Management.: Individuals with suspected GBS should have their respiratory function tested. A decrease in forced vital capacity (FVC) has been shown to correlate with the need for intubation in patients with GBS. An FVC of less than 20 mL/kg is associated with pending respiratory failure and the need for intubation, whereas patients with an FVC of more than 40 mL/kg do not usually require intubation.12,13 Likewise, patients with a negative inspiratory force of less than 30 cm H₂O are more likely to require mechanical ventilation.¹³ Other tests, such as the forced expiratory volume in 1 second and peak flow rate, can also be used to assess respiratory function. Patients unable to perform these tests and those with less than 100% of predicted values should have an arterial blood gas sample obtained. Evidence of alveolar hypoventilation (elevated carbon dioxide [PCO₂]) in a patient with an unsecured airway requires a level of intensive monitoring that is impractical in many EDs. Therefore, patients with weakness, carbon dioxide retention, or other evidence of early ventilatory failure should be considered for early, prophylactic intubation.¹⁴

Among patients with possible GBS who have normal pulmonary function, extensor neck strength can be monitored to predict impending ventilatory failure. Patients with probable GBS should receive neurologic consultation and admission for treatment with either plasma exchange or intravenous immune globulin (IVIG).There is sound evidence that both of these treatments are superior to placebo and that combination or sequential therapy confers no therapeutic advantage over either intervention alone. Plasma exchange is cumbersome and not available at many hospitals. IVIG is more readily available and is usually administered in a dose of 400 mg/kg/day for 5 days. However, IVIG is expensive, costing roughly $50 to $80 per gram.15,16 Although IVIG is not formally approved by the Food and Drug Administration for this purpose, its use is supported in national treatment guidelines.¹⁷ Corticosteroids are no longer recommended for treatment of GBS.¹⁸ Oral steroids have been shown to delay recovery. Intravenous steroids alone have been shown to impart no benefit, and although the combination of intravenous steroids and IVIG has hastened recovery, there was no effect on long-term outcome.^18–21 The marked elevation in blood pressure seen in some patients with GBS should not be treated because it is typically transient and may be followed by precipitous and unpredictable hypotension.

Compared with adults, children who have GBS have neuropathic pain more often (80%) and require mechanical ventilation less often (13%).16, 22

Management.: As with virtually all peripheral neuropathies, referral is indicated for management of diabetic DSPNs. If discomfort is severe, the etiology of the neuropathy seems likely to be diabetic, and if referral is delayed, it may be necessary to provide the patient with some symptomatic relief. Because treatment of neuropathic pain has traditionally been linked to etiology rather than to an underlying mechanism, the choice of pharmacologic agents is empirical, with substantial practice variation in the United States and worldwide. The costs for patients and health plans are considerable; patients will typically spend more than $1000 per year for pain relief from diabetic DSPN.⁹ Nonsteroidal anti-inflammatory drugs should not be considered first-line treatment because they have little proven efficacy and a high potential for renal impairment.³ On the basis of placebo-controlled randomized clinical trials, tricyclic antidepressants and anticonvulsants appear to have the best NNTs (number of patients needed to treat to provide at least 50% relief of symptoms in one patient). These are generally in the range of 3 to 5, with confidence intervals whose upper limits reach 10 in some instances.²⁵ Imipramine or amitriptyline may be started at a dose of 25 mg at bedtime (10 mg in elders) and titrated slowly up to a dose of 300 mg. Carbamazepine at a dose of 200 to 400 mg every 8 hours and gabapentin at a dose of 900 to 3600 mg/day are also effective treatments.^2,26 Tramadol in two studies has shown an NNT below 5.²⁴ Although tramadol is a mixed opioid, development of dependence in long-term use appears to be uncommon. Tramadol combined with acetaminophen has been found to be as effective as gabapentin in the treatment of painful diabetic neuropathy.²⁷ In a recently published guideline, the following medications were recommended for the treatment of neuropathic pain: gabapentin, opioids, tramadol, and tricyclic antidepressants.³ Pregabalin 150 to 600 mg/day, a more recent treatment option, has a mechanism of action similar to that of gabapentin. Duloxetine, a selective serotonin and norepinephrine reuptake inhibitor, has been found effective at a dose of 60 mg/day.³ Recently, tapentadol ER 100 to 250 mg twice daily was found to provide substantial pain relief in patients with diabetic neuropathy.²⁸ Topical capsaicin provides relief in some patients, but the burning associated with its application has limited its use. Improving glycemic control can prevent, diminish, or reverse early diabetic DSPNs, and even in diabetic patients with severe peripheral neuropathy, tight glycemic control can improve functionality and pain control.²⁹