halifax

10+ Year Member
5+ Year Member
Jul 19, 2007
69
0
0
Status
Resident [Any Field]
Have a patient 19/F with rapidly evolving GBS and within 3 days had to be intubated. did receive 5 day course of IVIG and now is 14 days s/p IVIG and still on vent with trach. minimal improvement in power and still areflexic.

My question is how soon can we try another course of IVIG?? The literature says can be repeated atleast after 4 weeks - any experience with giving another course earlier?? thanks.
 

halifax

10+ Year Member
5+ Year Member
Jul 19, 2007
69
0
0
Status
Resident [Any Field]
NERVE CONDUCTION STUDIES:

Right median nerve - prolonged motor distal latency.

Right ulnar nerve - normal.

Right peroneal nerve - absent F wave.

Right posterior tibial nerve - prolonged motor distal latency, low
amplitude, absent F wave.

Right sural nerve - normal.

NEEDLE ELECTRODE EXAM:
No effort in right tibialis anterior.

Only single motor unit potential in right gastrocnemius medial.

No denervative potentials seen.

EMG DIAGNOSIS: Suggestive of diffuse demyelinating polyneuropathy,
especially the proximal regions.

And we already looked PE after IVIG is C.I.

Thanks
 

exgatr

Senior Member
7+ Year Member
15+ Year Member
Nov 7, 2003
212
1
0
Visit site
Status
not truly contraindicated, it just washes out all of the IVIG. We do it all the time at my residency
 

danielmd06

Neurosomnologist
10+ Year Member
Sep 9, 2006
944
21
251
Florida
Status
Attending Physician
not truly contraindicated, it just washes out all of the IVIG. We do it all the time at my residency
Agreed. Mine too.
 
9

95439

not truly contraindicated, it just washes out all of the IVIG. We do it all the time at my residency
They do it at the hospital I trained at too. We just did it about two weeks ago. I'd definitely recommend it. You should also check for Campylobacter Jejuni antibodies, as GBS d/t C. Jejuni infection is more severe and can help determine management and prognosis.

Typhoonegator - were you wondering if it was Multifocal Motor Neuropathy (and wanted to know if there was a conduction block on EMG) too?
 

halifax

10+ Year Member
5+ Year Member
Jul 19, 2007
69
0
0
Status
Resident [Any Field]
so let me get this correct...all of you are saying that eventhough PE washes out the IVIG it's used all the time...just that I did come across IVIG following PE but could not find any evidence for doing PE after IVIG.

- so am I to understand that PE following IVIG is done not uncommonly and it works occasionally atleast??

- what's the earliest we can repeat a course of IVIG???

Thanks again.
 

halifax

10+ Year Member
5+ Year Member
Jul 19, 2007
69
0
0
Status
Resident [Any Field]
And also if its a common practise to do plasmapharesis after IVIG

- are there any scenarios or indications for this sequence and
- any papers supporting this practise would be most useful...

just that am in the ICU and the intensivist and the neurologist are at loggerheads regarding further management at this point.

any guidance is much appreciated.
 

typhoonegator

Neurointensivist
Moderator
10+ Year Member
Dec 22, 2006
1,865
853
381
Boston
Status
Attending Physician
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.
 

halifax

10+ Year Member
5+ Year Member
Jul 19, 2007
69
0
0
Status
Resident [Any Field]
Well but in this case I had to go with the intensivist for various reasons..for starters the patient didn't even get a LP - had a MRI of spine and than EMG followed by IVIG...anyways thanks a bunch for the articles.

the NCS report didn't mention about the axonal pattern and I'm not a neurologist to figure out from the conduction velocities which were documented...
 

halifax

10+ Year Member
5+ Year Member
Jul 19, 2007
69
0
0
Status
Resident [Any Field]
Well the official reason the neurologist gave was (2 of them) - since the weakness came on within like 4 days the LP would not reflect that change !!!! hope that sounds convincing enough...welcome to the real world folks....I don't know if its just this hospital but the last thing the neurologist do here is the LP....can't imagine why.
 

BlackFrancis33

10+ Year Member
Oct 10, 2008
188
33
261
Status
Attending Physician
Without numbers the nerve conduction study is difficult to interpret. Do the findings meet demyelinating criteria? With some loss of amplitude is this an Acute Motor Axonal Neuropathy or Acute Motor Sensory Axonal Neuropathy and not a demyelinating process (AMAN and AMSAN)? In practice there is often a combination of the two. AMANs and AMSANs often have protracted courses with the AMSANs having a worse prognosis. As T-gator points out above, evidence of early axonal involvement is usually a bad prognostic sign. Academically AMANs are classically GQ1b positive.