PAIN MANAGEMENT
- Pain is present in 50-80% of patients at the time of presentation[39]
- Pain is common during the recovery phase of muscle weakness. Between 70 and 90% have persistent pain or new pain over the first month or two of the illness[40]
- Pain in GBS is commonly due to - (a) Inflammation and entrapment of the nerve roots (back and limbs) and (b) alteration in the function or spontaneous discharges in the demyelinated sensory nerves (i.e. paraesthesia, causalgia)
Pain Syndromes in Guillain-Barre Syndrome[41]
- Bilateral sciatica like pain in the flanks or back and lower limbs, correlating with the distribution of the motor loss.
- Tender aching in the large muscles of the upper legs.
- Paraesthesia or causalgia-like neuritic pain is often severe.
- Visceral pain secondary to constipation, gastritis, peptic ulceration and urinary retention
- Headache because of dysautonomia, malignant hypertension or as an inherent feature of GBS
- Pressure palsies and sacral ulcers.
- Myositis ossificans
Treatment
OPIOIDS
- Severe pain may need oral or parenteral opioids[40]
- Patients in intensive care on ventilatory support are best managed with continuous subcutanoeus or intravenous opioid infusions[41]
- Titrated dosages of sustained release morphine are tolerated well in non-ventilated patients in the acute phase.
Disadvantages
- Tolerance
- Respiratory depression
- Potential for physical dependence.
NON STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs)
- New NSAIDs are useful in acute non-severe pain (e.g. ibuprofen) [42]
- An antacid (e.g. omeprazole/ranitidine) or sucralfate, administered while the child is in PICU or until enteral feeding is established, are drugs useful in treating the potential adverse effects of gastritis and gastrointestinal ulceration. Other potential adverse effects include renal and hepatic failure[43]
ANTI-EPILEPTIC DRUGS
- Carbamazepine is effective as an adjuvant treatment for neuralgic pain during the recovery phase in PICU.[44]
- Carbamazepine lowers the demand for systemic opioids and is less sedative.
- Carbamazepine is well tolerated[45]
- Gabapentin is probably also effective in treating chronic neuropathic pain[46]
TRICYCLIC ANTIDEPRESSANTS
- Also effective in neuralgic pain, which maybe severe[47]
PREVENTION.
- Air mattresses.
- Turning patients and careful positioning of limbs.
- Padding of elbows and knees.
- Appropriate splinting (ankles, wrists).
- Continuation of enteral feeding, effective antacids, e.g. omeprazole
Communication
- The child may be fully aware and conscious of the surroundings, depite paralysis. Everything that is said in front of the child is likely to be heard.
- It is important that the child is told what is happening and should be reassured by familiar voices and faces.
- A calm atmosphere is essential.
- The environment should be as child-friendly as possible. Bring in a favourite toy.
- Speech and language therapists and occupational therapists should be involved early. They will be able to assess the patients' need for augmented and alternative communicatiion devices.
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