A child with Acute Inflammatory Demyelinating Polyradiculoneuropathy (AIDP) – Guillian- Barre Syndrome (GBS)
Subathra Devi N, Ruby Ravichandran
Nursing Supervisor, Kauvery Hospitals, Cantonment, Trichy
Deputy Nursing Superintendent, Kauvery Hospitals, Cantonment, Trichy
Abstract
A 9-year-old child presented with complaints of vomiting and excessive sweating, followed by bilateral leg and thigh pain progressing to trunk neck, with bilateral lower limb weakness. As he had also lung findings- crepitations over right supra, inter, infra scapular region. GBS with right aspiration pneumonia was considered. There was leukocytosis with elevated ESR and CRP. Urea and creatinine were normal. Neurologist was consulted and IVIG 1 g/kg was administered. Dyselectrolytemia was corrected. The child gradually improved and was weaned off from ventilator support. He had aspiration to liquids and swallowing; therapist was consulted and diagnosed as GradeI laryngomalacia and advised to start oral soft solid diet and trial liquid. Motor power gradually improved, upper limbs more than lower limbs. He was started on occupational therapy and physiotherapy. The swallowing reflexes were reviewed and advised to start a liquid diet along with a solid diet. His power further improved. He was discharged and shifted to Hamsa for further care
Case Presentation
A 9-year-old male child came with complaints of vomiting, excessive sweating followed by bilateral leg and thigh pain progressing to trunk neck, with bilateral lower limb weakness.
He was initially treated in the nearby hospital and diagnosed as AIDP- GBSand treated with IVIG 2g/kg,
He showedimprovement in motor power.
Later, had persistent cough followed by breathing difficulty. Severe Bradycardia improved after 3 cycles of CPR., He was then referred hereto ventilator support.
Antenatal Birth history:Uneventful
Development history:Attained developmental milestones at appropriate age
Immunization history:Immunized till date
Clinical Findings:
Child was under sedation.
Pulse volume good, Temp: 98.6degF, HR: 150/mt, RR: 25/mt, SPO2: 98%, BP: 110/60mmHg with inotropes support
Systemic Examination
RS: Bilateral air entry equal, crepitation over right supra, inter, infra scapular region CNS: Under sedation
GCS – 2T/15
Systemic examination was normal
Management in Hospital
Intensive Care Unit Sta
Child was shifted to intensive care unit and started continuous mechanical ventilator support; maintenance dose of inotropic and sedation started.
Day 1: We found cough leak in the tube and it was displaced, under strict aseptic precaution child intubated with 5.5 endo tracheal tube and fixed; during intubation injection fentanyl 80mcg and injection Vecuronium 3 mg given
Day 2: The patient was on 2ndday of mechanical ventilation. We adhered to the bundle care. We did suction and while, before and after suction the child was hyper oxygenated prevent hypoxia. Every day we followed aggressive chest physio and limb physio. We maintained oral hygiene frequently when the patient was on ET because of oral cavity is a primary source of contamination of the lungs
Day 3-4:The child was on a ventilator. He had 7 episodes of loose stools, perianal redness noticed. We used Branden scaling in each shift, turn -O -Clock position chart followed by 2ndhourly position change, every 4thhourly we followed back care, the surface of the bed was changed by using foam wedges, pillows and airbed to relieve constant pressure over the pressure points, Dehydration prevented and balanced nutrients provided according to dietician assessment
Day 5: Planned for weaning from the ventilator, the trial weaning process was started. intensive opinion was obtained the next day, child changed to PS mode, no desaturation, breathing difficulty. Breathing effort was good and successfully child was extubated
Even though patient was extubated the next day, providing breathing exercise and limb physio was the most challenging task. As the child was not blowing incentive spirometer, we provided him balloon which was attached with small pipe to blow, which also was rejected by the child. It was difficult to get the child to understand and co-operate. Hence, we encouraged the child to cough to initiate breathing exercise. We motivating him to communicate through a notepad, pencil or magic slate, such as lip reading
Day6 to 10: The child had a grade II laryngomalacia; it was challenge for us first, we tried him in giving honey to check the swallowing effort ,he was unable to swallow and later he took around 8mls with several sips and swallowing improved. He tolerated oral feeds well, straw drinking and warm water intake.
<3>High Dependency Unit
Day11 to16:Successfully the patient was shifted to HDUs. He faced the challenge of doing his daily activities independently.
Physically and mentally, he and his parents were disturbed. We provided psychological and emotional support to a very young child. Active assisted exercise and passive exercise regularly given. We followed high sitting once a day. We followed as the occupational therapist advised.
Outcome
Day16 to19: We made him daily sit and stand with support, Day by day he improved. We brought him back to his routine life. Child’s power gradually improved, upper limbs more than lower limbs. He was started on occupational therapy and physiotherapy. Swallowing reflexes were reviewed and the child was advised to start a liquid diet along with a solid diet. His power improved. He was discharged and shifted to a rehabilitation center for further care.
Definition
Guillian- Barre syndrome (GBS) is also called acute inflammatory demyelinating polyradiculoneuropathy (AIDP). It is a neurological disorder in which the body’s immune system attacks the peripheral nervous system, the part of the nervous system outside the brain and spinal cord
- Nursing Management of the pediatric patient is always challenging
- Management of lines and tubes in a conscious baby.
- Venipuncture and intravenous (IV) cannula insertions are the two common sources of pain in hospitalized; children we used some evidence based comforting strategies of pain relief during pediatric peripheral IV-line insertion and maintenance. Prevented VIP scores and Infiltration. IV bundles followed.
- Monitoring of vitals, intake -output etc, closely every hour as the clinical situation can change in a matter of hours.
We followed strict aseptic technique: barriers, patient equipment and preparation, environmental controls, and contact guidelines which play an important role in infection prevention during a medical procedure. - Nursing a child for care and feeding in the absence of parents and relatives
- 2nd hourly suctioning done as per protocol
- Pressure injury management: Children in intensive care have a higher risk of developing pressure injury even in the early stages. Simple dressings were the main ones implemented by nurses,
- Informing every issue of the child to doctors and following the orders promptly as it was very important.
- Maintaining double checking before administering the medication to avoid medication errors
- CVC, CAUTI, VAE bundle care followed and prevented HAI.
Condition at Discharge
Child stable, afebrile, Hydration adequate, Urine output adequate,
Vitals stable
CNS: Tone – Improved;
Power – Upper limb 5/5, Lower limb: 3/5
Deep tendon reflux: Present
Other systems normal
Advice On Discharge
1. Diet as advised
2. Avoid live vaccine for 10 months
3. Physiotherapy and occupational therapy
Ms. Subhathra,
Nursing Supervisor
Ms. Ruby Ravichandran,
Deputy Nursing Superintendent