Developed Alcohol Withdrawal Research Articles

Propofol Use in Emergency Surgery in a Patient Having Alcohol Withdrawal

Abstract Alcohol use disorder is a common mental health issue with life-threatening consequences like sustaining polytrauma while driving under the influence of alcohol. Such patients frequently require surgical interventions. Because of the alcohol dependence, they have a high risk of developing alcohol withdrawal (including delirium tremens) immediately before or sometimes after the surgery. No clear guidelines exist regarding the choice of anesthetic agent in this special population, even though the diagnosis of alcohol withdrawal and/or delirium can affect the outcome of the surgical intervention in multiple ways. At times, the anesthetic agent used during the surgical procedure can delay the onset of alcohol withdrawal delirium in these patients, in the postoperative period, thus complicating its identification and management. In this report, we present two scenarios in which the presence of alcohol withdrawal symptoms in the perioperative period was markedly affected by the use of infusion of propofol during the surgery. We also discuss how the mindful use of propofol infusion for anesthesia and analgesia during surgery can be a useful method, in addition to the usual benzodiazepine-based management, in this specific population to reduce the consequences of alcohol withdrawal in the postoperative period.

From consumption to withdrawal: A broad synopsis of the effects of alcohol

AbstractThe consumption of alcohol reflects both societal norms and personal choices and has major clinical implications. Long‐term excess alcohol consumption leads to a domino effect of pathological outcomes and onset of chronic illness. However, the risks of alcohol consumption extend beyond long‐term health issues. Because habitual alcohol drinkers reach a state of systemic homeostasis, when they attempt withdrawal, they experience many negative physiological effects and may develop alcohol withdrawal syndrome. The complex interplay between alcohol consumption and withdrawal does not result solely in behavioral issues. Rather, a substantial number of important physiological adaptations and potential problems underly habitual drinking. Addressing these issues requires comprehensive medical observation and intervention. Here, we summarize the pathophysiological mechanisms, clinical diseases, and related treatment methods of alcohol consumption and withdrawal. The aim was to provide a reference to improve understanding of alcohol use and promote an informed approach to alcohol withdrawal.

Associated Factors for the Development of Alcohol Withdrawal Delirium

Abstract: This study was conducted to evaluate some associated factors predicting the development of alcohol withdrawal delirium; 56 patients in E hospital were divided into two groups including group 1 of 28 patients diagnosing mental and behavioral disorders due to use of alcohol, withdrawal state with delirium (F10.4) and group 2 of 28 patients diagnosing mental and behavioral disorders due to use of alcohol, withdrawal state (F10.3) according to ICD-10 criteria; Method: cross-sectional study; Result showed that clinical features are sweating and seizure; laboratory tests are GGT, total bilirubin, direct bilirubin, platelet emerged as associated factors of alcohol withdrawal delirium. The level of direct bilirubin over 13 μmol/L is the strongest associated factor with OR(95%CI) 6(1.648-21.840). These risk factors about alcohol dependence featured can be easily evaluated in a clinical setting for physicians to identify patients at risk for developing alcohol withdrawal delirium to make intensive therapy plans for them.
 Keywords: Alcohol withdrawal delirium, risk factor, clinical feature, laboratory test.

Trauma center admission risk conditions and the probability for developing alcohol withdrawal syndrome: A retrospective study

BackgroundBecause the proportion of trauma patients developing alcohol withdrawal syndrome (AWS) is low, AWS risk conditions have not been precisely delineated. We aimed to create multifactor screening strategies to assess probabilities for the likelihood of developing AWS. MethodsWe performed a retrospective chart review of 1,011 trauma patients admitted to a Level I trauma center to investigate the associations between AWS and probable AWS risk conditions. Included patients were adults who met trauma registry inclusion criteria and had blood alcohol concentration (BAC) testing performed. Patients were excluded if they had a traumatic brain injury with a Glasgow Coma Score (GCS) ≤ 8, or no BAC testing performed. We defined heavy drinking as daily drinking or >7 per week. ResultsAWS had univariate associations with heavy drinking history, Injury Severity Score (ISS) ≥15, psychiatric disorders, liver disease, smoking history, in-hospital bronchodilator administration, age ≥45, male sex, Intensive Care Unit (ICU) admission, serum aspartate aminotransferase (AST) ≥40 U/L, and cognitive preservation (GCS ≥13 with BAC ≥100 mg/dL) (all, p < 0.05). ICU admission, AST ≥40 U/L, cognitive preservation, male sex, and age ≥45 had associations with ISS ≥15 or alcohol misuse (all, p < 0.0001). For patients with age ≥45 and heavy drinking history or age <45 and heavy drinking history with ISS ≥15 and ICU admission, the AWS proportion (15.3%) was greater in comparison to other patients (0.3%). The AWS risk score was the sum of the following nine conditions, assigned a zero when the condition was absent and one when present (range 0–9): ISS ≥15, psychiatric disorders, liver disease, smoking history, in-hospital bronchodilator administration, age ≥45, male sex, AST ≥40 U/L, and cognitive preservation. The AWS proportion was greater with a risk score of 5–9 (16.8%) than of 0–4 (1.2%; p < 0.0001). ConclusionsAWS in the setting of traumatic injury is associated with multiple risk conditions. The presence of multiple risk conditions might have additive effects that could contribute toward a clinical manifestation of AWS. The identified risk conditions may be associated with a hyperadrenergic state.

Derivation and validation of a multivariable model, the alcohol withdrawal triage tool (AWTT), for predicting severe alcohol withdrawal syndrome

BackgroundAlcohol withdrawal and its consequences are a common concern for the large numbers of patients who present to emergency departments (EDs) with alcohol use disorders. While the majority of patients who go on to develop alcohol withdrawal experience only mild symptoms, a small proportion will experience seizures or delirium tremens. The aim of this study was to develop a tool to predict the need for hospital admission in patients at risk for alcohol withdrawal using only objective criteria that are typically available during the course of an ED visit. MethodsWe conducted a retrospective study at an academic medical center. Our primary outcome was severe alcohol withdrawal syndrome (SAWS), which we defined as a composite of delirium tremens, seizure, or use of high benzodiazepine doses. All candidate predictors were abstracted from the electronic health record. A logistic regression model was constructed using the derivation dataset to create the alcohol withdrawal triage tool (AWTT). ResultsOf the 2038 study patients, 408 20.0 %) developed SAWS. We identified eight independent predictors of SAWS. Each of the predictors in the regression model was assigned one point. Summing the points for each predictor generated the AWTT score. An AWTT score of 3 or greater was defined as high risk based on sensitivity of 90 % and specificity of 47 % for predicting SAWS. ConclusionsWe were able to identify a set of objective, timely, independent predictors of SAWS. The predictors were used to create a novel clinical prediction rule, the AWTT.

What level of pharmacological and psychological support are we providing OMFS patients affected by alcohol misuse? A cross-sectional survey across the UK

Background: Alcohol misuse is a risk factor for developing head and neck cancer including recurrence. [1] Withdrawing from alcohol abruptly however puts patients at risk of developing alcohol withdrawal symptoms. It is imperative that patients who misuse alcohol are supported to help reduce intake to lessen their risk of developing cancer, and also to help prevent alcohol withdrawal symptoms. [2]

Abstract TP408: Alcohol Withdrawal is Associated With Poorer Outcome in Ischemic Stroke

Objective: Prevalence of alcohol abuse (AA) in the United States (US) is on the increase. AA patients may develop alcohol withdrawal (AW) during hospitalization, but it remains unknown how AW influences acute ischemic stroke (AIS) outcome. Methods: All adult AIS admissions in the US from 2004–2014 were identified from the National Inpatient Sample (NIS) (weighted N=4,438,968). Multivariable-adjusted models were used to evaluate the association of AW with in-hospital medical complications, mortality, cost, and length-of-stay in patients with AIS. Results: During this period, 3.9% of all AIS admissions had comorbid codes for AA but prevalence differed significantly by age; 10.6% of AA patients, representing 0.4% of all AIS, developed AW. Prevalence of AA and AW in AIS increased by 45.2% and 40.0%, respectively, over time (p-value for trend &lt;0.001). AA patients were predominantly men (80.2%), white (65.9%), and in the 40–59-year (44.6%) and 60–79-year (45.6%) age groups. After multivariable adjustment, AIS patients with AW had &gt;50% increased odds of urinary tract infection, pneumonia, sepsis, gastrointestinal bleeding, deep venous thrombosis, and acute renal failure compared to those without AW. Patients with AW were also 32% more likely to die during their AIS hospitalization compared to those without AW (OR 1.32, 95% CI 1.11–1.58). AW was associated with 15-day increase in length-of-stay and $5,000 increase in hospitalization cost (p-values &lt;0.001). Conclusions: AW is associated with increased cost, longer hospitalizations, and higher odds of medical complications and in-hospital mortality following AIS. Proactive surveillance and management of AW may be important in improving outcomes in these patients.

Diagnosis and treatment of acute alcohol intoxication and alcohol withdrawal syndrome: position paper of the Italian Society on Alcohol.

The chronic use of alcohol can lead to the onset of an alcohol use disorder (AUD). About 50% of subjects with an AUD may develop alcohol withdrawal syndrome (AWS) when they reduce or discontinue their alcohol consumption and, in 3-5% of them, convulsions and delirium tremens (DTs), representing life-threatening complications, may occur. Unfortunately, few physicians are adequately trained in identifying and treating AWS. The Italian Society on Alcohol has, therefore, implemented a task force of specialists to draw up recommendations for the treatment of AWS with the following main results: (1) while mild AWS may not require treatment, moderate and severe AWS need to be pharmacologically treated; (2) out-patient treatment is appropriate in patients with mild or moderate AWS, while patients with severe AWS need to be treated as in-patients; (3) benzodiazepines, BDZs are the "gold standard" for the treatment of AWS and DTs; (4) alpha-2-agonists, beta-blockers, and neuroleptics may be used in association when BDZs do not completely resolve specific persisting symptoms of AWS; (5) in the case of a refractory form of DTs, the use of anaesthetic drugs (propofol and phenobarbital) in an intensive care unit is appropriate; (6) alternatively to BDZs, sodium oxybate, clomethiazole, and tiapride approved in some European Countries for the treatment of AWS may be employed for the treatment of moderate AWS; (7) anti-convulsants are not sufficient to suppress AWS, and they may be used only in association with BDZs for the treatment of refractory forms of convulsions in the course of AWS.

Implementation of an ICU-Specific Alcohol Withdrawal Syndrome Management Protocol Reduces the Need for Mechanical Ventilation.

Alcohol use disorders are prevalent and put patients at risk for developing alcohol withdrawal syndrome (AWS). Treatment of AWS with a symptom-triggered protocol standardizes management and may avoid AWS-related complications. The objective of this study was to evaluate whether implementation of a specific intensive care unit (ICU) symptom-triggered protocol for the management of AWS was associated with improved clinical outcomes and, in particular, would reduce the risk of patients with AWS requiring mechanical ventilation. Retrospective pre- and postprotocol implementation study. A 36-bed closed medical ICU (MICU) at a large tertiary care teaching hospital in an urban setting. A total of 233 adults admitted to the MICU with any diagnosis of alcohol use disorders based on International Classification of Diseases, Ninth Revision codes and who received at least one dose of any benzodiazepine; of these patients, 139 were in the preprotocol era (August 2009-January 2010 and August 2010-January 2011), and 94 were in the postprotocol era (August 2012-January 2013) after implementation of the Yale Alcohol Withdrawal Protocol (YAWP) in April 2012. The YAWP pairs a modified Minnesota Detoxification Scale with an order set that includes benzodiazepine dosing regimens and suggests adjuvant therapies. AWS was the primary reason for ICU admission (107/233 patients [45.9%]) and did not significantly vary between study eras (p=0.2). Of the 233 patients included, 81.1% were male and 67.0% were white, which did not significantly differ by study era. Severity of illness at MICU admission did not significantly differ between patients in the preprotocol and postprotocol eras (Acute Physiology and Chronic Health Evaluation [APACHE] II median scores of 12 [interquartile range (IQR) 9-17] and 12.5 [IQR 7-16], respectively, p=0.4). Median lorazepam-equivalent dose per MICU day, duration of benzodiazepine infusion, and use of adjuvant therapy were not significantly different between eras. MICU intubation was less common in the postprotocol era (36/139 patients [25.9%] preprotocol vs 8/94 patients [8.5%] postprotocol, p=0.0009). ICU-related pneumonia was also decreased in the postprotocol era (30/139 patients [21.6%] preprotocol vs 10/94 patients [10.6%] postprotocol, p=0.03). After adjusting for demographics, adjuvant therapies, and APACHE II scores, protocol implementation was associated with a decreased odds of MICU intubation (odds ratio 0.13, 95% confidence interval 0.04-0.39). Implementation of YAWP was associated with a decreased risk of MICU intubation in patients at risk for AWS.

Weekend Effect in Acute Pancreatitis-Related Hospital Admissions in the United States: An Analysis of the Nationwide Inpatient Sample.

This study aimed to assess the difference in overall outcomes between weekend admissions for acute pancreatitis (AP) and weekday admissions. Between 2005 and 2012, data were extracted from the Nationwide Inpatient Sample on adult patients with AP. Exclusion criteria were applied for chronic pancreatitis and other pancreatic and biliary malignancies. In-hospital mortality, length of stay, hospitalization costs, comorbidities, complications, and intervention rates were compared between the weekend and weekday admissions. During the study period, there were a total of 432,303 weekday admissions and 147,435 weekend admissions for AP in the United States hospitals. Weekend AP admissions were more likely to develop alcohol withdrawal (5.9% vs 5.7%, P = 0.001) and ileus (4.1% vs 3.1%, P = 0.04). They were also more likely to develop acute respiratory distress syndrome (4.7% vs 4.4%, P < 0.001) and required more endotracheal intubation (3.9% vs 3.6%, P < 0.001). There was no significant in-hospital mortality difference between the weekend and weekday admissions on both univariate and multivariate analysis. Weekend AP admissions develop more severe complications requiring intensive care. Despite this, there was no weekend effect for in-hospital mortality for AP-related admissions.

Management of Acute Alcohol Withdrawal Syndrome in Critically Ill Patients.

Approximately 16-31% of patients in the intensive care unit (ICU) have an alcohol use disorder and are at risk for developing alcohol withdrawal syndrome (AWS). Patients admitted to the ICU with AWS have an increased hospital and ICU length of stay, longer duration of mechanical ventilation, higher costs, and increased mortality compared with those admitted without an alcohol-related disorder. Despite the high prevalence of AWS among ICU patients, no guidelines for the recognition or management of AWS or delirium tremens in the critically ill currently exist, leading to tremendous variability in clinical practice. Goals of care should include immediate management of dehydration, nutritional deficits, and electrolyte derangements; relief of withdrawal symptoms; prevention of progression of symptoms; and treatment of comorbid illnesses. Symptom-triggered treatment of AWS with γ-aminobutyric acid receptor agonists is the cornerstone of therapy. Benzodiazepines (BZDs) are most studied and are often the preferred first-line agents due to their efficacy and safety profile. However, controversy still exists as to who should receive treatment, how to administer BZDs, and which BZD to use. Although most patients with AWS respond to usual doses of BZDs, ICU clinicians are challenged with managing BZD-resistant patients. Recent literature has shown that using an early multimodal approach to managing BZD-resistant patients appears beneficial in rapidly improving symptoms. This review highlights the results of recent promising studies published between 2011 and 2015 evaluating adjunctive therapies for BZD-resistant alcohol withdrawal such as antiepileptics, baclofen, dexmedetomidine, ethanol, ketamine, phenobarbital, propofol, and ketamine. We provide guidance on the places in therapy for select agents for management of critically ill patients in the presence of AWS.

SY44-4 * ALCOHOL USE DISORDER AND RELATED MEDICAL PROBLEMS IN A GENERAL HOSPITAL

Introduction. Alcohol use disorder is the leading cause of years lost due to disability among Thai males in 2009. When assessed in disability-adjusted life years, it is ranked as the number one psychiatric disorder. Consequently, this makes alcohol-related problems very common in general medical settings. One of the most serious psychiatric conditions related to alcohol use disorder is alcohol withdrawal delirium, which is the focus this study. Methods. Medical records from a cohort of alcohol-dependent patients admitted in a general hospital between 2012-2013 were reviewed. The history of alcohol use, withdrawal symptoms, clinical and medical conditions of patients who developed alcohol withdrawal delirium were extracted and compared with those who did not. Results. As compared to the psychiatric inpatient unit, most of the alcohol-dependent patients admitted in the medical/ surgical inpatient units suffered from alcohol withdrawal delirium and showed more complications. We also found out that certain symptoms of alcohol withdrawal and laboratory parameters were predictive of the development of alcohol withdrawal delirium (detailed results will be presented during the symposium). Conclusions. Patients with alcohol dependence and alcohol withdrawal delirium are commonly associated with deteriorated physical health conditions. Hence, it is important to be aware of the risk factors and prevent or promptly treat alcohol withdrawal symptoms. On top of that, the set up an intra-hospital consultation-liaison system between psychiatric and other departments will definitely improve the overall care of these patients.

Benzodiazepine loading versus symptom-triggered treatment of alcohol withdrawal: a prospective, randomized clinical trial

ObjectivesThe objectives were to compare the efficacy of a benzodiazepine loading versus a symptom-triggered protocol in the management of alcohol withdrawal. MethodsWe conducted a prospective, randomized, controlled trial including 47 consecutive patients admitted to one of two tertiary care medical centers who developed alcohol withdrawal syndrome. Patients were randomly assigned to either a benzodiazepine loading protocol or a symptom-triggered treatment protocol. The Clinical Institute Withdrawal Assessment for Alcohol-Revised scale (CIWA-Ar) was recorded throughout the length of stay, along with measures of autonomic system functioning. ResultsThe average rate of change of CIWA-Ar scores was −1.5±1.3 for the symptom-triggered group and −2.3±2.5 for the loading group. Average rate of change for systolic blood pressure was −2.7±5.3 for the symptom-triggered group and −2.3±6.4 for the loading group. There was no significant difference between the rates of change for either group on either measure. Similarly, there was no significant difference in total benzodiazepine use between groups. Within 72 h of treatment, 69.6% of patients in the loading group were free of withdrawal symptoms versus 41.7% in the symptom-triggered group, a difference not reaching statistical significance. ConclusionsThis study did not reveal clear evidence of a clinical advantage for choosing either treatment method.

Alcohol Biomarkers in Patients Admitted for Trauma

To assess the value of blood alcohol levels (BAL) and carbohydrate-deficient transferrin (CDT) in trauma patients. A prospective study was conducted among 213 patients admitted to a university hospital after trauma. Outcomes of interest included the development of alcohol withdrawal, infections, respiratory problems, cardiac events, thromboembolism, and length of stay. The majority (78%) of the trauma patients in the study was males over the age of 18. Seventy-five percent were reported drinking an alcohol-containing beverage in the previous 30 days, 34% had > or =5 heavy drinking days, and 18.7% met current DSM-IV criteria for alcohol abuse and 13.1% current criteria for dependence. Twenty-two percent (n = 48) had a positive BAL and 14% (n = 30) a CDT level >2.5%. Twelve percent (n = 27) of the sample developed alcohol withdrawal and 55% (n = 113) had one or more adverse health events during their hospitalization. The development of alcohol withdrawal was associated with an admission CDT >2.5% (chi(2): 4.77, p < 0.029) and/or a positive BAL (chi(2): 54.01, p < 0.001). The alcohol biomarkers identified 13 male and 3 female high-risk patients (7.4% of the total sample) who denied excessive alcohol use, and who would have been missed if these markers were not used. A composite morbidity trauma score composed of 25 adverse health events was associated with a positive BAL (p < 0.022). The study provides additional empirical evidence that supports the use of BAL in all patients admitted for trauma. The usefulness of CDT in trauma patients remains unclear and will require larger samples in more critically ill patients.

Alcohol Withdrawal Prophylaxis in Patients Undergoing Surgical Treatment of Head and Neck Squamous Cell Carcinoma

Alcohol abuse is common in patients with squamous cell cancer of the head and neck. Postoperative alcohol withdrawal is associated with increased morbidity and prolonged hospitalization and is commonly treated with benzodiazepines. We reviewed our experience with benzodiazepine prophylaxis in high-risk patients undergoing surgical treatment of head and neck cancer. We sought to determine whether benzodiazepine prophylaxis was successful in preventing complications from alcohol withdrawal. Nonrandomized, retrospective patient analysis. The medical records of all patients diagnosed with squamous cell carcinoma of the head and neck from 1999 to 2004 were retrospectively reviewed. Patients who underwent surgical resection and who were considered high risk for postoperative alcohol withdrawal received benzodiazepine prophylaxis following an established institutional protocol and comprised the study group. Of 96 patients who met study criteria, 13 (13.5%) patients developed alcohol withdrawal symptoms, and 9 (9.4%) patients developed delirium tremens. Patients who manifested alcohol withdrawal remained in the hospital an average of 10.8 days longer (19.0 vs. 8.2) and had an overall complication rate of 50% (11 of 22) versus a 17.6% (13 of 74) complication rate in patients that did not develop withdrawal (P < .05). Alcohol withdrawal is associated with a significantly greater incidence of postoperative complications and duration of hospitalization. Benzodiazepine prophylaxis does not prevent postoperative alcohol withdrawal symptoms in all patients at risk. Alternate methods of prophylaxis should be explored.

Clonidina como droga adjuvante no tratamento da síndrome de abstinência alcoólica em unidade de terapia intensiva: relato de caso

Sedation of patients with past history of alcohol and drug abuse in Intensive Care Units (ICU) is a challenge due to the high incidence of sedative drugs tolerance and withdrawal syndromes. This report aimed at describing a case of a young patient admitted to the ICU who developed alcohol withdrawal syndrome and tolerance to sedatives, resolved only after clonidine administration.Male patient, 18 years old, alcohol, tobacco, cocaine and marijuana abuser, victim of firearm accident, who was admitted to the ICU in the first post-enterectomy day, after gastric content aspiration during tracheal re-intubation. Clinical evolution was: vasoactive drugs up to the 4th day; bilateral bronchopneumonia with pleural effusion and need for artificial ventilation up to the 15th day. Initial sedation scheme was the association of midazolam and fentanyl. As from the 4th day, patient presented with several psychomotor agitation episodes, even after the association of lorazepam in the 6th day. In the 9th day, patient received the largest doses but remained agitated. Dexmedetomidine was associated, which has decreased other drug doses in 35% and has improved agitation. In the 12th day, midazolam and dexmedetomidine were replaced by propofol infusion with worsening of agitation. In the 13th day, clonidine was associated to the sedation scheme with total resolution of agitation. Propofol was withdrawn in the 14th day, fentanyl was maintained and midazolam infusion was restarted, with doses 75% and 65% lower as compared to peak doses of such drugs. Patient was extubated in the 15th day and was discharged from ICU.Benzodiazepines should remain the drugs of choice for the treatment of acute alcohol withdrawal syndrome. However in this report, only adjuvant clonidine was able to adequately treat the patient.

A model for predicting alcohol withdrawal delirium.

The aim of this study was to develop a model for identifying patients with a high risk of developing alcohol withdrawal delirium after assessment in the emergency department. Patients seeking acute treatment for alcohol withdrawal at St. Göran's hospital in Stockholm were evaluated for known risk factors for alcohol withdrawal delirium. All patients with any risk factor were admitted to the hospital and received standard treatment with benzodiazepines. All patients were evaluated at admission by the physician in charge at the psychiatric and dependency emergency unit at the hospital. Treatment and final assessment were conducted at the unit's inpatient acute-treatment facility. Correlations were determined between risk factors noted at admission and development of alcohol withdrawal delirium, as defined in DSM-IV, after admission. A total of 334 alcohol-dependent patients were included in the study. Twenty-three patients, or 6.9 percent, developed alcohol withdrawal delirium after admission despite benzodiazepine treatment. In a stepwise multiple regression model, five risk factors were significantly correlated with the development of alcohol withdrawal delirium: current infectious disease; tachycardia, defined as a heart rate above 120 beats per minute at admission; signs of alcohol withdrawal accompanied by an alcohol concentration of more than 1 gram per liter of body fluid; a history of epileptic seizures; and a history of delirious episodes. No patient without these five risk factors developed delirium. Assessment for five easily detectable risk factors can enable the clinician to make an accurate and quantitative assessment of a patient's risk of developing alcohol withdrawal delirium.

Convulsions associated with postoperative abstinence from alcohol

A 37 year old Caucasian male with known alcohol dependence, was anaesthetised for the repair of a paraumbilical hernia on a day stay basis. On discharge he was instructed not to drink alcohol for 24 h. The patient developed acute alcohol withdrawal symptoms within 48 h. Alcohol abuse is a common problem. Patients with this problem occasionally present to the day surgery unit for short surgical procedures under general anaesthesia or sedation. These procedures are, often carried out in the day unit, as long as the patient has no physical problem attributable to alcohol. However, there is a potential for some patients to develop alcohol withdrawal symptoms. These can be serious, as there is, in the majority of cases, no mechanism for the early detection of the withdrawal symptoms and signs. We report a case of postoperative convulsions associated with alcohol withdrawal following the repair of a paraumbilical hernia on a day stay basis. We present a short review of related literature.

β-Carbolines in alcohol-dependent intensive care patients during prophylactics and therapy of alcohol withdrawal syndrome.

The primary aim of this study was to investigate whether the naturally occurring beta-carbolines norharman and harman differed between alcohol-dependent patients who developed alcohol withdrawal syndrome (AWS) and those who did not. The secondary aim was to determine whether different treatment regimens influenced the levels of the beta-carbolines. Thirty chronic alcoholics with carcinoma of the upper digestive tract were included in this study. They were prophylactically treated by two different medical regimens: flunitrazepam and clonidine (FNZ regimen) and gamma-hydroxybutyrate and clonidine (GHB regimen). Patients exceeding the Revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar) score of 20 were assigned to the AWS therapy group and received haloperidol in addition to their prevous prophylactic treatment. Patients without AWS remained in the prophylactic group. From days 1-4 of the intensive care unit (ICU) stay norharman, but not harman, was increased in the AWS therapy group. In the FNZ regimen, six of 16 patients (38%) and in the GHB regimen, nine of 14 patients (64%) developed AWS (p= 0.14). Norharman levels did not differ between the two regimens. However, harman levels were increased in the GHB treated regimen on days 1, 2 and 4 following admission to the ICU and correlated with the severity of alcohol withdrawal syndrome. As norharman was elevated in the therapeutically treated ICU patients, this marker appears to be involved in the pathogenesis of AWS. As harman was elevated before and during hallucinations on the GHB regimen, it seems reasonable to carry out further investigations into the potential role of harman as a hallucinatory substance.

Beta-carbolines in chronic alcoholics following trauma.

In our society every second polytraumatized patient is a chronic alcoholic. A patient's alcohol-related history is often unavailable and laboratory markers are not sensitive or specific enough to detect alcohol-dependent patients who are at risk of developing alcohol withdrawal syndrome (AWS) during their post-traumatic intensive care unit (ICU) stay. Previously, it has been found that plasma levels of norharman are elevated in chronic alcoholics. We investigated whether beta-carbolines, i.e. harman and norharman levels, could identify chronic alcoholics following trauma and whether possible changes during ICU stay could serve as a predictor of deterioration of clinical status. Sixty polytraumatized patients were transferred to the ICU following admission to the emergency room and subsequent surgery. Chronic alcoholics were included only if they met the DSM-III-R and ICD-10 criteria for alcohol dependence or chronic alcohol abuse/harmful use and their daily ethanol intake was > or =60 g. Harman and norharman levels were assayed on admission and on days 2, 4, 7 and 14 in the ICU. Harman and norharman levels were determined by high pressure liquid chromatography. Elevated norharman levels were found in chronic alcoholics (n = 35) on admission to the hospital and remained significantly elevated during their ICU stay. The area under the curves (AUC) showed that norharman was comparable to carbohydrate-deficient transferrin (CDT) and superior to conventional laboratory markers in detecting chronic alcoholics. Seventeen chronic alcoholics developed AWS; 16 of these patients experienced hallucinations or delirium. Norharman levels were significantly increased on days 2 and 4 in the ICU in patients who developed AWS compared with those who did not. An increase in norharman levels preceded hallucinations or delirium with a median period of approximately 3 days. The findings that elevated norharman levels are found in chronic alcoholics, that the AUC was in the range of CDT on admission and that norharman levels remained elevated during the ICU stay, support the view that norharman is a specific marker for alcoholism in traumatized patients. Since norharman levels increased prior to the onset of hallucinations and delirium it seems reasonable to investigate further the potential role of norharman as a possible substance which triggers AWS.