Alcohol Withdrawal Syndrome In Patients Research Articles

Evaluation of the Use of Phenobarbital and Benzodiazepines in the Management of Alcohol Withdrawal Syndrome in Patients Requiring Neurological/Neurosurgical Critical Care: A Propensity-Matched Analysis.

Objective There is growing interest in the use of phenobarbital for alcohol withdrawal syndrome in critically ill patients, though experience in neurologically injured patients is limited. The purpose of this study was to compare the safety and effectiveness of phenobarbital-containing alcohol withdrawal regimens versus benzodiazepine monotherapy in the neurocritical care unit. Methods We conducted a retrospective cohort study of adult patients admitted to the neurocritical care unit from January 2014 through November 2021 who received pharmacologic treatment for alcohol withdrawal. Treatment groups were defined as benzodiazepine monotherapy versus phenobarbital alone or in combination with benzodiazepines. The primary outcome was the percentage of patients requiring intubation after receiving alcohol withdrawal treatment. Secondary outcomes included all-cause, in-hospital mortality, intensive care unit length of stay, discharge disposition, change in Glasgow Coma Scale (GCS) score, and the use of adjunctive agents. Results We analyzed data from 156 patients, with 77 (49%) in the benzodiazepine group and 79 (51%) in the phenobarbital combination group. The groups were well-balanced for baseline characteristics, though more males (67, 85%) were in the phenobarbital group. Only three (1.9%) patients received phenobarbital monotherapy, and the rest (153, 98.1%) received combination therapy. The percentage of patients requiring mechanical ventilation was significantly higher in the phenobarbital combination group compared to benzodiazepine monotherapy (39% (n=31) versus 13% (n=10); OR: 4.33, 95% CI: 1.94-9.66; p<0.001). The use of adjunctive propofol and dexmedetomidine was higher in the phenobarbital group (propofol 35% (n= 28) versus 9% (n=7) and dexmedetomidine 30% (n=24) versus 5% (n=4), respectively). Patients in the phenobarbital group also had lower GCS scores and higher Clinical Institute Withdrawal Assessment of Alcohol (CIWA-Ar) scores during their intensive care unit admission, possibly suggesting more severe alcohol withdrawal. There was no difference in intensive care unit length of stay, all-cause, in-hospital mortality, discharge disposition, or therapeutic adjuncts. Conclusions Combination therapy of phenobarbital plus benzodiazepines was associated with higher odds of requiring mechanical ventilation. Few patients received phenobarbital monotherapy. Additional studies are needed to better compare the effects of phenobarbital monotherapy versus benzodiazepines in neurocritical patients.

A National Analysis of Alcohol Withdrawal Syndrome in Patients with Operative Trauma

BackgroundAlcohol withdrawal syndrome (AWS) presents with a complex spectrum of clinical manifestations that complicate postoperative management. In trauma setting, subjective screening for AWS remains challenging due to the criticality of injury in these patients. We thus identified several patient characteristics and perioperative outcomes associated AWS development. MethodsThe 2016–2020 National Inpatient Sample was queried to identify all non-elective adult (≥18 years) hospitalizations for blunt or penetrating trauma undergoing operative management with a diagnosis of AWS. Patients with traumatic brain injury or with a hospital duration of stay <2 days were excluded. Outcomes of interest included in-hospital mortality, perioperative complications, hospitalization costs, length of stay (LOS) and non-home discharge. ResultsOf an estimated 2,965,079 operative trauma hospitalizations included for analysis, 36,415 (1.23 %) developed AWS following admission. The AWS cohort demonstrated increased odds of mortality (Adjusted Odds Ratio [AOR] 1.46, 95 % Confidence Interval [95 % CI] 1.23–1.73), along with infectious (AOR 1.73, 95 % CI 1.58–1.88), cardiac (AOR 1.24, 95 % CI 1.06–1.46), and respiratory (AOR 1.96, 95 % CI 1.81–2.11) complications. AWS was associated with prolonged LOS, (β: 3.3 days, 95 % CI: 3.0 to 3.5), greater cost (β: +$8900, 95 % CI $7900–9800) and incremental odds of nonhome discharge (AOR 1.43, 95 % CI 1.34–1.53). Furthermore, male sex, Medicaid insurance status, head injury and thoracic operation were linked with greater odds of development of AWS. ConclusionIn the present study, AWS development was associated with increased odds of in-hospital mortality, perioperative complications, and resource burden. The identification of patient and operative characteristics linked with AWS may improve screening protocols in trauma care.

Erratum: Management of alcohol withdrawal syndrome in patients with alcohol-associated liver disease.

Erratum: Management of alcohol withdrawal syndrome in patients with alcohol-associated liver disease.

Management of alcohol withdrawal syndrome in patients with alcohol-associated liver disease.

Alcohol-associated liver disease is a common and severe sequela of excessive alcohol use; effective treatment requires attention to both liver disease and underlying alcohol use disorder (AUD). Alcohol withdrawal syndrome (AWS) can be dangerous, is a common barrier to AUD recovery, and may complicate inpatient admissions for liver-related complications. Hepatologists can address these comorbid conditions by learning to accurately stage alcohol-associated liver disease, identify AUD using standardized screening tools (eg, Alcohol Use Disorder Identification Test), and assess risk for and symptoms of AWS. Depending on the severity, alcohol withdrawal often merits admission to a monitored setting, where symptom-triggered administration of benzodiazepines based on standardized scoring protocols is often the most effective approach to management. For patients with severe liver disease, selection of benzodiazepines with less dependence on hepatic metabolism (eg, lorazepam) is advisable. Severe alcohol withdrawal often requires a "front-loaded" approach with higher dosing, as well as intensive monitoring. Distinguishing between alcohol withdrawal delirium and HE is important, though it can be difficult, and can be guided by differentiating clinical characteristics, including time to onset and activity level. There is little data on the use of adjuvant medications, including anticonvulsants, dexmedetomidine, or propofol, in this patient population. Beyond the treatment of AWS, inpatient admission and outpatient hepatology visits offer opportunities to engage in planning for ongoing management of AUD, including initiation of medications for AUD and referral to additional recovery supports. Hepatologists trained to identify AUD, alcohol-associated liver disease, and risk for AWS can proactively address these issues, ensuring that patients' AWS is managed safely and effectively and supporting planning for long-term recovery.

A ketogenic dietary supplement for alcohol withdrawal syndrome in patients with alcohol use disorder – a randomized, placebo-controlled clinical trial

A ketogenic dietary supplement for alcohol withdrawal syndrome in patients with alcohol use disorder – a randomized, placebo-controlled clinical trial

Alcohol Withdrawal Syndrome in Neurocritical Care Unit: Assessment and Treatment Challenges.

Alcohol withdrawal syndrome (AWS) can range from mild jittery movements, nausea, sweating to more severe symptoms such as seizure and death. Severe AWS can worsen cognitive function, increase hospital length of stay, and in-hospital mortality and morbidity. Due to a lack of reliable history of present illness in many patients with neurological injury as well as similarities in clinical presentation of AWS and some commonly encountered neurological syndromes, the true incidence of AWS in neurocritical care patients remains unknown. This review discusses challenges in the assessment and treatment of AWS in patients with neurological injury, including the utility of different scoring systems such as the Clinical Institute Withdrawal Assessment and the Minnesota Detoxification Scale as well as the reliability of admission alcohol levels in predicting AWS. Treatment strategies such as symptom-based versus fixed dose benzodiazepine therapy and alternative agents such as baclofen, carbamazepine, dexmedetomidine, gabapentin, phenobarbital, ketamine, propofol, and valproic acid are also discussed. Finally, a treatment algorithm considering the neurocritical care patient is proposed to help guide therapy in this setting.

Drug Utilization Evaluation of Lorazepam in Alcohol Withdrawal Syndrome Patients: A Secondary Care Teaching Hospital Based Study

Background: Drug utilization evaluation is an important parameter for the safe, effective and rational use of medications in medical care. Alcoholism results in abundant cases of alcohol withdrawal which can prove to be life-threatening if untreated, lorazepam is a drug of choice for Alcohol Withdrawal Syndrome and requires close monitoring as its over-dosing or under-dosing is common in case of withdrawal. Objective: ensures the safe and rational use of Lorazepam in the management of Alcohol Withdrawal Syndrome. Materials and Method: This prospective, observational study was conducted among alcoholic patients admitted in the KC General Hospital, Karnataka, India. Baseline data for Clinical Institute Withdrawal Assessment for Alcohol revised scale (CIWA-Ar) was collected on the day of admission and the response to lorazepam treatment was recorded using the same with respect to the baseline data every 12th hourly after the initial administration until withdrawn. Results: Statistical analysis for 72 patients was done using ANOVA to calculate the overall progression of the syndrome with treatment. Among 72 patients 94.44% were male and 5.55% were female. The mean age of patients reported with AWS was found to be 44.90 years. A significant CIWA-Ar score reduction was observed with a p-value of &lt;0.0001. Conclusion: Our study revealed a strong predominance of male patients with alcohol withdrawal syndrome, where maximum patients started consuming alcohol before the age of 20 years. After the administration of lorazepam, a significant CIWA-Ar score reduction was observed.&#x0D; Keywords: Alcohol Withdrawal Syndrome, CIWA-Ar scale, Drug utilization evaluation, Lorazepam.

The Efficacy of Tiapride and Carbamazepine Combination Therapy in Reducing Alcohol Withdrawal Symptoms: A Systematic Review and Meta-Analysis.

The combination of tiapride (TIA) and carbamazepine (CBZ) as an alternative treatment option to benzodiazepines and clomethiazole has been investigated by several investigations. We performed a systematic review and meta-analysis to further explore the efficacy of this combination in order to render more definite answers whether this combination can be recommendable in the clinical practice. We systematically searched electronic databases including PubMed (MEDLINE), EMBASE, OVID, Cochrane, Google Scholar, and Scopus for human studies. Statistical homogeneity was checked by χ2 test and I2 using Cochran heterogeneity statistic. Our analysis showed a significant efficacy of the combination of TIA and CBZ in reducing alcohol withdrawal syndrome (AWS) (p<0.0001, z-value: 4.07). The cumulative analysis illustrated that the favorable efficacy of this combination therapy has been consistent over time. Our study shows that the combination of TIA/CBZ is an effective treatment in management of AWS in patients with alcohol abstinence. However, the safety of this combination could not be proven, so we recommend its prescription after an informed consent.

Routine screening and related interventions significantly improve the effectiveness of emergency department detection and management of alcohol withdrawal syndrome

To evaluate the effectiveness of a routine screening and triage tool for alcohol withdrawal syndrome (AWS) in improving clinical care delivery in an ED setting. In a regional ED in Australia, a screening and triage tool for AWS was introduced to routine ED assessment for a 13 week period. Subjects were all presentations to ED aged 16 and above with relevant presenting problems during the pre-intervention phase (1 January 2015-31 December 2016) and the post-intervention phase (8 August 2016-4 November 2016). Key clinical care delivery elements related to AWS in patients presenting to ED were compared pre- and post-intervention, namely proportion of presentations: (i) meeting criteria for AWS; (ii) receiving appropriate management for AWS; and (iii) with alcohol documentation in patient notes. A total of 5.8% of total ED presentations in the post-intervention phase and 4.5% in the pre-intervention 1 year phase had relevant presenting problems. Compared to the 1 year pre-intervention phase, post-intervention showed: (i) a significant decrease in the number of presentations meeting criteria for AWS (χ2 = 6.56, P = 0.01); (ii) a significant increase in appropriate management of AWS (χ2 = 17.09, P < 0.001); and (iii) a significant increase in alcohol documentation in notes (χ2 = 13.29, P < 0.001). Detection and appropriate management of AWS and documentation of alcohol use can be improved significantly through adoption of a brief screening and triage tool, and related interventions to increase awareness of alcohol-related problems.

Safety and Efficacy of Flumazenil for Reversal of Iatrogenic Benzodiazepine-Associated Delirium Toxicity During Treatment of Alcohol Withdrawal, a Retrospective Review at One Center

Both alcohol withdrawal syndrome (AWS) and benzodiazepines can cause delirium. Benzodiazepine-associated delirium can complicate AWS and prolong hospitalization. Benzodiazepine delirium can be diagnosed with flumazenil, a GABA-A receptor antagonist. By reversing the effects of benzodiazepines, flumazenil is theorized to exacerbate symptoms of AWS and precludes its use. For patients being treated for alcohol withdrawal, flumazenil can diagnose and treat benzodiazepine delirium without precipitating serious or life-threatening adverse events. Hospital admission records were retrospectively reviewed for patients with the diagnosis of AWS who received both benzodiazepines and flumazenil from December 2006 to June 2012 at a university-affiliated inpatient toxicology center. The day of last alcohol consumption was estimated from available blood alcohol content or subjective history. Corresponding benzodiazepine, flumazenil, and adjunctive sedative pharmacy records were reviewed, as were demographic, clinical course, and outcome data. Eighty-five patients were identified (average age 50.3years). Alcohol concentrations were detectable for 42 patients with average 261mg/dL (10-530mg/dL). Eighty patients were treated with adjunctive agents for alcohol withdrawal including antipsychotics (n = 57), opioids (n = 27), clonidine (n = 35), and phenobarbital (n = 23). Average time of flumazenil administration was 4.7days (1-11days) after abstinence, and average dose was 0.5mg (0.2-1mg). At the time of flumazenil administration, delirium was described as hypoactive (n = 21), hyperactive (n = 15), mixed (n = 41), or not specified (n = 8). Response was not documented in 11 cases. Sixty-two (72.9%) patients had significant objective improvement after receiving flumazenil. Fifty-six patients required more than one dose (average 5.6 doses). There were no major adverse events and minor adverse effects included transiently increased anxiety in two patients: 1 patient who received 0.5mg on abstinence day 2 and another patient who received 0.2mg flumazenil on abstinence day 11. This is the largest series diagnosing benzodiazepine delirium after AWS in patients receiving flumazenil. During the treatment of AWS, if delirium is present on day 5, a test dose of flumazenil may be considered to establish benzodiazepine delirium. With the limited data set often accompanying patients with AWS, flumazenil diagnosed benzodiazepine delirium during the treatment of AWS and improved impairments in cognition and behavior without serious or life-threatening adverse events in our patients.

Propofol for benzodiazepine-refractory alcohol withdrawal in a non–mechanically ventilated patient

Long-term alcohol use confers neurochemical changes in response to alcohol's exogenous inhibitory effects. Downregulation and decreased sensitivity of γ-aminobutyric acid receptors render benzodiazepines less effective at controlling psychomotor agitation. Propofol has been reported to have successfully relieved alcohol withdrawal syndrome (AWS) symptoms in part because of activation of γ-aminobutyric acid channels in combination with antagonism of excitatory amino acids such as N-methyl-D-aspartate. Successful use of propofol in refractory AWS in patients with endotracheal intubation and mechanical ventilation has been reported. We present a case of resolution of AWS symptoms in a benzodiazepine-refractory, nonintubated, non-mechanically ventilated alcohol withdrawal patient with low-dose, continuous-infusion propofol.

Alcohol Withdrawal Prevention: A Randomized Evaluation of Lorazepam and Ethanol--A Pilot Study

Alcohol withdrawal syndrome, characterized by confusion, agitation, and hallucinations, decreases the safety of patients with acute myocardial infarction. Unexpected hospitalization and sudden cessation of alcohol consumption may increase in-hospital complications and length of stay and even precipitate death. To perform a randomized evaluation of lorazepam and ethanol/lorazepam to evaluate the safety and efficacy of these 2 strategies for preventing alcohol withdrawal syndrome in patients with acute coronary syndromes. Patients (n = 57) with myocardial infarction were screened for alcohol dependence by using the CAGE questionnaire and randomized to treatment with lorazepam or ethanol with lorazepam. Demographics and complication rates were analyzed by using χ² tests (categorical variables) and t tests (continuous variables). Safety (composite complication rates) of the treatment strategy was evaluated by using the Fisher exact test, and length of stay by using the Wilcoxon rank-sum test. Safety-associated complication rates (self-extubation, delirium tremens, reinfarction) did not differ between groups (24% lorazepam vs 18% ethanol; P = .56). Days spent in the cardiac intensive care unit (7% lorazepam vs 2% ethanol; P = .32) and overall hospital stay (6% lorazepam vs 6% ethanol; P = .72) did not differ between the 2 groups. These preliminary findings suggest that a randomized evaluation of treatment strategies to prevent complications associated with alcohol withdrawal in patients with acute myocardial infarction is safe and feasible.

Control study of comprehensive nursing intervention in patients with alcohol withdrawal syndrome

Objective To explore the clinical efficacy of comprehensive nursing intervention on patients with alcohol withdrawal syndrome in clinic. Methods 60 cases of alcohol withdrawal delirium tremors were randomly divided into the integrated nursing intervention group (the research group) and the general nursing intervention group (the control group), with 30 cases in each group. On the basis of drug therapy, the general care, psychological care, cognitive behavior modification, health education and other measures were adopted in the research group. Only the general nursing measure was given in the control group on the basis of drug therapy. The efficacy was assessed using the alcohol withdrawal syndrome scale, self-rating depression scale (SDS), self-rating anxiety scale (SAS), and clinical global impression (CGI). Results The scores of the alcohol withdrawal syndrome scale and clinical global impression (CGI) in the 14th day in the research group were(2.56±0.70) and (3.10±0.20), respectively, which were significantly lower than those of the control group. And the scores of the self-rating depression scale (SDS) and self-rating anxiety scale (SAS) in the 14th day also were significantly lower than those of the control group. There was a statistical meaning (P < 0. 01 ).Conclusions The integrated nursing intervention in combination with the drug therapy contributes to the curative effect of alcohol withdrawal syndrome patients, and to consolidate their rehabilitation effects. Key words: Alcohol; Withdrawal syndrome; Nursing intervention

Pharmacokinetic Dosing of Phenobarbital in the Treatment of Alcohol Withdrawal Syndrome

We used a pharmacokinetically derived phenobarbital dosing protocol to treat alcohol withdrawal syndrome in patients admitted to a family medicine inpatient service. We describe the protocol and include two case reports documenting its efficacy. Although benzodiazepine agents are considered by many to be the primary agents of choice, based upon our experience and its ease of administration, relative safety, therapeutic efficacy, and lower cost, phenobarbital should be reconsidered as a promising alternative. Comparative trials between these two therapeutic classes will clarify their roles in the treatment of alcohol withdrawal syndrome.

Treatment of alcoholic liver disease

With advances in our understanding of the pathophysiology of alcoholic liver disease, pharmacological treatments of some of the basic disease processes are now in sight. The most notable development has been the introduction of propylthiouracil for the treatment of alcoholic hepatitis. In a recent trial the mortality rate of patients treated with this drug was 62% lower than that of a control group. Its beneficial effects may stem not from its anti-thyroid properties but rather from other actions such as free radical scavenging. Corticosteroids now appear to have no place in the treatment of alcoholic liver disease. Anabolic steroids, however, show promise, though longer term trials are required before this can be confirmed. Colchicine, too, has been reported to improve survival in patients with established cirrhosis. More experience is required with this and other anti-inflammatory and anti-fibrogenic drugs. β Adrenergic blocking drugs, such as propranolol, reduce portal venous pressure. In a trial among patients with alcoholic cirrhosis who had oesophageal varices, 39% of those receiving propranolol had not experienced a haemorrhage by 2 years compared with 74% in the control group. The mortality rates at this time were 28% and 49% respectively. Results of treatment once the first haemorrhage has occurred are less impressive. Treatment of the alcohol withdrawal syndrome in patients with liver disease is often problematic. The dose of any sedative should be reduced to 25–50% of the usual dose and sedatives should be avoided in patients who are encephalopathic. Once the patient has recovered from the acute illness, abstinence from alcohol remains the single most important factor that determines long term survival.