Anesthetic management in a patient with Guillain-Barré syndrome undergoing open reduction and internal fixation for subtrochanteric femur fracture: a case report

Abstract

Guillain-Barré syndrome (GBS) is an acute immune-mediated polyradiculoneuropathy associated with peripheral nerve involvement, autonomic dysfunction, and heightened sensitivity to anesthetic agents, making anesthetic technique selection challenging. We report a patient with a prior diagnosis of GBS (axonal variant, acute motor-sensory axonal neuropathy) confirmed on nerve conduction velocity studies, who presented with a subtrochanteric femur fracture requiring open reduction and internal fixation. Pre-operatively the patient had recovered neurologically with no residual paralysis but showed sinus tachycardia, mild anemia, low-grade fever treated with antipyretics, a Mallampati grade III airway, and grade 2 left ventricular diastolic dysfunction. Focused autonomic assessment revealed no active autonomic dysfunction. General anesthesia was precluded by the predicted difficult airway and the risk of succinylcholine-induced hyperkalaemia in denervated muscle, while epidural anesthesia was impractical due to positional limitations from fracture pain. Spinal anesthesia was administered using 0.75% hyperbaric ropivacaine via a 25G Quincke needle. Post-spinally the patient developed hypotension and tachycardia, attributed to multi-factorial hemodynamic compromise including spinal sympathectomy, anemia, febrile illness and diastolic dysfunction, and was managed with colloid and mephentermine. The intra-operative and post-operative course were otherwise uneventful, with no neurological deterioration. Neuraxial anesthesia is feasible in neurologically recovered GBS patients undergoing urgent non-obstetric surgery when general anesthesia is contraindicated. Thorough pre-anesthetic assessment, anticipation of disproportionate hemodynamic instability, and close post-operative monitoring are essential.