In this episode of Hospital Medicine Unplugged, we blitz Guillain–Barré Syndrome (GBS)—recognize early, monitor relentlessly, start immunotherapy on time, prevent complications.

We open with the do-firsts in the hospital: admit all suspected GBS; check vital capacity (VC) & negative inspiratory force (NIF) at baseline and serially; continuous telemetry & BP for dysautonomia; early swallow screen to prevent aspiration. Move moderate–severe weakness or bulbar signs to a monitored/ICU setting.

Diagnosis is clinical-first, tests support: rapidly progressive, symmetric weakness with areflexia/hyporeflexia; look for albuminocytologic dissociation on CSF and use NCS to subtype (AIDP vs axonal). Rule out mimics (myelitis, MG crisis, CIP/CIM, botulism, cord compression).

Treatment—build the evidence-based core:
• Immunotherapy for non-ambulatory or rapidly progressive patients: IVIg (2 g/kg over 5 days) or plasma exchange (PE; 4–5 exchanges over ~2 weeks)—equally effective for speeding recovery; do not combine (no added benefit).
• Steroids don’t work for typical GBS; reserve for select immune–checkpoint–inhibitor cases with expert input.
• For treatment-related fluctuations, a repeat course of the initial therapy can be considered in select cases.

Supportive care that saves lives:
• Airway & breathing: trend VC/NIF at least twice daily; intubate early if VC < 15 mL/kg, rapidly falling metrics, or bulbar failure.
• Autonomic surveillance: watch for tachy/bradyarrhythmias and labile BP; temporary pacing may be needed in severe cases.
• DVT prevention: LMWH or heparin + compression; turn, mobilize early.
• Pain: prioritize non-opioid neuropathic agents; treat constipation, bladder retention.
• Nutrition & skin: enteral feeding if unsafe swallow; meticulous pressure injury prevention.
• Rehab starts day 1: PT/OT, respiratory physio, contracture prevention, patient/family education.

Risk & disposition plays:
• Up to 20–30% require ventilation—strongest predictor of poor outcome.
• Autonomic dysfunction (~20%) can trigger malignant arrhythmias or BP swings—keep on monitors.
• Complication shield: aspiration pneumonia, sepsis, PE/DVT, pressure injuries—anticipate and prevent.
• Use EGRIS (respiratory insufficiency risk) and mEGOS (functional outcome) to triage level of care, counseling, and resource planning.

Subtypes & nuance:
• AIDP predominates in the West; AMAN/AMSAN (axonal) skew more severe and recover slower; Miller Fisher = ophthalmoplegia/ataxia/areflexia. Subtype by NCS may inform prognosis but doesn’t change first-line immunotherapy.

Quality & safety pearls:
• Don’t delay IVIg/PE for confirmatory tests if the patient is deteriorating.
• Avoid PE when hemodynamically unstable from dysautonomia; prefer IVIg.
• IVIg cautions: hyperviscosity/thrombosis risk—hydrate, monitor high-risk patients.
• Combination IVIg+PE = no gain; early steroids = harm/no benefit in classic GBS.

Prognosis talk track:
• Most regain independent ambulation by 6–12 months, but ~20% have persistent disability; ~3–5% die despite care. Axonal subtype, older age, severe nadir, C. jejuni antecedent, and the need for ventilation worsen outlook.

We close with the hospital bundle that sticks:
(1) Admit all suspected; baseline VC/NIF/telemetry + swallow screen.
(2) Default to IVIg or PE (one, not both), started early.
(3) ICU for bulbar signs, rapid progression, dysautonomia, or EGRIS high-risk.
(4) Airway algorithm with objective thresholds (VC <15 mL/kg, falling NIF).
(5) Autonomic pathway: continuous monitoring → pacing capable environment.
(6) Complication prophylaxis: DVT, pressure, aspiration, sepsis.
(7) Rehab-on-admission with daily PT/OT and caregiver education.
(8) Score and re-score (EGRIS/mEGOS) to guide expectations and follow-up.

Fast recognition, monitoring that doesn’t blink, and timely IVIg or PE—that’s how you keep GBS safe in the hospital and set the table for recovery.