing the dose of IVIG with subsequent treatment.
I asked about the EMG because I wanted to know if the patient had developed an axonal pattern, which may respond quite differently to treatment and may be more amenable to repeat IVIG treatment and/or a steroid trial. It could be indicative of a rapid-onset CIDP rather than AIDP. See the reference below.
Checking anti-GQ1b and anti-GM1 antibodies could theoretically also be helpful with prognosis.
There are excellent Cochrane reviews for both IVIG and pheresis in GBS. They summarize the levels of evidence for each treatment, as well as some dosing information.
Winer JB. When the Guillain-Barre patient fails to respond to treatment. Pract Neurol. 2009 Aug;9(4):227-30.
Kuitwaard K, de Gelder J, Tio-Gillen AP, Hop WC, van Gelder T, van Toorenenbergen AW, van Doorn PA, Jacobs BC. Pharmacokinetics of intravenous immunoglobulin and outcome in Guillain-Barré syndrome. Ann Neurol. 2009 Nov;66(5):597-603.
Dionne A, Nicolle MW, Hahn AF. Clinical and electrophysiological parameters distinguishing acute-onset chronic inflammatory demyelinating polyneuropathy from acute inflammatory demyelinating polyneuropathy. Muscle Nerve. 2010 Feb;41(2):202-7.