Management Of Alcohol Withdrawal Syndrome Research Articles

Effect of Phenobarbital-Based Alcohol Withdrawal Protocol on Provider Practice and Patient Outcomes—A Quality Improvement Study

Introduction: Alcohol is the most common substance use disorder in the United States. Despite this prevalence, there remains significant heterogeneity in medical management of alcohol withdrawal syndrome (AWS). While the 2020 American Society of Addition Medicine continues to recommend the use of benzodiazepines as first-line therapy for AWS, there is increasing use of phenobarbital in patients at high risk of severe AWS. Despite phenobarbital’s favorable pharmacologic profile, historically, clinical utilization on general medicine services has been low and often restricted. In this project, we have examined practice patterns and associated clinical outcomes in adult patients experiencing AWS on the general medicine service pre and post implementation of a phenobarbital-based protocol for the treatment of severe AWS at our institution. Methods: This quality improvement study evaluated changes in management of AWS on general medicine units associated with implementation of a phenobarbital-based protocol and order set in the electronic medical record (EMR). Our primary outcome measures were receipt of a phenobarbital loading dose, concomitant benzodiazepine administration, and total benzodiazepine dose. Safety outcomes were also explored to assess clinical impacts of this protocol implementation. The project was determined “not research” by our Institutional Review Board. Results: Phenobarbital-protocol implementation was associated with increased frequency of receiving a phenobarbital loading dose (49.5% vs 9.4%; P < .001), decreased use of concomitant benzodiazepine/phenobarbital (4.3% vs 28.9%; P < .001), and decreased total benzodiazepine dose (7.8 vs 15.5 mg; P < .001). Regarding safety, there was no significant pre/post difference in the rate of ICU transfer, but among those transferred there was a trend toward decreased mechanical ventilation rate (100% vs 28.6%; P = .051), and a significantly reduced ICU length of stay (median 11 vs 3 days; P = .04). There were no pre/post differences in seizures, delirium or use of adjunct medications. Conclusions: This quality improvement study demonstrates a marked change in provider prescribing practices for treating AWS after implementation of an institutional phenobarbital-based protocol. We observed no difference in overall clinical outcomes after protocol implementation, although a larger follow-up study is needed to confirm this and to further explore the shorter ICU length of stay for patients with AWS postimplementation.

Evaluation of Clinical Outcomes Associated With Phenobarbital With Taper Compared to No Taper for the Management of Alcohol Withdrawal Syndrome.

Phenobarbital (PHB) has been shown to be an effective treatment of alcohol withdrawal syndrome (AWS), with multiple dosing strategies used (e.g., single-dose and symptom-triggered). Studies have often used tapered doses, typically following a front-loaded dose, despite PHB's long half-life which should lead to an ability to auto-taper. The purpose of this study was to compare clinical outcomes associated with two PHB dosing strategies (taper [T], no taper [NT]) for AWS. This retrospective cohort study compared adult patients admitted to the ICU from October 2017 to May 2019 who received an initial loading dose of PHB for AWS. The use of PHB was at the discretion of the clinician per our institutional guidelines. Prior to November 2018, patients were prescribed a PHB taper, while after this period, the taper was no longer recommended. The primary outcome was the proportion of patients requiring rescue PHB or adjunctive medications for AWS. Secondary outcomes included number of adjunctive agents used, prevalence of severe manifestations of AWS, ICU and hospital lengths of stay, and incidence of potentially significant drug interactions. A total of 172 patients were included (T: n = 81, NT: n = 91). Baseline characteristics were similar between groups, including history of severe AWS and cumulative benzodiazepine dose pre-PHB. There was no difference in the primary outcome between groups (T: 70.4% vs NT: 59.3%, P = 0.152). The median number of adjunctive agents per patient, severe manifestations, and ICU and hospital length of stay did not differ between groups. Twenty-five patients (14.5%) had potentially significant drug interactions. The use of a PHB loading dose without a taper may be comparable to a taper strategy on clinical outcomes. Prospective studies are needed to further delineate the optimal dose of PHB for AWS.

Review of Abstinence Syndrome: A Comprehensive Analysis of Current Practices and Recommendations

Alcohol use disorder is frequently accompanied with the diverse and sometimes fatal consequence of alcohol withdrawal syndrome (AWS). Many patients with AUD may develop AWS during their Emergency Department stay, and AUD is one of the top causes of death worldwide. This study summarizes the etiology, epidemiology, and emergency management of Alcohol Withdrawal Syndrome and Alcohol Use Disorder.The influence of AWS on the therapy of ED is highlighted, along with its temporal course. Once AWS is diagnosed, the most common therapy is still symptom- triggered benzodiazepine injection; however, patients who have significant medical or psychiatric comorbidities or are about to be discharged may not be good candidates for this approachIn these circumstances, emergency department doctors can consider employing alternative regimens based on state-of-the-art anticonvulsants or shorter barbiturate durations. For clinical practice, specific treatment procedures are described. Lastly, in addition to managing acute patients' AWS, emergency physicians also need to provide the groundwork for effective AUD therapy. A strategy for the patient with AUD's disposition is offered.

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.

Screening for Alcohol Use Disorder and Management of Alcohol Withdrawal Syndrome in Critical Care Patients.

Evidence-based research indicates that subjective questionnaires should be eliminated in screening for alcohol use disorder and management of alcohol withdrawal syndrome in critical care patients. However, transitioning clinicians away from these screening tools remains challenging. To improve screening for alcohol use disorder and management of alcohol withdrawal syndrome in the critical care setting by implementing an evidence-based alcohol use disorder screening tool and alcohol withdrawal syndrome protocol for critical care patients. The project site was a 17-bed adult medical intensive care unit in a large, southeastern US teaching hospital. Interventions consisted of the elimination of previously used tools such as the Clinical Institute Withdrawal Assessment for Alcohol-Revised and implementation of the Prediction of Alcohol Withdrawal Severity Scale for alcohol use disorder screening and the Richmond Agitation-Sedation Scale and symptom-triggered benzodiazepine administration for alcohol withdrawal syndrome management. Alcohol use disorder screening among the critical care patient population increased by 49% from before to after the intervention. Of the patients at risk for withdrawal, 79% had an order for monitoring with the new intensive care unit alcohol withdrawal protocol in the postintervention group, compared with 35% who had an order for monitoring with the Clinical Institute Withdrawal Assessment for Alcohol-Revised in the preintervention group. The elimination of previously used tools and the implementation of the Prediction of Alcohol Withdrawal Severity Scale and the new intensive care unit alcohol withdrawal protocol improved alcohol use disorder screening and alcohol withdrawal syndrome management among critical care patients.

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.

Practice Patterns in the Diagnosis and Management of Alcohol Withdrawal Syndrome in Indian Intensive Care Units.

Gopaldas JA, Padyana M, Rai PP. Practice Patterns in the Diagnosis and Management of Alcohol Withdrawal Syndrome in Indian Intensive Care Units. Indian J Crit Care Med 2023;27(11):816-820.

Comparison of phenobarbital monotherapy to a benzodiazepine-based regimen for management of alcohol withdrawal syndrome in trauma patients.

Alcohol withdrawal syndrome (AWS) is associated with increased morbidity and mortality in the trauma population. Benzodiazepines (BZDs) are standard of care for AWS; however, given the risk of delirium with BZDs and reports of BZD-refractory withdrawal, phenobarbital (PHB) has emerged as an alternative therapy for AWS. Safety and efficacy studies of PHB for AWS in trauma patients are lacking. Our aim was to compare a BZD versus PHB protocol in the management of AWS in trauma patients. We performed a retrospective cohort study at a level 1 trauma center of patients at risk for AWS managed with either a BZD or a low-dose oral PHB regimen. Patients were excluded if they were taking BZDs or barbiturates before admission, received propofol or dexmedetomidine before initiation of the study drug, presented with delirium tremens or seizures, or died or discharged within 24 hours of presentation. The primary outcome was complicated AWS (seizures or alcohol withdrawal delirium/delirium tremens). Secondary outcomes included uncomplicated AWS; therapy escalation; oversedation; delirium-, intensive care unit-, and ventilator-free days; and length of stay. A total of 411 patients were identified; 118 received BZD, and 293 received PHB. The odds of developing complicated AWS with PHB versus BZD-based therapy were not statistically significant (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.21-1.39); however, patients receiving PHB were less likely to develop uncomplicated AWS (OR, 0.08; 95% CI, 0.04-0.14) and less likely to require escalation of therapy (OR, 0.45; 95% CI, 0.24-0.84). The PHB group had a length of stay 3.1 days shorter than the BZD group ( p = 0.002). There was no difference in intensive care unit-, ventilator-, or delirium-free days. A PHB-based protocol for the management of AWS is a safe and effective alternative to BZD-based regimens in trauma patients. Therapeutic/Care Management; Level IV.

Assessment of a modified MINDS-based protocol for management of alcohol withdrawal syndrome on an inpatient medical service.

To determine if a novel symptom-based alcohol withdrawal syndrome (AWS) protocol in a US Veterans cohort leads to significant clinical improvements in patient outcomes and safety. Prior studies of AWS management, oftentimes using the revised version of the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) index, have demonstrated the effectiveness of symptom-triggered therapy for AWS. The Minnesota Detoxification Scale (MINDS) is an alternative to the CIWA-Ar index but remains unevaluated outside of the intensive care unit (ICU) setting. This study assesses outcomes in AWS management prior to and after the implementation of a novel MINDS-based AWS protocol (SDAWP) utilizing a revised MINDS index (MINDS-rev) in an inpatient medical ward setting. Retrospective cohort study including encounters prior to (n = 342) and after (n = 338) the implementation of the protocol. Pre- and post-protocol encounters were selected by combinations of diagnostic codes and charting elements. Outcome measures of AWS management were obtained in both groups. The primary endpoint was median total benzodiazepine exposure. Secondary outcomes included median length of hospitalization, median duration of benzodiazepine administration, and the incidence of complications. The median total benzodiazepine exposure in the post-SDAWP group was significantly lower than the pre-SDAWP group (21.2 vs. 12.0 mg, p < 0.0001) and for a significantly shorter median duration of time (4.0 vs. 3.0 days, p < 0.0001). There was no significant difference in the median length of stay (4.0 vs. 4.0 days, p = 0.50). The incidence of delirium tremens (21 vs. 7, p = 0.01) and need for transfer to a higher level of care (33 vs. 12, p = 0.002) was significantly lower in the post-SDAWP group. The SDAWP has provided significant improvements in AWS management in our institution and may potentially serve as a template for wider use in other inpatient settings.

Phenobarbital versus Lorazepam for the Management of Alcohol Withdrawal Syndrome (AWS) in Hospitalized Patients- A Retrospective Cohort Study

Phenobarbital versus Lorazepam for the Management of Alcohol Withdrawal Syndrome (AWS) in Hospitalized Patients- A Retrospective Cohort Study

Evaluation of Gabapentin and Baclofen Combination for Inpatient Management of Alcohol Withdrawal Syndrome.

Benzodiazepines are considered the gold standard for treatment of alcohol withdrawal syndrome (AWS), a group of symptoms that occur after abrupt cessation of alcohol use, but may be associated with serious adverse effects. Given the safety concerns, alternative treatment options for AWS management have been investigated, including gabapentin and baclofen. Because no available studies have investigated the inpatient use of the gabapentin and baclofen combination for alcohol detoxification, this study aims to evaluate their efficacy and safety in the inpatient hospital setting. This retrospective cohort study at the Captain James A. Lovell Federal Health Care Center in North Chicago, Illinois, included patients who were aged ≥ 18 years and who were admitted to the general acute medicine floor for the primary indication of AWS from January 1, 2014, to July 31, 2021. The primary outcome was the length of stay, defined as hours from admission to either discharge or 36 hours with a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score ≤ 8. Electronic health records were reviewed to collect CIWA scores, alcohol withdrawal seizure and delirium tremens incidence, rates of conversions from gabapentin/baclofen to lorazepam, rates of transitions to a higher level of care, and readmission for AWS within 30 days. Mean length of stay in the gabapentin/baclofen group was statistically significantly shorter compared with the benzodiazepine group (42.6 vs 82.5 hours, P < .001). The study found no significant difference between the gabapentin/baclofen and benzodiazepine groups in AWS readmission, adjuvant medications for AWS management, and number of patients who transitioned to a higher level of care. Overall, the safety of gabapentin/baclofen vs benzodiazepine were comparable; however, 1 patient experienced a seizure, and 1 patient experienced delirium tremens during admission in the benzodiazepine group. Gabapentin/baclofen combination seems to be an effective and safe alternative to benzodiazepines and may be considered for managing mild AWS in hospitalized patients, but additional research is needed to examine this regimen.

Approach and Management of Alcohol Withdrawal Syndrome in Operative Head and Neck Cancer Patients.

Postoperative head and neck cancer patients are at increased risk for alcohol withdrawal syndrome. Literature has shown that in this patient population, alcohol withdrawal is associated with an increase in postoperative medical and surgical complications, length of hospitalization, and hospital-related costs. Harm reduction and addiction medicine philosophies can reduce morbidity and mortality, but have not been fully validated in perioperative surgical management for head and neck cancer. This commentary synthesizes key principles of addiction medicine and current strategies that Otolaryngology-Head and Neck Surgery surgeons can consider in their perioperative assessment and management of alcohol withdrawal syndrome in their patients.

Clinical Impact of the CYP2C19 Gene on Diazepam for the Management of Alcohol Withdrawal Syndrome.

Diazepam is a benzodiazepine widely prescribed for the management of patients with severe alcohol withdrawal syndrome to prevent agitation, withdrawal seizures, and delirium tremens. Despite standard dosing of diazepam, a subset of patients experience refractory withdrawal syndromes or adverse drug reactions, such as impaired motor coordination, dizziness, and slurred speech. The CYP2C19 and CYP3A4 enzymes play a key role in the biotransformation of diazepam. Given the highly polymorphic nature of the CYP2C19 gene, we reviewed the clinical impact of variants in the CYP2C19 gene on both the pharmacokinetics of diazepam and treatment outcomes related to the management of alcohol withdrawal syndrome.

Symptoms-triggered approach versus fixed-scheduled approach of benzodiazepines for management of alcohol withdrawal syndrome: Non-randomized controlled trial.

Alcohol withdrawal syndrome, if untreated, can lead to potentially life-threatening complications. Benzodiazepines are the drugs of choice for the treatment of alcohol withdrawal syndrome. We aimed to compare the symptoms-triggered approach and fixed-dose approach of benzodiazepine administration for treatment of alcohol withdrawal syndrome in regard to the health care utilization measured by the total dose of benzodiazepines, length of hospital stays, and 90-day readmissions rate. A single-center prospective non-randomized controlled trial included all patients diagnosed with alcohol withdrawal syndrome. The group of patients admitted between October 1, 2019, and September 30, 2020, were treated with the fixed-scheduled approach (n=150), while all patients admitted between November 1, 2020, to October 31, 2021, were treated with the symptoms-trigger approach (n=50). The fixed-dose approach group showed a significant higher 90-day readmissions rate (HR: 2.61; 95% CI=1.18, 6.84; p=0.01). Kaplan-Meier survival analysis showed a significantly shorter duration to the first readmission in the fixed-scheduled approach group (HR: 2.3; 95% CI=5.6, 1.16; p=0.02). The symptoms-triggered approach group required a significantly lower dose of diazepam (40mg vs. 10mg; p<0.01) and a higher dose of thiamine (800mg vs. 600mg; p<0.01). Length of hospital stay was significantly increased in the symptoms-triggered approach group (3.9 vs. 2.2 days; p<0.01). The use of a symptoms-triggered approach to treat alcohol withdrawal syndrome was associated with a lower 90-day readmission rate, prolonged period to the first readmission, and reduced total dose of benzodiazepines, but longer length of hospital stays. The symptoms-triggered approach is safe, cost-effective, and associated with reduced alcohol dependence relapse.

Evaluation of Dexmedetomidine as an Adjunct to Phenobarbital for Alcohol Withdrawal in Critically Ill Patients.

Dexmedetomidine (DEX) is commonly used with benzodiazepines for the management of alcohol withdrawal syndrome (AWS), but limited data exist regarding its use with phenobarbital (PHB). This analysis evaluated the utility of DEX in addition to PHB for AWS in adult patients admitted to the intensive care unit (ICU). This was a single-center, retrospective cohort analysis of critically ill adult patients who received PHB plus either DEX or different adjunctive therapies (NO-DEX) for AWS between 2018 and 2021. Patients were excluded if they had underlying altered mental status or seizure disorder unrelated to AWS or received PHB at outside hospitals. Coarsened exact matching (CEM) was performed to match patients on baseline characteristics in a 1:1 ratio. The primary outcome was ICU length of stay (LOS). A multivariate linear regression analysis was performed to assess the effects of DEX on ICU LOS when accounting for confounders. Secondary outcomes included days with delirium and incidence of mechanical ventilation after PHB administration. Of the 606 encounters evaluated, 197 met criteria for inclusion. After CEM, 56 encounters remained in each group for analysis. The median ICU LOS was 97.2 [50.1:139.5] hours for the DEX group and 47.5 [28.8:88.1] hours for the NO-DEX group (P = .002). The multivariate linear regression analysis showed the use of DEX (P = .008) was independently associated with an increased ICU LOS by 49.8 h. The DEX group had higher rates of total delirium days (208 vs 143 days, P < .001) and a higher incidence of mechanical ventilation after PHB administration (32% vs 9%, P < .001). This analysis suggests the use of adjunctive DEX with PHB for AWS was associated with a prolonged ICU LOS. Additional studies are needed to further understand the role of adjunctive DEX in the treatment of AWS in critically ill patients.

Phenobarbital and Alcohol Withdrawal Syndrome: A Systematic Review and Meta-Analysis.

Alcohol withdrawal syndrome (AWS) is a complication frequently encounteredamongpatients who are chronic alcohol abusers. It is considered to have a significant impact on the United States healthcare system. It not only has a toll on the healthcare spending but also contributes to significant morbidity and mortality. Benzodiazepines are considered first line in the treatment of AWS. Since patients with alcohol use disorder have downregulated gamma aminobutyric acid (GABA) receptors, this often leads to benzodiazepine resistance. Phenobarbital is also usedin the management of alcohol withdrawal syndrome. Here we present a systematic review and meta-analysis of the efficacy and safety of the drug. We conducted an electronic database search for relevant studies published between the inception of the project and November 20, 2022, in three databases, including Medline/PubMed, Embase, and Cochrane Library. Our study included all original studies with prime focus on the baseline characteristics of patients admitted to the intensive care unit (ICU) for alcohol withdrawal syndrome and management/monitoring protocol implemented for its treatment.The primary outcomes that were the focus of our study consisted of changes in the length of hospital stay, length of ICU stay, and changes in scoring systems (for alcohol withdrawal assessment and monitoring) following the implementation of phenobarbital. The secondary outcomes included complications such as intubation and mortality. Based on our analysis, the mean difference in hospital stay was statistically significant at -2.6 (95% CI, -4.48, -0.72, P=0.007) for phenobarbital compared to the benzodiazepine group. We were unable to comment on the heterogeneity in our meta-analysis due to the standard deviationnot being reported in one study. There was no statistically significant difference regarding the length of stay in the intensive care unit compared to the control/comparative arm, with a mean difference of -1.17 (95% CI, -1.17, 0.09, P=0.07), with considerable heterogeneity (I2=77%, P=0.002). Our meta-analysis also investigated the risk of intubation between the phenobarbital and the control/comparative group. There was statistically significant difference in the incidence of intubation, relative risk (RR) 0.52 (95% CI, 0.25, 1.08, P=0.08), with considerable heterogeneity (I2=80%, P=0.0001). Our study concludes that phenobarbital is an effective tool in the management of AWS in an ICU setting. However, various studies have reported contradictory results, and vital information appears to be lacking. Moreover, there is a lack of uniformity in terms of phenobarbital dosing. Drug administration should be adapted according to the severity of the symptoms. Further studies need to be conducted discussing the safety profile and adverse effects of the drug when it comes to the management of alcohol withdrawal syndrome.

Agmatine and Acetyl L Carnitine - A Novel Adjunctive Therapy for Management of Alcohol Withdrawal Syndrome

Agmatine and Acetyl L Carnitine - A Novel Adjunctive Therapy for Management of Alcohol Withdrawal Syndrome

1290: PHENOBARBITAL VERSUS BENZODIAZEPINE-BASED REGIMEN FOR ALCOHOL WITHDRAWAL SYNDROME IN TRAUMA PATIENTS

Introduction: Alcohol withdrawal syndrome (AWS) is associated with increased morbidity and mortality in the trauma population. Benzodiazepines (BZD) are standard of care for AWS; however, given the risk of delirium with BZDs and reports of BZD-refractory withdrawal, phenobarbital (PHB) has emerged as an alternative. Safety and efficacy studies of PHB for AWS in trauma patients are lacking. Our aim is to compare a BZD versus PHB regimen in the management of AWS in trauma patients. Methods: We performed a retrospective cohort study at a level 1 trauma center of patients at risk for AWS managed with either a BZD or a low dose oral PHB regimen. Patients were excluded if they were taking a study medication prior to admission, receiving propofol or dexmedetomidine prior to initiation of the study drug, presenting with delirium tremens or seizures, died, or were discharged within 24 hours of presentation. The primary outcome was complicated AWS (seizures or alcohol withdrawal delirium/delirium tremens). Secondary outcomes included uncomplicated AWS, therapy escalation, oversedation, delirium-, ICU-, and ventilator-free days, and length of stay (LOS). Results: 411 patients were identified; 118 received BZD, and 293 received PHB. The odds of developing complicated AWS with PHB versus BZD-based therapy was not statistically significant (OR 0.62; 95% CI, 0.23-1.69); however, patients in the PHB group were less likely to develop uncomplicated AWS (OR 0.09; 95% CI, 0.05-0.17) or require escalation of therapy (OR 0.47; 95% CI, 0.24-0.9). The PHB group had a LOS 3.26 days shorter than the BZD group (p=0.001). There was no difference in ICU-, ventilator-, or delirium-free days. Conclusions: PHB is a safe and effective alternative to BZD-based regimens in the management of AWS in trauma patients.

Phenobarbital for the Management of Alcohol Withdrawal Syndrome in Critically Ill, Surgical-Trauma Patients

IntroductionWhile benzodiazepines (BZD) are the standard of care therapy for the management alcohol withdrawal syndrome (AWS), phenobarbital (PHB) is often used as an alternative agent. The objective of this study is to assess the use of PHB therapy for the management of AWS in trauma-surgical intensive care unit (TSCU) patients. Materials and methodsThis is an institutional review board–approved single-center, retrospective study conducted at a large academic medical center. Patients aged ≥ 18 y admitted to the TSCU receiving PHB therapy for primary management of AWS were included. The primary outcome evaluated was the incidence of AWS-related complications (AWSRC) defined as severe agitation, delirium tremens, or seizures following initiation of PHB. Secondary outcomes included the incidence of oversedation and duration of mechanical ventilation. ResultsSixty patients were included in this study. AWSRC following initiation of PHB occurred in 65% of patients. Median time to initiation of PHB (42 versus 18 h, P = 0.001) and rates of oversedation (79.5% versus 28.6%, P < 0.001) were significantly greater among patients who experienced AWSRC compared to those who did not. Univariate analysis revealed use of BZD therapy for ≥ 24 h prior to PHB initiation, time from hospital admission to PHB initiation ≥ 24 h, presence of AWS symptoms at baseline, and baseline MINDS score > 6 were risk factors for AWSRC. ConclusionsDelays in initiation of PHB appear to be associated with an increased risk for developing AWSRC. Further research is needed to identify an optimal dosing strategy for TSCU patients at high risk for severe AWS.

Clinical utility of benzodiazepine in the management of alcohol withdrawal syndrome in a tertiary care teaching hospital

Background: Alcohol dependence is one of the common psychiatric disorder which is characterized by a pathological pattern of alcohol use, effecting mental health. Patients show severe symptoms, requiring clinical intervention. Benzodiazepines treatment can decrease the severity of withdrawal symptoms, and incidence of seizures and delirium tremens after abrupt cessation of alcohol. Objectives: To check the severity of alcohol use and assess the alcohol withdrawal symptoms, and to monitor the efficacy of different Benzodiazepines in alcohol detoxification. Methodology: A prospective study of eight months’ duration, conducted in the de-addiction unit attached to Psychiatric department (in-patients). A suitable data collection form was designed. All patients were screened using AUDIT scale and CIWA-Ar scale was used to assess the duration and severity of AWS. Data were analysed using descriptive statistics. Results: 220 patients were included in the study. Mean AUDIT score was 25.74, all the patients scored 8 or more on AUDIT. Majority of the patients were observed to have an AUDIT score between 25-32. A gradual decrease of signs and symptoms in each patient were observed. All patients were prescribed with Benzodiazepine, among which 135 (61.36%) patients were prescribed with Lorazepam followed by 85 (38.63%) patients with Diazepam and Chlordiazepoxide. Conclusion: Even though both Lorazepam and Diazepam are equally effective Benzodiazepines, in the present study, we observed that Lorazepam is the most commonly prescribed. The choices of drugs differ for each patient, and is patient specific. The management works best when it is individualized with the help of rating scales.