Clinical Commander

Back to dossier
neuro.gbs.core.v1PRODUCTION
neuro.gbs.core.v1

Guillain-Barré Syndrome

neurologyacuteadultpediatric
Hard-required inputs
0 / 11
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm acute neuromuscular weakness — exclude cord/structural and CIPM mimics (AAN 2012)

Inputs
1
Actions
0
Advance rule
Set
Advance when

GBS-compatible pattern and no immediate cord-compression flag

Patient inputs (12)

Demyelinating vs axonal pattern → AIDP vs AMAN/AMSAN (AAN 2012)

Age + pregnancy status drive treatment selection (IVIG vs PLEX) and dosing (EAN/PNS 2023)

Campylobacter, CMV, EBV, Mycoplasma, Zika in 6wk pre-onset informs variant + tx urgency (IGOS Doets 2018)

Ascending vs bulbar-predominant vs descending separates GBS variants from mimics (Brighton 2011)

Albuminocytologic dissociation — present in ~50% wk1, 75% wk2 (AAN 2012)

IgA deficiency screen before IVIG (anaphylaxis risk) (EAN/PNS 2023)

Exclude transverse myelitis, cord compression; enhancing nerve roots support GBS (NICE 2024)

20-30-40 rule — FVC <20 mL/kg or MIP magnitude <30 cmH2O triggers elective intubation (AAN 2012)

Autonomic dysregulation — paroxysmal tachy/brady, ileus (IGOS Doets 2018)

Autonomic BP swings — labile HTN/hypotension (IGOS Doets 2018)

MRC sum 0–60 quantifies severity + tracks progression (AAN 2012)

Anti-GQ1b → Miller Fisher; anti-GM1/GD1a → AMAN (IGOS Doets 2018)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (13)

13 need judgement
  • informationallife_threateningrespiratory_failure
    FVC <20 mL/kg OR NIF magnitude <30 cmH2O OR rapid decline OR severe bulbar weakness; ~1/3 of GBS patients require MV (AAN 2012; EGRIS Walgaard 2010 PMID 20517939)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningamsan_phenotype
    GBS variant: acute motor + sensory axonal neuropathy — severe axonal loss in motor AND sensory fibers; worse prognosis; often residual disability; longer recovery (van Doorn 2008 PMID 18848313)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererapidly_progressive_weakness
    Loss of ambulation within 7 days of onset OR weakness progression to maximal nadir in 24–48 h (IGOS Doets 2018 PMID 30247567)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebulbar_involvement
    Dysphagia, dysarthria, choking on saliva, facial diplegia — aspiration risk + airway compromise (AAN 2012)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereautonomic_dysregulation
    Paroxysmal bradycardia/tachycardia, BP swings >40 mmHg, ileus, urinary retention, sudden cardiac arrhythmia (IGOS Doets 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaidp_phenotype
    GBS variant: acute inflammatory demyelinating polyneuropathy — ~85% of Western cases; ascending weakness + areflexia; NCS shows segmental slowing + conduction block + prolonged distal latencies + temporal dispersion (AAN 2012; van Doorn 2008 PMID 18848313)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaman_phenotype
    GBS variant: acute motor axonal neuropathy — common in Asia post-Campylobacter; pure motor; NCS reduced CMAP without slowing (axonal); anti-GM1/GD1a antibodies positive (IGOS Doets 2018 PMID 30247567)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebickerstaff_phenotype
    GBS variant: Bickerstaff brainstem encephalitis — overlapping with Miller-Fisher: encephalopathy + brainstem signs + anti-GQ1b; cross-sectional spectrum with MFS (van Doorn 2008 PMID 18848313)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepcb_phenotype
    GBS variant: pharyngeal-cervical-brachial — bulbar + neck + upper limb weakness predominant; sparing legs initially; ICU concern for airway compromise (van Doorn 2008 PMID 18848313)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateiga_deficiency
    Total IgA <7 mg/dL pre-IVIG (EAN/PNS 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecidp_transition
    Recurrent or progressive weakness >8 weeks from initial GBS onset with relapsing-remitting pattern → CIDP transition (~5% of GBS) (van Doorn 2008 PMID 18848313)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatetreatment_related_fluctuation
    Initial improvement then worsening at weeks 2–3 after IVIG/PLEX in 5–10% of patients (EAN/PNS 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatemiller_fisher_phenotype
    GBS variant: Miller-Fisher syndrome — ophthalmoplegia + ataxia + areflexia triad; anti-GQ1b antibodies in ~85%; usually milder course (van Doorn 2008 PMID 18848313)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

GBS — IVIG/PLEX + supportive bundle
axis: gbs_immunomodulation_supportivestep 1 - Step 1 — Immunomodulation (within 2–4 weeks of onset)
Selected step "Step 1 — Immunomodulation (within 2–4 weeks of onset)" — GBS Brighton level 1–3 with progressive weakness or non-ambulatory (Brighton 2011; EAN/PNS 2023)
  • ivig
    first line
    pooled_human_IgG
    0.4 g/kg/d × 5 d (total 2 g/kg) • IV • daily × 5 d (max: 2 g/kg cumulative)
    triggers: Brighton_1-3, non_ambulatory_or_progressive
    EAN/PNS 2023 — IVIG and PLEX equivalent; check IgA pre-IVIG (Cochrane Hughes 2014)
    rxcui 1426680
  • plasmapheresis
    first line
    apheresis
    5 sessions over 7–10 days (every other day) • IV • 5 sessions q2 days (max: 5 sessions per course)
    triggers: IgA_deficient, IVIG_unavailable, rapidly_progressive
    Cochrane Hughes 2014 — 5 sessions reduces ventilation; alternative when IgA deficient (EAN/PNS 2023)

outpatient playbook — drug actions (1)

  1. 1. pain Rx tapering
    Per response • PO • taper
    trigger: Pain resolving (NICE 2024)
    Most pain resolves over months (IGOS Doets 2018)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Symmetric ascending limb weakness over hours–4 weeks (Brighton 2011); Areflexia / hyporeflexia on exam (Brighton 2011); Glove-and-stocking paresthesia (AAN 2012).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Guillain-Barré Syndrome** (neuro.gbs.core.v1).
Phenotype framing: Apply Brighton criteria; classify AIDP/AMAN/AMSAN/MFS/PCB; rule out botulism, MG, transverse myelitis (Brighton 2011)
Scope: Confirm acute neuromuscular weakness — exclude cord/structural and CIPM mimics (AAN 2012)

No severity triggers fired against current inputs.

Plan

Regimen axis: **GBS — IVIG/PLEX + supportive bundle** — step "Step 1 — Immunomodulation (within 2–4 weeks of onset)".
1. ivig 0.4 g/kg/d × 5 d (total 2 g/kg) IV daily × 5 d (pooled_human_IgG, first line) — EAN/PNS 2023 — IVIG and PLEX equivalent; check IgA pre-IVIG (Cochrane Hughes 2014)
2. plasmapheresis 5 sessions over 7–10 days (every other day) IV 5 sessions q2 days (apheresis, first line) — Cochrane Hughes 2014 — 5 sessions reduces ventilation; alternative when IgA deficient (EAN/PNS 2023)

Setting playbook (outpatient) — Recovery monitoring, rehab continuity, CIDP surveillance, vaccine planning (NICE 2024)
3. pain Rx tapering Per response PO taper — Pain resolving (NICE 2024) (Most pain resolves over months (IGOS Doets 2018))

Non-pharmacologic actions:
- Continued PT/OT (NICE 2024)
- Vaccinations: discuss timing with neurology (delay live vaccines, consider risk-benefit for influenza) (NICE 2024)
- Driving assessment (NICE 2024)
- Return to work planning (NICE 2024)

AVOID / contraindication checks:
- No_steroids_alone_for_GBS
- Check_IgA_before_IVIG
- Avoid_succinylcholine_use_rocuronium_with_sugammadex
- DVT_prophylaxis_high_immobility_risk
- Vaccination_delay_post_GBS_check_with_neurology

Monitoring

Regimen monitoring:
- FVC NIF q4-6h during progression (AAN 2012)
- continuous ECG for autonomic arrhythmias (IGOS Doets 2018)
- BP q1-2h during unstable phase (IGOS Doets 2018)
- MRC sum score daily (AAN 2012)
- IVIG AE TRALI aseptic meningitis thrombosis (EAN/PNS 2023)
- watch for treatment related fluctuation weeks 2-3 (EAN/PNS 2023)

Setting (outpatient) monitoring:
- Functional recovery 6 wk, 3 mo, 6 mo, 1 yr (NICE 2024)
- CIDP red-flag watch (EAN/PNS 2023)

Follow-up plan: Neuro rehab planning, vaccine-delay advice, CIDP watch if recurrence, psychology support (NICE 2024)
- Close-out criterion: rehab + outpatient neurology follow-up scheduled

Monitoring phase: q4–6h FVC/MIP, continuous ECG (autonomic), serial MRC + disability score, watch for treatment-related fluctuation wk2–3 (EAN/PNS 2023)

Disposition

Current setting: outpatient — Recovery monitoring, rehab continuity, CIDP surveillance, vaccine planning (NICE 2024)

Disposition criteria:
- Routine follow-up, then annual neuromuscular review (NICE 2024)

Escalation triggers (move to higher acuity):
- Worsening or new weakness >8 weeks post-GBS → CIDP workup (EAN/PNS 2023)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] FVC <20 mL/kg OR NIF magnitude <30 cmH2O OR rapid decline OR severe bulbar weakness; ~1/3 of GBS patients require MV (AAN 2012; EGRIS Walgaard 2010 PMID 20517939)
- [LIFE_THREATENING] GBS variant: acute motor + sensory axonal neuropathy — severe axonal loss in motor AND sensory fibers; worse prognosis; often residual disability; longer recovery (van Doorn 2008 PMID 18848313)
- [SEVERE] Loss of ambulation within 7 days of onset OR weakness progression to maximal nadir in 24–48 h (IGOS Doets 2018 PMID 30247567)

Citations

- 2023 EAN/PNS Guideline on Diagnosis and Treatment of GBS (van Doorn/Van den Bergh, Eur J Neurol 2023, PMID 37814552) + Brighton case definition validation (Fokke, Brain 2014, PMID 24163275) + IGOS prognostic (mEGOS/EGRIS) + Cochrane Hughes IVIG / Cochrane Raphaël PLEX [PMID:37814552](https://pubmed.ncbi.nlm.nih.gov/37814552/)
- Cited evidence (PMID 24163275) [PMID:24163275](https://pubmed.ncbi.nlm.nih.gov/24163275/)
- Cited evidence (PMID 22694000) [PMID:22694000](https://pubmed.ncbi.nlm.nih.gov/22694000/)
- Cited evidence (PMID 18848313) [PMID:18848313](https://pubmed.ncbi.nlm.nih.gov/18848313/)
- Cited evidence (PMID 25238327) [PMID:25238327](https://pubmed.ncbi.nlm.nih.gov/25238327/)

Last reconciled with current guidelines: 2026-05-18.
References
  • 2023 EAN/PNS Guideline on Diagnosis and Treatment of GBS (van Doorn/Van den Bergh, Eur J Neurol 2023, PMID 37814552) + Brighton case definition validation (Fokke, Brain 2014, PMID 24163275) + IGOS prognostic (mEGOS/EGRIS) + Cochrane Hughes IVIG / Cochrane Raphaël PLEX — PMID:37814552
  • Cited evidence (PMID 24163275) — PMID:24163275
  • Cited evidence (PMID 22694000) — PMID:22694000
  • Cited evidence (PMID 18848313) — PMID:18848313
  • Cited evidence (PMID 25238327) — PMID:25238327