Management Of Alcohol Withdrawal Research Articles

Brief review: Obstetric care and perioperative analgesic management of the addicted patient

Addiction to alcohol and illicit drugs occurs in approximately 10% of the Canadian population and thus likely affects numerous perioperativepatients. Provision of perioperative analgesia to these patients is challenging for physiological and behavioural reasons. Seven electronic databases were searched to identify papers addressing the perioperative management of analgesia in addicted patients. There are few controlled trials on addiction care in obstetrical management, and controlled trials are lacking in obstetrical analgesia and addiction and in perioperative analgesia and addiction. The focus of the limited number of publications in the obstetrical population is on addiction management during pregnancy and does not address analgesic requirements. There are principle-based discussions on factors affecting analgesic management in patients receiving chronic opioid therapy and multimodal analgesic therapy. This discourse includes consideration of the physiological and affective factors that impact perioperative management. A number of empirically derived protocols available for managing alcohol withdrawal are based on response to the physical manifestations of withdrawal. Protocols for management of patients receiving opioid replacement therapy for opioid addiction are also well described. Nevertheless, evaluations of these protocols are lacking in clinical trials, and the impact of addiction on perioperative outcomes is unknown. Perioperative analgesic management of addicted patients remains poorly understood. Most clinical trials specifically exclude addicted patients. Suggestions for management are provided.

Perioperative management of alcohol withdrawal in an achondroplastic dwarf with an unstable cervical spine: a difficult management dilemma.

Patients presenting with alcohol withdrawal syndrome have an increased risk of perioperative events related to hemodynamic and respiratory instability. We present the case of a 49-year-old achondroplastic dwarf in alcohol withdrawal with cervical spinal cord injury and aortic dissection requiring emergency surgery. Due to conflicting perioperative management goals, a decision was made to delay surgery until the patient became clinically stable. Additional options might have been explored and resulted in better outcome.

Editorial comments on perioperative management of alcohol withdrawal in achondroplastic dwarf with an unstable cervical spine: a difficult management dilemma.

A & A Case Reports: November 15, 2013 - Volume 1 - Issue 4 - p 58 doi: 10.1213/XAA.0000000000000009

A retrospective chart review of a symptom-triggered alcohol withdrawal protocol versus previous standard of care at a veterans hospital

Alcohol is a commonly abused substance, and it is important that healthcare facilities properly manage alcohol withdrawal. Studies have found that the most efficient way to manage alcohol withdrawal is to use a symptom-triggered approach and only administer medications if symptoms surpass a specific threshold determined by a clinician administered rating scale. Alternatively, a standard fixed-dose medication regimen can be utilized. This study assessed if a new symptom-triggered protocol, utilizing the Clinical Institute Withdrawal for Alcohol, Revised (CIWA-Ar) scale for the assessment of symptoms, resulted in the anticipated patient outcomes of decreased length of hospital stay, less benzodiazepine administered per patient, and a shorter administration time from first dose of benzodiazepine given to last dose, when compared to the previous standard of care. A retrospective chart review was performed for 70 patients who had been treated for alcohol withdrawal. Patients who were treated with the symptom-triggered protocol had a decreased length of hospital stay when compared to the previous standard of care (−2.62 days, p = 0.0054). Both secondary efficacy outcomes were also statistically significant in favor of the symptom-triggered group. This retrospective chart review adds to the body of evidence supporting the use of symptom-triggered protocols as opposed to fixed-dose protocols in the management of alcohol withdrawal.

Management of acute alcohol withdrawal in the setting of a quick diagnostic unit integrated in an emergency department setting

Background Alcohol consumption can have adverse social, legal, occupational, psychological, and medical consequences. The prevalence of alcohol-use disorders is high in Emergency Departments. The novel establishment of a Quick Diagnostic Unit (QDU) in an ED setting has allowed expeditious and focused, medically supervised acute alcohol withdrawal. The purpose of the study was to describe the alcohol-use disorder clientele and treatment in this new setting.

ALCOHOL WITHDRAWAL RECOGNITION, SCREENING AND PRESCRIPTION PRACTICES IN THE ACUTE MEDICAL SETTING

IntroductionDelirium tremens (DT) is defined by hallucinations, tachycardia, hypertension, fever, agitation, and diaphoresis in the setting of acute reduction or abstinence from alcohol. DT is a medical emergency associated with...

PTU-092 The Management of Alcohol Withdrawal in Patients with advanced Liver Disease

IntroductionAlcohol withdrawal syndrome (AWS) is a common reason for hospital admission. However a significant number of these patients have co-existent liver disease or other medical problems. There is little information...

Managing alcohol withdrawal in hospitalized patients

Managing alcohol withdrawal in hospitalized patients

Identification and management of alcohol dependence and withdrawal in alcoholic liver disease.

Identification and management of alcohol dependence and withdrawal in alcoholic liver disease.

Assessment and management of alcohol‐related admissions to UK intensive care units

The critical care environment has felt the overwhelming impact of the growing problem of alcohol abuse. However, there is ambiguity concerning the assessment and management of this patient group. The aim of this study was to explore current practice in the use of assessment and management tools for alcohol-related admissions in UK intensive care units (ICU). Two hundred and forty-eight lead consultants across England, Scotland, Northern Ireland and Wales were sent an electronic survey using the SurveyMonkey(®) ( www.surveymonkey.com) website. A total of 103 (41·05%) lead consultants responded to the survey. Most units (67%) utilized the volume of alcohol consumed per week to assess patient alcohol use. Furthermore, 12 units (11%) used the Clinical Institute Withdrawal Assessment tool, 5 units (5%) used the Glasgow Modified Alcohol Withdrawal Scale and 79 units (73%) used no tool for the management of alcohol withdrawal syndrome. There appears to be a diverse approach to the assessment and management of alcohol-related admissions in UK ICUs. Further research is required in this area to identify the most effective way to assess and manage alcohol-related admissions within intensive care. Under recognition and poor assessment of alcohol use can have major implications for critically ill patients.

A Case‐Based Approach to the Practical Application of Dexmedetomidine in Critically Ill Adults

Dexmedetomidine is a selective α(2) -adrenoceptor agonist that offers unique sedation because patients are readily awakened while administration continues and the drug does not suppress the respiratory center. Limitations of use include higher acquisition cost, inability to produce deep sedation, and bradycardia and hypotension. Using a case-based approach, the purpose of this review was to qualitatively assess the role of dexmedetomidine in the care of the critically ill and in the management of alcohol withdrawal, and to formulate recommendations regarding its clinical application. Sixty-six studies were identified that investigated dexmedetomidine for the provision of sedation. These studies were heterogeneous in design and patient populations; most investigated patients did not require heavy sedation, and few used propofol as the comparator. In general, though, the aggregate results of all studies demonstrate that dexmedetomidine provides comfort, possibly shortens the duration of mechanical ventilation to facilitate extubation, reduces the occurrence of acute brain dysfunction, and facilitates communication, but the drug is associated with hemodynamic instability and requires the supplemental use of traditional sedative and analgesic agents. These outcomes need to be substantiated in additional studies that include assessments of cost-effectiveness. Dexmedetomidine should be considered when patients require mild to moderate levels of sedation of short to intermediate time frames, and they qualify for daily awakenings with traditional sedative therapies. The data for dexmedetomidine in relation to alcohol withdrawal are limited to 12 retrospective reports representing a total of 127 patients. Its role for this indication requires further study, but it may be considered as adjunctive therapy when clinicians are concerned about respiratory suppression associated with escalating doses of γ-aminobutyric acid agonists. Regardless of the indication for dexmedetomidine, the practitioner must closely monitor patient comfort and the occurrence of hemodynamic deviations with the realization that as-needed administration of traditional sedatives and analgesics will be required and some degree of bradycardia and hypotension expected but intervention rarely required.

Predictors of Severity of Alcohol Withdrawal in Hospitalized Patients

BackgroundAlcohol withdrawal is a relatively common problem among chronic alcohol users, and its severity will determine the setting in which it will be more appropriate to take care of the patients. Those with mild symptoms will be managed in an outpatient setting, as opposed to those with advanced moderate or severe symptoms who will require inpatient management. Among those patients who will require hospitalization, some of them will do well in a regular floor, but some of them will have to be managed in an intensive care unit. We tried to determine whether some variables could be predictive of an increased risk of being managed in an intensive care unit as opposed to being managed in a regular medical floor.MethodsA retrospective non-randomized review trial design was implemented and a total of 110 medical charts of patients admitted to our institution with severe alcohol withdrawal during the calendar year of 2009 were reviewed. Different demographic and clinical parameters were analyzed, and their significance established in regard to the clinical settings (ICU vs. medical floor) in which the patients were managed.ResultsThe patients managed in the ICU were found to be younger than their counterparts who were managed in the medical floor, and they were more likely to be white and unemployed. On the other hand, being diabetic, using over-the-counter drugs or prescribed medications appeared to be protective factors, resulting in management of alcohol withdrawal on the medical floors.ConclusionA likely explanation to our findings could be that patients exhibiting better health protective behaviors have a better chance to stay away from the ICU. However no tools could be developed to stratify the patients’ risks and more behavioral and observational cohort studies will be needed for that purpose.

1212 – Audit on the management of patients with alcohol withdrawal within inpatient setting in relation to the local guidelines (based on nice recommendations)

Alcohol dependency can cause serious complications if not managed appropriately. To evaluate if the local guidelines (based on NICE) for the management of acute withdrawal are followed at the Bede Unit/South Tyneside. These advises a three day course of intramuscular Pabrinex and seven days reducing regime of benzodiazepine (commonly Chlordiazepoxide) with additional PRN (as required) benzodiazepine. The project's main objective is to identify how the guidelines can be delivered more effectively. Retrospective data collection from all kardex for all patients (21 identified) who received a reducing regime of benzodiazepines between Oct/11 & Jan/12, for alcohol withdrawal symptoms, examining if they were prescribed bezodiazepines regularly, ‘as required’ or both to treat withdrawal symptoms. Vitamin supplementation as part of their management of alcohol withdrawal was also reviewed. All patients were prescribed chlordiazepoxide. Seventeen of these were prescribed both regular and PRN chlordiazepoxide, while one received regular only and three patients received PRN only. Period of treatment ranged from 2-11. Five received the recommended seven days reducing regimen. Only one patient was managed in accordance with local guidelines (three days of intramuscular Pabrinex/seven days reducing chlordiazepoxide/PRN benzodiazepine) There was inconsistency in the use of PRN benzodiazepine. There might be doubts about patients’ knowledge regarding as required medication, and on how withdrawal symptoms are monitored. The reducing regime of benzodiazepines is limited to the format of the kardex, which made it difficult to identify drug errors or omissions and hence increased the margin for medication errors.

Clinical management of alcohol withdrawal: A systematic review.

Alcohol withdrawal is commonly encountered in general hospital settings. It forms a major part of referrals received by a consultation-liaison psychiatrist. This article aims to review the evidence base for appropriate clinical management of the alcohol withdrawal syndrome. We searched Pubmed for articles published in English on pharmacological management of alcohol withdrawal in humans with no limit on the date of publication. Articles not relevant to clinical management were excluded based on the titles and abstract available. Full-text articles were obtained from this list and the cross-references. There were four meta-analyses, 9 systematic reviews, 26 review articles and other type of publications like textbooks. Alcohol withdrawal syndrome is a clinical diagnosis. It may vary in severity. Complicated alcohol withdrawal presents with hallucinations, seizures or delirium tremens. Benzodiazepines have the best evidence base in the treatment of alcohol withdrawal, followed by anticonvulsants. Clinical institutes withdrawal assessment-alcohol revised is useful with pitfalls in patients with medical comorbidities. Evidence favors an approach of symptom-monitored loading for severe withdrawals where an initial dose is guided by risk factors for complicated withdrawals and further dosing may be guided by withdrawal severity. Supportive care and use of vitamins is also discussed.

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Introduction: Alcohol withdrawal management in hospitalized patients is a challenging problem with implications on patient and staff safety, outcomes and overall cost of hospital stays. Hypothesis: Based on increasing reports of violent behavior and costly cases possibly related to alcohol withdrawal syndrome, our three hospital system formed a multidisciplinary team to optimize the alcohol withdrawal management protocol. The goal was to reduce violent behavior, protect staff, and improve patient outcomes by reducing rapid response team (RRT) calls related to oversedation or respiratory causes. The team also did extensive education to promote the use of the new order set to ensure appropriate monitoring and therapy. Methods: Improvements based on literature review were incorporated into alcohol withdrawal protocol in the electronic health record. The alcohol withdrawal risk screen was updated to include the CAGE questionnaire. The order of symptom assessment for the CIWA-Ar was changed to support symptom driven medication selection. Separate order sets were developed for prevention and treatment of withdrawal. Benzodiazepine treatment options were expanded to include more aggressive dosing schemes for severe acute withdrawal, promoting IV push dosing over continuous infusion benzodiazepines. Antipsychotic dosages were increased and criteria were designated for symptom driven administration. Clonidine was added as a treatment option for adrenergic symptoms. Results: An association was observed between the creation of an evidence based alcohol withdrawal prevention and treatment order set and a decrease in RRT calls. There was a 55.9% relative risk reduction in RRT calls related to oversedation or respiratory cases after implementation of the new protocol. Conclusions: By utilizing literature review and expert opinion, our team identified opportunities to improve the management of alcohol withdrawal by modifying nursing assessments to determine patient risk level and by directing pharmacologic therapy based on symptomatology. The protocol was widely used before and after improvements were made, leading to a decrease in RRT calls.

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Introduction: Benzodiazepines (BZD) are initially used for treatment of alcohol withdrawal. Phenobarbital (PB) is a barbiturate agent that has also been used in managing alcohol withdrawal symptoms, especially refractory to BZD. However, limited data is available in critically ill patients. The purpose of our study is to describe our institution’s experience with adjunctive PB use in managing severe alcohol withdrawal in the intensive care unit (ICU). Hypothesis: PB can be safely used adjunctively with BZD in managing severe alcohol withdrawal symptoms in the ICU. Methods: A retrospective review was performed for patients who received PB for severe alcohol withdrawal admitted to the medical ICU from July 2011 to February 2012. Patients were managed with the medical ICU severe alcohol withdrawal protocol which utilizes a step-wise approach with BZD and PB. IRB approval was granted. Data were collected on demographics, time to symptom control, medication doses, ventilator days, ICU length of stay and adverse effects of PB. Results: Of the 28 patients analyzed, the mean values for medication requirements were as follows: average amount of PB administered = 1086 mg + 390 mg, cumulative dose of lorazepam administered in the first 24 hours of protocol initiation = 209 mg + 145 mg and duration of continuous sedative infusions = 97 + 59.8 hours. The average time to symptom control was 1.4 + 0.7 hours. The majority of patients (18/28) requiring mechanical ventilation were for reasons unrelated to PB. Average duration of mechanical ventilation was 5.7 + 2.1 days and average ICU length of stay was 7.9 + 2.4 days. Complications of PB included respiratory failure requiring intubation in 2/28 (7.1%) and hypotension in 3/28 (10.7%) of the study population. Conclusions: PB when used adjunctively with BZD was able to control severe alcohol withdrawal symptoms in the ICU with minimal complications. PB may have a potential role for managing severe alcohol withdrawal symptoms in critically ill patients that are not adequately controlled with BZD. Continued work is directed at comparing outcomes before and after PB use in the medical ICU.

Supplementary Thiamine is Still Important in Alcohol Dependence

To assess the effect of mandatory thiamine enrichment of wheat flour on blood thiamine levels in an alcohol-dependent population. Alcohol-dependent clients (n = 100) entering an inpatient service for the management of alcohol withdrawal had thiamine blood tests and diet interviews. Approximately half (n = 46) the alcohol-dependent participants reported taking vitamin supplements prior to admission. Standard treatment included thiamine supplementation in the form of an intramuscular injection and 100 mg tablets. If consent was gained, a second thiamine blood test was taken prior to discharge (n = 77). Control participants (n = 20) with no history of treatment for alcohol abuse had thiamine blood tests and diet interviews. Control participants consumed significantly larger amounts of thiamine in their diet compared with alcohol-dependent participants (P < 0.0001). Alcohol-dependent participants who reported no use of vitamin supplements had significantly lower (P < 0.05) blood thiamine levels compared with controls, whereas controls and those who reported using vitamin supplements had no significant difference. No significant correlation was found between thiamine blood levels and reported levels of alcohol consumption. Reduced blood levels of thiamine in people who are alcohol dependent, compared with those with no history of alcohol abuse, are likely to be because of the poor diet. Consumption of vitamin supplements appears to bring thiamine levels closer to those seen in control participants. Supplementation of dietary intake of thiamine in people who are alcohol dependent remains an important measure for the prevention of Wernicke-Korsakoff's syndrome in this population.

Alcohol Withdrawal

Alcohol withdrawal is a common clinical condition that has a variety of complications and morbidities. The manifestations can range from mild agitation to withdrawal seizures and delirium tremens. The treatments for alcohol withdrawal include benzodiazepines, anticonvulsants, beta-blockers and antihypertensives. Although benzodiazepines are presently a first-line therapy, there is controversy regarding the efficacies of these medications compared with others. Treatment protocols often involve one of two contrasting approaches: symptom-triggered versus fixed-schedule dosing of benzodiazepines. We describe these protocols in our review and examine the data supporting symptom-triggered dosing as the preferred method for most patients in withdrawal.The Clinical Institute Withdrawal Assessment for Alcohol scoring system for alcohol withdrawal streamlines care, optimizes patient management, and is the best scale available for withdrawal assessment. Quality improvement implications for inpatient management of alcohol withdrawal include increasing training for signs of withdrawal and symptom recognition, adding new hospital protocols to employee curricula, and ensuring manageable patient-to-physician and patient-to-nurse ratios.

The treatment of alcohol and opioid dependence in pregnant women

This article addresses the question of 'best treatment options', which clinicians face when treating pregnant women with alcohol and opioid dependence. Studies show that alcohol consumption is associated with fetal abnormalities and long-term cognitive problems depending on the amount consumed, drinking pattern, and time of gestation. Screening and evaluation of specific interventions are important to reduce alcohol consumption during pregnancy and associated problems in infants. Opioid detoxification is only recommended beyond the first trimester and only in those pregnant women who refuse opioid maintenance therapy. Methadone is the most established treatment of pregnant opioid-dependent women, though recent results indicate some advantages of buprenorphine, slow-release oral methadone and diamorphine compared with methadone. Benzodiazepines seem to be the most recommendable option for managing alcohol withdrawal, and psychosocial interventions succeed in reducing alcohol consumption or in maintaining abstinence in alcohol-dependent pregnant women. Regarding opioid dependence, current results suggest that factors like the health status of the mother, the need for additional medications (e.g. treatment for HIV), comorbid drug dependence, and concurrent drug use need to be considered in order to find the 'best opioid substitute'.

Intranasal Oxytocin Blocks Alcohol Withdrawal in Human Subjects

The neuropeptide, oxytocin (OT), has been reported to block tolerance formation to alcohol and decrease withdrawal symptoms in alcohol-dependent rodents. Numerous recent studies in human subjects indicate that OT administered by the intranasal route penetrates into and exerts effects within the brain. In a randomized, double-blind clinical trial, intranasal OT (24 IU/dose, N = 7) or placebo (N = 4) was given twice daily for 3 days in alcohol-dependent subjects admitted to a research unit for medical detoxification using Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score-driven PRN administration of lorazepam. Subjects rated themselves on the Alcohol Withdrawal Symptom Checklist (AWSC) each time CIWA scores were obtained. Subjects also completed the Penn Alcohol Craving Scale, an Alcohol Craving Visual Analog Scale (ACVAS) and the Profile of Mood States (POMS) on inpatient days 2 and 3. All subjects had drunk heavily each day for at least 2 weeks prior to study and had previously experienced withdrawal upon stopping/decreasing alcohol consumption. OT was superior to placebo in reducing alcohol withdrawal as evidenced by: less total lorazepam required to complete detoxification (3.4 mg [4.7, SD] vs. 16.5 [4.4], p = 0.0015), lower mean CIWA scores on admission day 1 (4.3 [2.3] vs. 11.8 [0.4], p < 0.0001) and day 2 (3.4 [2.2] vs. 11.1 [3.6], p < 0.002), lower AWSC scores on days 1 and 2 (p < 0.02; p = 0.07), and lower ACVAS ratings (p = 0.01) and lower POMS Tension/Anxiety subscale scores on day 2 (p < 0.01). This is the first demonstration that OT treatment may block alcohol withdrawal in human subjects. Our results are consistent with previous findings in rodents that OT inhibits neuroadaptation to and withdrawal from alcohol. OT could have advantages over benzodiazepines in managing alcohol withdrawal because it may reverse rather than maintain sedative-hypnotic tolerance. It will be important to test whether OT treatment is effective in reducing drinking in alcohol-dependent outpatients.