背景:格林-巴利综合征(GBS)通常预后良好。成人GBS患者,在疾病的急性期,10-30%需要机械通气。急性期过后,焦点转移到恢复运动强度,步行,和神经功能,具有可变的速度和恢复程度。这些指南的目的是就作为神经预后基础的选定临床预测因子的可靠性提供建议,并为为患有GBS和/或其替代药物的成年患者提供咨询的临床医生提供指导。
方法:使用建议评估等级完成叙述性系统综述,开发和评估(等级)方法。候选预测因子,包括临床变量和预测模型,根据临床相关性和适当证据的存在进行选择。人口/干预/比较/结果/时间范围/设置(PICOTS)问题的框架如下:“当咨询患有格林-巴利综合征的危重病患者或代理人时,应该[预测,如果适当的话,评估时间]被认为是[结果的可靠预测因子,与评估的时间范围]?\“额外的全文筛选标准被用来排除小型和低质量的研究。在构建证据概况和调查结果摘要之后,建议基于四个等级标准:证据质量,理想和不良后果的平衡,价值观和偏好,和资源使用。此外,良好实践建议解决了无法以PICOTS格式构建的神经预后的基本原则。
结果:选择了八个候选临床变量和六个预测模型。共有45篇文章符合我们指导建议的资格标准。我们建议延髓无力(疾病最低点时的运动无力程度)和伊拉斯musGBS呼吸功能不全评分可用于预测机械通气的需求。ErasmusGBS结果评分(EGOS)和改良的EGOS被确定为3个月及以后独立行走的中度可靠预测因子。良好做法建议包括在预测期间考虑疾病的急性期和恢复期,讨论咨询期间可能需要机械通气和肠内营养,并考虑完整的临床状况,而不是预测期间的单个变量。
结论:这些指南对机械通气需要的预测因素的可靠性提供了建议,功能效果不佳,以及在咨询患者和/或代理人的情况下GBS后的独立行走,并提出了神经预后的广泛原则。根据现有的证据,很少有预测因子被认为是中等可靠的,需要更高质量的数据。
Guillain-Barré syndrome (GBS) often carries a favorable prognosis. Of adult patients with GBS, 10-30% require mechanical ventilation during the acute phase of the disease. After the acute phase, the focus shifts to restoration of motor strength, ambulation, and neurological function, with variable speed and degree of recovery. The objective of these
guidelines is to provide recommendations on the reliability of select clinical predictors that serve as the basis of neuroprognostication and provide guidance to clinicians counseling adult patients with GBS and/or their surrogates.
A narrative systematic review was completed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Candidate predictors, including clinical variables and prediction models, were selected based on clinical relevance and presence of appropriate body of evidence. The Population/Intervention/Comparator/Outcome/Time frame/Setting (PICOTS) question was framed as follows: \"When counseling patients or surrogates of critically ill patients with Guillain-Barré syndrome, should [predictor, with time of assessment if appropriate] be considered a reliable predictor of [outcome, with time frame of assessment]?\" Additional full-text screening criteria were used to exclude small and lower quality studies. Following construction of an evidence profile and summary of findings, recommendations were based on four GRADE criteria: quality of evidence, balance of desirable and undesirable consequences, values and preferences, and resource use. In addition, good practice recommendations addressed essential principles of neuroprognostication that could not be framed in PICOTS format.
Eight candidate clinical variables and six prediction models were selected. A total of 45 articles met our eligibility criteria to guide recommendations. We recommend bulbar weakness (the degree of motor weakness at disease nadir) and the Erasmus GBS Respiratory Insufficiency Score as moderately reliable for prediction of the need for mechanical ventilation. The Erasmus GBS Outcome Score (EGOS) and modified EGOS were identified as moderately reliable predictors of independent ambulation at 3 months and beyond. Good practice recommendations include consideration of both acute and recovery phases of the disease during prognostication, discussion of the possible need for mechanical ventilation and enteral nutrition during counseling, and consideration of the complete clinical condition as opposed to a single variable during prognostication.
These
guidelines provide recommendations on the reliability of predictors of the need for mechanical ventilation, poor functional outcome, and independent ambulation following GBS in the context of counseling patients and/or surrogates and suggest broad principles of neuroprognostication. Few predictors were considered moderately reliable based on the available body of evidence, and higher quality data are needed.