Neuroanaesthesia01 / 14
Guillain-Barré with dysautonomia for ICU tracheostomy46-year-old woman, 70 kg, ventilated in ICU for 9 days with Guillain-Barré syndrome after a chest infection
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Know this first
- FVC under 20 mL/kg calls for ICU observation; 15 mL/kg means intubation is likely.
- Dysautonomia: BP falls with posture, blood loss or positive pressure, and surges with laryngoscopy.
- No suxamethonium, even after recovery, because of hyperkalaemia.
- Indirect-acting vasopressors can produce exaggerated responses.
- Bradycardia: atropine 1 mg every 3–5 min, maximum 3 mg.
The patient
46-year-old woman, 70 kg, ventilated in ICU for 9 days with Guillain-Barré syndrome after a chest infection; on day 4 of IV immunoglobulin.
Bulbar weakness with pooled secretions; forced vital capacity fell to 12 mL/kg before intubation. Systolic BP has swung between 80 and 190.
Drugs: immunoglobulin, enoxaparin, gabapentin, propofol and fentanyl sedation.
For surgical tracheostomy in the ICU today.
Vitals: BP 168/94, HR 118, SpO2 96% on FiO2 0.4, temperature 37.4 °C.
The examiner asks
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Consider
What are your concerns?
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- A 46-year-old ventilated with Guillain-Barré on immunoglobulin, for a planned bedside tracheostomy in ICU. Patient
- Her FVC fell to 12 mL/kg, below the 15 mL/kg level where intubation becomes likely. Disease
- Bulbar weakness means she can't protect her airway, so a long ventilator course needs this tracheostomy.
- Dysautonomia: posture, sedation or positive pressure can drop her BP sharply.
- Tube handling and the incision can set off marked surges of BP. Surgery
- Sudden death in this illness is mostly autonomic, so arrhythmia and arrest are real risks. Disease
Prepare
How will you prepare her?
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- Arterial line for beat-to-beat pressure; her swings are fast and unpredictable. Disease
- Atropine drawn up and pacing pads on before anyone touches her airway. Crisis
- Short-acting, titratable vasoactive drugs in small doses; she over-responds to indirect agents like ephedrine. Disease
- Preoxygenate on 100% and keep her filled; she can't compensate for hypovolaemia.
- Immunoglobulin continues; enoxaparin timing agreed with the surgeon, as immobility keeps her at high VTE risk. After surgery
Plan
How will you anaesthetise her?
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- TIVA, deepening her existing propofol slowly rather than giving a bolus. Disease
- No suxamethonium: her denervated muscle can release enough potassium to stop her heart.
- If she needs relaxant, a small rocuronium dose guided by quantitative twitch monitoring.
- Hypotension: small steps of a direct agent, never a full bolus; she overshoots.
- Her neuropathic pain responds better to anticonvulsants than opioids, so gabapentin carries on. After surgery
- Back on the ventilator in ICU, with thromboprophylaxis and physiotherapy continuing.
Crisis
During tracheal suction just before the incision, HR falls from 110 to 30, then the ECG shows asystole with no arterial trace. What do you do?
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- Adult arrest algorithm: asystole after a vagal bradycardia from suction, in her dysautonomia. Crisis
- Stop suction, start CPR, call the arrest team; 100% oxygen through her tube.
- Non-shockable rhythm: adrenaline 1 mg IV every 3–5 minutes.
- Pacing won't rescue an established arrest; compressions and adrenaline will.
- Her likely causes: hypoxia from suction, or a displaced or blocked tube.
- Slow pulse returns: atropine 1 mg, repeated to 3 mg; then adrenaline 2–10 mcg/min or transcutaneous pacing.
- Afterwards: preoxygenate before every suction, short passes, pads left on. After surgery
Fatal mistakes
- Suxamethonium in her denervated muscle.
- A full-dose vasopressor bolus in a patient who over-responds.
- Suctioning with no atropine drawn up and no pacing backup.
Checked against: Stoelting 8e · Miller 10e · AHA guidelines: adult advanced life support (2025) · Faust
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