Management of Alcohol Withdrawal Syndromes


Alcohol withdrawal:

Delirium:

A. Discontinuation of prolonged heavy alcohol intake

B. At least two of the following symptoms:

 Autonomic hyperactivity

 Hand tremors

 Insomnia

 Nausea or vomit

 Transient hallucinations or illusions

 Psychomotor agitation

 Anxiety

 Generalized tonic clonic seizures

Decreased attention or awareness

Disturbance in attention, awareness, memory, orientation, language, Visuospatial ability, perception, or all of these abilities that is a change from the normal level and fluctuates in severity during the day

Disturbances in memory, orientation, language, visuospatial ability, or perception

No evidence of coma or other evolving neurocognitive disorders

Predictors of delirium tremens: [1]

 CIWA-AR scores > 15

 Tachycardia (heart rate > 100 bpm)

 Hypertension (systolic blood pressure > 150 mmHg)

 Older age

 Recent or prior seizures/AWS

 Recent misuse of other depressant drugs

 Electrolyte abnormalities

 Other comorbidities (cardiac, pulmonary, gastrointestinal)




Table 92.2
The revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar) [4]

A329322_1_En_92_Tab2_HTML.gif


A score greater than 10 indicates the need for admission to the hospital, with higher scores correlating with severity of withdrawal and probability of seizures [5, 6]




Principles of Management



Diagnosis


Alcohol withdrawal is a clinical diagnosis based on appropriate patient history and symptoms, with reasonable exclusion of other etiologies (e.g. infectious workup if patient presents with fever). Patients should have a history of chronic alcohol abuse with a recent abrupt reduction in intake. The symptoms of alcohol withdrawal can be divided into three broad categories: CNS excitation, autonomic hyperactivity, and psychosis. CNS excitation occurs 12–48 h following alcohol cessation, and is due to decreased inhibitory tone of the γ-amino butyric acid (GABA) receptor, and increased excitatory activity of the N-methyl-aspartate glutamate receptor (previously suppressed by alcohol intake). The patient may present with anxiety, agitation and restlessness, which, if left untreated, can progress to seizures. Most of the seizures are self- limited but can progress to status epilepticus. Autonomic hyperactivity typically occurs 24–48 h following alcohol cessation and is related to increased noradrenergic response. The patient may experience fevers, tachycardia, hypertension, diaphoresis and fevers. Psychosis occurs due to excess dopamine release through the mesolimbic tract. The patient will show confusion, hallucinations, and paranoia [3, 7].


Initial Phase of Care


The management of alcohol withdrawal is directed towards alleviating symptoms of withdrawal and avoiding its progression into seizures or DTs. For patients with marked alteration in mentation, hemodynamic instability, or those requiring frequent nursing assessment and intervention, ICU admission is suggested. Due to disease and medication related alterations in mentation; patients may require endotracheal intubation for airway protection. Benzodiazepines (e.g. lorazepam, diazepam) remain the first line of treatment, and are typically given intravenously to patients requiring ICU monitoring. Initially, a symptom-triggered escalating dose strategy has been shown to reduce the duration of therapy and the total dose of the medication given [8]. The goal of this protocol is to rapidly increase the doses until a desired level of sedation is achieved, before severe agitation occurs (Table 92.3). In cases of DTs, continuous benzodiazepine infusion may be required to alleviate symptoms [1, 7, 9, 10]. As propylene glycol toxicity may occur with high doses of IV lorazepam, it is recommend to check serum osmolarity (Osm) and the osmolar gap in these patients, and to stop the infusion if serum osm >350 mOsm/kg or serum osmol gap >10 [10, 11].


Table 92.3
Pharmacologic treatment of alcohol withdrawal delirium [9, 12]






































Drug

Loading dose

Repeated dosing regimen if ineffective

Diazepam

5 mg IV

1. Repeat dose of 2.5 mg IV in 10 min, then

2. Administer additional 2.5 mg dose, then

3. Repeat dosing every 10 min increasing to 5 mg, then 10 mg, then 20 mg as is needed

Lorazepam

1–4 mg IV

1–4 mg IV every 5–15 min, can repeat hourly

1–40 mg IM

Repeat 1–40 mg IM

Phenobarbital

260 mg IV

130–260 mg IV every 15–20 min

The following drugs must be utilized as adjunct therapy or in combination with benzodiazepines for the treatment of DTs [1216]

Propofol

Can be bolused and/or administered as an infusion (5–80 ug/kg/min)

Haloperidol

0.5–5 mg IV/IM every 30–60 min

Dexmedetomidine

Infusion: 0.2–0.7 ug/kg/h, with no bolus.


Note: phenobarbital and propofol must be administered in an ICU. Phenobarbital may be administered as monotherapy or in combination with benzodiazepines for refractory DTs. In the ICU, medications are titrated according to the Richmond Agitation Severity Score (RASS)

The goal of care must also include nutritional supplementation and hydration, with emphasis in avoiding excessive fluid administration. Blood glucose and electrolytes must be monitored closely. Thiamine (500 mg IV once or twice a day for 3 days) is recommended to prevent the development of Wernicke encephalopathy, and it’s particularly important to be given before the administration of IV dextrose, as the latter can precipitate acute thiamine efficiency [1, 9, 10].

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Jul 20, 2017 | Posted by in Uncategorized | Comments Off on Management of Alcohol Withdrawal Syndromes

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