Long-term transvenous temporary pacing with active fixation bipolar lead in the management of severe autonomic dysfunction in Miller-Fisher syndrome: A case report

Use of pacemaker in GBS dysautonomia

Autonomic dysfunction in Guillain-Barrè syndrome (GBS) involves labile hypotension, hypertension, resting tachycardia and sweating. While autonomic involvement affects 66% of patients with GBS, the changes are usually transient and reversible. We hereby delineate a case of a female who presented to our medical centre with flaccid, painless progressive quadriparesis with features of dysautonomia. She had resting tachycardia, was tachypneic with reduced chest expansion and required immediate invasive mechanical ventilation. After pertinent laboratory evaluation, nerve conduction studies were promptly performed at the bedside and findings were concordant with acquired acute inflammatory demyelinating polyneuropathy. The diagnosis of GBS was made on the standard set of investigations and plasmapheresis was initiated on the same day. Her intensive care unit stay was complicated by the multiple episodes of asystole. Even though a temporary transvenous pacemaker was inserted, she, unfortunately, succumbed to a sudden episode of asystole. This paper illustrates that GBS-associated autonomic dysfunction can be severe and close cardiac monitoring is imperative in these patients.

Miller Fisher Variant of Guillain-Barré Syndrome Triggered by Ventilator-Associated Pneumonia

Background

Miller Fisher syndrome (MFS), a triad of ophthalmoplegia, areflexia and ataxia, is one of the regional variants of Guillain-Barré syndrome (GBS) that might account for a quarter of all cases of GBS, especially in Asian countries. There is history of an antecedent upper respiratory tract infection in up to two thirds of MFS cases. However, association of MFS in adults and pneumonia is rarely reported and in those cases causative pathogen was Mycoplasma pneumonia e. To our knowledge, association of MFS and ventilator-associated pneumonia has never been reported. So, we hereby report the first case of MFS which followed ventilator-associated pneumonia (VAP).

Case Report

We report case of a 22-year-old male who was known to have temporal lobe epilepsy and mental retardation. He presented with status epilepticus. He was sedated and put on mechanical ventilation. Two days later, he developed a fever associated with increased tracheobronchial secretions and new infiltrates on chest X-ray. Diagnosis of VAP was made. Upon improvement, he was extubated and shifted out of ICU. Ten days after the onset of fever, he developed gradual onset bulbar weakness and ataxia. On examination, he had generalized areflexia and ataxia. CSF analysis showed cytoalbuminic dissociation. Antibodies against ganglioside complex were elevated. Diagnosis of sero-negative MFS was made, and intravenous immunoglobulin (IVIG) was started. He improved remarkably within two days.

Conclusion

MFS is immune-mediated entity which is usually triggered by upper respiratory tract infection but in rare cases it can be consequence of pneumonia including VAP. Further research is needed to establish link between MFS and VAP.

A Review of Temporary Permanent Pacemakers and a Comparison with Conventional Temporary Pacemakers

Temporary cardiac pacing is commonly used in patients with life-threatening bradycardia and serves as a bridge to implantation of a permanent pacemaker (PPM). For years, passive fixation leads have been used for this purpose, offering the advantage of that they can be placed at bedside. The downside, however, is that patients must remain on telemetry and bed rest until lead removal due to the risk of displacement and failure to capture. Even then, the latter cannot always be prevented. Temporary cardiac pacing with passive fixation leads has also been related to a higher incidence of infection and venous thrombosis, delayed recovery, and increased length of stay. Thus, over the last couple of decades, pacemaker leads with an active fixation mechanism have become increasingly used. This is known as a temporary PPM (TPPM) approach, which carries a very low risk of lead dislodgement and allows patients to ambulate, among other advantages. Here, we performed a review of the literature on the use of TPPMs and their advantages over temporary pacemakers with passive fixation leads and in order to evaluate the advantages and disadvantages of active and passive fixation leads in temporary cardiac pacing. Most articles found were case reports and case series, with few prospective studies. We excluded documents such as editorials and image case reports that provided little to no useful information for the final analysis. The literature search was performed in PubMed, Google Scholar, and other databases and articles written in English and Spanish were considered. Articles were screened up to January 2017. The search keywords used were "temporary permanent pacemaker," "external permanent pacemaker," "active fixation lead," "explantable pacemaker," "hybrid pacing," "temporary permanent generator," "prolonged temporary transvenous pacing," and "semipermanent pacemaker." A total of 24 studies with 770 patients were ultimately included in our review. The age group was primarily above the sixth decade of life, with the exception of one that included pediatric patients. Indications for pacing included device infection, sick sinus syndrome, atrioventricular block, ventricular tachycardia, and bradyarrhythmias associated with systemic illness. The duration of TPPM usage varied from a few days up to 336 days. A total of 18 (2.3%) TPPM-related infections were reported, in which the duration of TPPM use was less than 30 days in at least 15 patients. Loss of capture was documented in only eight patients (1.0%). Complication rates varied from 0% to 30%, with the highest event rates being present in studies that used femoral venous access. In conclusion, although no high-quality studies were identified in our literature search, we found the data retrieved suggest the association of overall favorable outcomes with the use of TPPMs. Device placement and removal typically involve a simple procedure, although fluoroscopy, usually applied in the cardiac catheterization laboratory, is necessary for implantation, which could represent an additional risk in a patient who is already hemodynamically unstable. When possible, a screw-in-lead pacemaker should be used for temporary pacing.

Autonomic involvement in Guillain-Barré syndrome: an update

BACKGROUND

Guillain-Barré syndrome (GBS), an inflammatory, usually demyelinating polyradiculopathy, is characterized by ascending symmetrical limb weakness, sensory disturbances, and absent or reduced deep tendon reflexes. There is extensive literature suggesting that GBS is associated with autonomic dysfunction in up to two-thirds of patients. However, it is interesting that there is still no consensus amongst medical professionals regarding whether GBS patients should be routinely screened for autonomic nervous system (ANS) neuropathy. This is an important issue, as the mortality rate from presumed ANS abnormalities now exceeds that of respiratory failure. Given the long interval since this literature was last comprehensively reviewed, an update on this topic is warranted.

METHODS

A PubMed search yielded 193 results with the terms "GBS or Guillain-Barré syndrome and autonomic symptoms" and 127 results with the terms "GBS or Guillain-Barré syndrome and dysautonomia."

RESULTS

This review will summarize the current literature involving GBS and autonomic dysfunction in terms of presentation, management, and a brief discussion of prognosis. We also examine prospective approaches that may be helpful and update a proposed management plan.

Cardiac Involvement in Peripheral Neuropathies

Cardiac autonomic neuropathy (CAN) is the least recognized and understood complication of peripheral neuropathy. However, because of its potential adverse effects including sudden death, CAN is one of the most important forms of autonomic neuropathies. CAN presents with different clinical manifestations including postural hypotension, exercise intolerance, fluctuation of blood pressure and heart rate, arrhythmia, and increased risk of myocardial infarction. In this article, the prevalence, clinical presentations, and management of cardiac involvement in certain peripheral neuropathies, including diabetic neuropathy, Guillain-Barré syndrome, chronic inflammatory polyneuropathy, human immunodeficiency virus-associated neuropathy, hereditary neuropathies, and amyloid neuropathy are examined in detail.

Predictors for good functional outcome after neurocritical care

Introduction

There are only limited data on the long-term outcome of patients receiving specialized neurocritical care. In this study we analyzed survival, long-term mortality and functional outcome after neurocritical care and determined predictors for good functional outcome.

Methods

We retrospectively investigated 796 consecutive patients admitted to a non-surgical neurologic intensive care unit over a period of two years (2006 and 2007). Demographic and clinical parameters were analyzed. Depending on the diagnosis, we grouped patients according to their diseases (cerebral ischemia, intracranial hemorrhage (ICH), subarachnoid hemorrhage (SAH), meningitis/encephalitis, epilepsy, Guillain-Barré syndrome (GBS) and myasthenia gravis (MG), neurodegenerative diseases and encephalopathy, cerebral neoplasm and intoxication). Clinical parameters, mortality and functional outcome of all treated patients were analyzed. Functional outcome (using the modified Rankin Scale, mRS) one year after discharge was assessed by a mailed questionnaire or telephone interview. Outcome was dichotomized into good (mRS ≤ 2) and poor (mRS ≥ 3). Logistic regression analyses were calculated to determine independent predictors for good functional outcome.

Results

Overall in-hospital mortality amounted to 22.5% of all patients, and a good long-term functional outcome was achieved in 28.4%. The parameters age, length of ventilation (LOV), admission diagnosis of ICH, GBS/MG, and inoperable cerebral neoplasm as well as Therapeutic Intervention Scoring System (TISS)-28 on Day 1 were independently associated with functional outcome after one year.

Conclusions

This investigation revealed that age, LOV and TISS-28 on Day 1 were strongly predictive for the outcome. The diagnoses of hemorrhagic stroke and cerebral neoplasm leading to neurocritical care predispose for functional dependence or death, whereas patients with GBS and MG are more likely to recover after neurocritical care.

Cardiovascular complications of the Guillain-Barré syndrome

The Guillain-Barré syndrome (GBS) is the most common cause of acute flaccid paralysis in young adults and the elderly and an important cause of admission to intensive care units. Manifestations of the GBS vary from monoparesis to life-threatening paralysis of the respiratory muscles. The latter is often punctuated by the presence of cardiac involvement. This ranges from variations in blood pressure to involvement of the myocardium and potentially fatal arrhythmias. This review addresses some of the common cardiovascular complications of the GBS, with their myriad presentations and therapeutic options, as well as potential preventive measures that can be helpful in the management of patients admitted to intensive care units. In conclusion, it is necessary to recognize the potentially fatal cardiovascular complications associated with the GBS and treat them accordingly.