Risk For Alcohol Withdrawal Syndrome Research Articles

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.

Phenobarbital as Anticonvulsant Prophylaxis in Patients With Traumatic Brain Injury at Risk for Alcohol Withdrawal Syndrome.

Background: Anticonvulsant prophylaxis (ACP) for early post-traumatic seizures (PTS) is recommended in patients with traumatic brain injury (TBI). Phenobarbital (PB) may be used to prevent alcohol withdrawal syndrome (AWS) in at-risk patients. The dual-purpose use of PB in the TBI population would allow for consolidation of pharmacotherapy. Objective: The primary objective of this study was to determine the frequency of early PTS in TBI patients at risk of AWS treated with PB as ACP. Secondary objectives included determining rates of over sedation and endotracheal intubation. Methods: Patients received an intravenous (IV) loading dose of PB at 15-20mg/kg followed by 1mg/kg every 12hours for 7days with a goal level of 15-20mcg/mL. Medication data, seizure frequency, and episodes of over sedation and endotracheal intubation were collected. Results: Eighty patients were treated with PB over a 1-year period. Thirty-nine patients were analyzed. Median loading dose was 19.9 (Interquartile Range 19.1-20.0) mg/kg with a median post load level of 21.7mcg/mL (IQR 18.3-25.8) mcg/mL. One patient (2.6%) had electrographic evidence for early PTS. PB was discontinued in 4 (10.3%) patients out of concern for over sedation. One patient required endotracheal intubation after rapid PB loading. Conclusion: The frequency of early PTS was low when PB was used as primary ACP in patients with TBI at risk for AWS. Over sedation is a potential adverse effect that should be considered in the choice of ACP. No conclusions can be drawn as to the effectiveness of PB in preventing AWS.

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.

Free Papers Compiled

Background:Alcohol withdrawal syndrome occurs in patients who have decreased or discontinued taking alcohol most patients who undergo withdrawal experience mild to moderate symptoms including nausea vomiting agitation however delirium tremens occurs in very few individuals and is associated with significant mortality and morbidityAim:To assess Prevalence end correlate of delirium tremens in male Alcoholics.Materials and Methods:All adult patients admitted above the age of 18 years Who did not have early manifestation of DT at zero time they were at risk for alcohol withdrawal syndrome at zero time and they were admitted primarily for detoxification from alcohol. the patients who were already in delirium or had very low chances of going into delirium were excluded. They were assessed with a self made Socio demographic proforma,Severity of alcohol dependence questionnaire, clinical institute withdrawal assessment of alcohol scale revised.Results:30 % males with alcohol dependence went into delirium tremens. Net income ,education ,years since consuming, amount and type of alcohol had an impact on prevalence of delirium tremens.Conclusion:Chances of delirium tremens increases with factors like age , net income, employment and also time since consuming , type and amount of alcohol.

Phenobarbital Monotherapy for the Management of Alcohol Withdrawal Syndrome in Surgical-Trauma Patients.

Benzodiazepine is first-line therapy for alcohol withdrawal syndrome (AWS), and phenobarbital is an alternative therapy. However, its use has not been well validated in the surgical-trauma patient population. To describe the use of fixed-dose phenobarbital monotherapy for the management of patients at risk for AWS in the surgical-trauma intensive care unit. Surgical-trauma critically ill patients who received phenobarbital monotherapy, loading dose followed by a taper regimen, for the management of AWS were included in this evaluation. The effectiveness of phenobarbital monotherapy to treat AWS and prevent development of AWS-related complications were evaluated. Safety end points assessed included significant hypotension, bradycardia, respiratory depression, and need for invasive mechanical ventilation. A total of 31 patients received phenobarbital monotherapy; the majority of patients were at moderate risk for developing AWS (n = 20; 65%) versus high risk (n = 11; 35%). None of the patients developed AWS-related complications; all patients were successfully managed for their AWS. Nine patients (29%) received nonbenzodiazepine adjunct therapy for agitation post-phenobarbital initiation. Three patients (10%) experienced hypotension, and 3 (10%) were intubated. None of the patients had clinically significant bradycardia or respiratory depression. Fixed-dose phenobarbital monotherapy appears to be well tolerated and effective in the management of AWS. Further evaluation is needed to determine the extent of benefit with the use of phenobarbital monotherapy for management of AWS.

Impact of Traumatic Brain Injury on Clinical Institute Withdrawal Assessment Use in Trauma Patients: A Descriptive Study.

Alcohol withdrawal syndrome (AWS) and traumatic brain injury (TBI) present with similar signs and symptoms, yet their treatment strategies differ greatly. AWS treatment includes the Clinical Institute Withdrawal Assessment (CIWA) protocol, which grades withdrawal signs and symptoms. A major purpose of CIWA is to guide the addition and titration of central nervous system (CNS) depressants, most commonly benzodiazepines. Conversely, best practice is to avoid these same CNS depressants in the setting of TBI. Thus, patients with TBI presenting with AWS risk may receive undesirable interventions that could worsen outcome. To describe the relationship of TBI diagnosis with CIWA protocol scores and intervention implementation. Retrospective cohort observational study. Single university-based, level one trauma center. Three hundred seventy-five patients with head trauma or AWS classification, identified through the trauma center's trauma registry. CIWA protocol and related medication use. Frequency of elevated CIWA score, length of CIWA administration, and medication administration incidence were abstracted from patients' medical records. The percentage of elevated CIWA scores increased significantly with TBI severity, from 4.5%(0-60) in the No TBI group, up to 12.5% (0-36) in the Mild TBI group, 27.1% (0-57) in the Moderate TBI group, and 50.0% (14-77) in the Severe TBI group. Nominally, lorazepam use showed a similar pattern of escalation with TBI severity, but it did not reach statistical significance. Haloperidol use did significantly escalate with higher TBI severity. No group differences were observed for total lorazepam equivalents or length on the CIWA protocol. TBI diagnosis and higher TBI severity level correlate with higher CIWA scores, but neither increased nor decreased benzodiazepine usage was observed. Antipsychotic use did escalate with TBI diagnosis and severity. The risks versus benefits of minimizing benzodiazepines in patients with TBI who are at risk for AWS warrant future study.

Reducing the severity of alcohol withdrawal with oral baclofen: a randomized controlled trial

Background: Alcohol withdrawal syndrome (AWS) increases the complexity of inpatient medical care. Baclofen has shown promise in previous studies to modulate the symptoms of AWS. Our objective was to determine if baclofen, when added to symptom triggered benzodiazepines, could prevent medical inpatients at risk for AWS from progressing to moderate or severe AWS.Methods: Double Blind, placebo controlled, randomized trial. Trial registered at ClinicalTrials.gov registration ID NCT02052440. Medical inpatients at a University-affiliated, urban public safety net hospital who were at risk for, or with mild, AWS received Baclofen 10 mg or placebo by mouth every 8 h plus usual care. The primary outcome was the percentage of patients progressing to moderate or severe AWS. Secondary outcomes included the difference in the mean AWS assessment scores at 24, 48, and 72 h and peak and total dosages of benzodiazepines.Results: 101 of 166 targeted patients were enrolled. The primary outcome occurred in 13 of 50 (26%) patients receiving baclofen and 16 of 51 (31%) receiving placebo (p = 0.55). Mean cumulative diazepam administered was 66 mg (±51 SD) in the baclofen group and 85 mg (±63) in the placebo group (p = 0.13). Mean highest dose diazepam was 11 mg (±3) in the baclofen group and 12 mg (±7) in the placebo group (p = 0.14).Conclusion: The addition of baclofen to usual care did not result in a significant difference in progression to moderate or severe AWS but we interpret this result with caution given that we did not meet the enrollment goal.Trial registration: ClinicalTrials.gov identifier: NCT02052440.

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.

Evaluation of the appropriate use of a CIWA-Ar alcohol withdrawal protocol in the general hospital setting

ABSTRACTBackground: The Clinical Institute Withdrawal Assessment-Alcohol, Revised (CIWA-Ar) is an assessment tool used to quantify alcohol withdrawal syndrome (AWS) severity and inform benzodiazepine treatment for alcohol withdrawal. Objectives: To evaluate the prescribing patterns and appropriate use of the CIWA-Ar protocol in a general hospital setting, as determined by the presence or absence of documented AWS risk factors, patients’ ability to communicate, and provider awareness of the CIWA-Ar order. Methods: This retrospective chart review included 118 encounters of hospitalized patients placed on a CIWA-Ar protocol during one year. The following data were collected for each encounter: patient demographics, admitting diagnosis, ability to communicate, and admission blood alcohol level; and medical specialty of the clinician ordering CIWA-Ar, documentation of the presence or absence of established AWS risk factors, specific parameters of the protocol ordered, service admitted to, provider documentation of awareness of the active protocol within 48 h of initial order, total benzodiazepine dose equivalents administered and associated adverse events. Results: 57% of patients who started on a CIWA-Ar protocol had either zero or one documented risk factor for AWS (19% and 38% respectively). 20% had no documentation of recent alcohol use. 14% were unable to communicate. 19% of medical records lacked documentation of provider awareness of the ordered protocol. Benzodiazepine associated adverse events were documented in 15% of encounters. Conclusions: The judicious use of CIWA-Ar protocols in general hospitals requires mechanisms to ensure assessment of validated alcohol withdrawal risk factors, exclusion of patients who cannot communicate, and continuity of care during transitions.

Alcohol Withdrawal Syndrome in Critically Ill Patients: Identification, Assessment, and Management.

Management of alcohol withdrawal in critically ill patients is a challenge. The alcohol consumption histories of intensive care patients are often incomplete, limiting identification of patients with alcohol use disorders. Abrupt cessation of alcohol places these patients at risk for alcohol withdrawal syndrome. Typically benzodiazepines are used as first-line therapy to manage alcohol withdrawal. However, if patients progress to more severe withdrawal or delirium tremens, extra adjunctive medications in addition to benzodiazepines may be required. Sedation and mechanical ventilation may also be necessary. Withdrawal assessment scales such as the Clinical Institute of Withdrawal Assessment are of limited use in these patients. Instead, general sedation-agitation scales and delirium detection tools have been used. The important facets of care are the rapid identification of at-risk patients through histories of alcohol consumption, management with combination therapies, and ongoing diligent assessment and evaluation. (Critical Care Nurse. 2016;36[1]:28-39).

Inpatient Alcohol Withdrawal: Time to Prevent the Preventable?

Inpatient Alcohol Withdrawal: Time to Prevent the Preventable?

Alcohol Withdrawal Syndrome in Trauma Patients: A Prospective Cohort Study

Introduction: Trauma patients with a positive blood alcohol concentration (BAC) are often believed to be at high risk for the alcohol withdrawal syndrome (AWS). Therefore some centers prophylaxis all BAC positive patients. This study prospectively measures the incidence of AWS among trauma patients admitted to the hospital who have consumed alcohol and determines their risk factors for AWS. Methods: A cohort of trauma patients admitted to a non-ICU hospital setting was prospectively monitored for the development of AWS during the first 10 days of hospitalization. The 10-item Alcohol Use Disorders Identification Test (AUDIT) and questions about alcohol withdrawal history were administered on the first day and the revised Clinical Institute for Withdrawal of Alcohol Scale (CIWA-Ar) was administered daily. Results: 113 patients were followed through discharge or for the first 10 days of hospitalization. 74.3% (n = 84) reported drinking alcohol. Of the 89 patients with a measured BAC, 25 (28%) were positive. Mean BAC for positive patients was 187.7 mg/dl. No person who denied drinking had a measurable BAC or developed AWS. Among the 84 drinkers, 3 were diagnosed with AWS by CIWA-Ar (3.6% risk), giving an incidence rate of 1.4 episodes per 100 patient days. All patients developing AWS admitted to a previous history of AWS symptoms upon stopping drinking. All AWS patients drank at least 2-3 times per week compared to only 37% of drinkers who did not develop AWS (p = .05). Positive response to dependence items from the AUDIT were highly associated with AWS risk (67% AWS vs 16% non-AWS, p = .005). Implementation of a prophylaxis protocol for all positive BAC would have resulted in 88% (22/25) of BAC positive patients receiving unwarranted medication. Conclusion: AWS has a low incidence rate among intoxicated trauma patients admitted to a non-ICU setting. It is associated with frequent drinking and is found in patients who report dependence symptoms. Patients can reliably tell physicians whether they are at risk for AWS. Routine prophylaxis for positive BAC patients will likely result in substantial excess medication use.

Physical Therapy Management of a Patient Experiencing Alcohol Withdrawal

Background and Purpose: The consumption of alcohol is common, leading to many health concerns such as alcohol withdrawal syndrome (AWS); AWS may occur within 6-24 hours of the sudden interruption of alcohol intake. Many inpatients may be at risk for AWS, complicating all aspects of their hospital stays, including physical therapy (PT). This case report serves to describe the role of PT in a patient experiencing AWS. Case Description: The patient was an 80-year-old man who fell in his home prior to hospital admission and had lain on the floor for five hours. He had several complicating medical factors, including the presence of AWS. The patient was referred to physical therapy to determine whether he would be able to return home independently. Examination revealed deficits in functional lower extremity strength and balance, as well as with transfers and ambulation. Interventions included lower extremity strengthening, balance training, transfers, and ambulation. Outcomes: Despite the medical record's indication of AWS, no overt signs of withdrawal were observed during PT interventions. The patient improved in functional activities but impairments in transfers and ambulation remained at the time of his hospital discharge, requiring a stay at a skilled nursing facility prior to returning home. Discussion: Alcohol withdrawal is a potentially life-threatening condition for which physical therapists, like all staff in an inpatient setting, need to be vigilant.

Is your medical/surgical patient withdrawing from alcoho

Look beyond the stereotype. Any hospitalized patient could be dependent on alcohol-and at risk for alcohol withdrawal syndrome.

Alcohol Withdrawal Syndrome: Turning Minor Injuries Into a Major Problem

Abrupt cessation of chronic drinking patterns places hospitalized patients at risk for alcohol withdrawal syndrome (AWS). The purpose of this study was to investigate the effect of AWS on length of stay, morbidity, mortality, and cost in low injury acuity trauma patients. A retrospective review of the National Trauma Registry of the American College of Surgeons database from July 1999 to February 2004 was performed. All patients 15 years or older admitted to our Level I trauma center with an Injury Severity Score (ISS) <16 were included. AWS patients were compared with those without AWS. Demographics, mechanism of injury (MOI), ISS, revised trauma score, Glasgow Coma score, hospital course, morbidity, requirement of additional procedures, mortality, and cost were compared. Analysis was done with chi2 test and Student's t test. A p value of < or =0.05 determined significance. Of 6,431 patients, 55 (0.9%) developed AWS. AWS patients were likely men (p < 0.001); had a higher ISS (p = 0.001) and lower Glasgow Coma score (p = 0.01); had more ventilator days (p = 0.008), intensive care unit days (p < 0.0001), and hospital days (p < 0.0001); suffered more complications, including respiratory failure (p < 0.0001), pneumonia (p < 0.0001), urinary tract infection (p = 0.0005), sepsis (p < 0.0001), tracheostomy (p < 0.0001), and percutaneous endoscopic gastrostomy (p < 0.0001); and had higher cost (p < 0.0001). Mortality was similar (p = 0.38) among groups. Low injury acuity patients with AWS have increased morbidity, leading to increased hospital stay and cost. To allow minor injuries to remain minor problems, the best modality to identify patients at risk and to achieve AWS prophylaxis require further investigation.

An Ethanol Protocol To Prevent Alcohol Withdrawal Syndrome

Alcohol withdrawal syndrome (AWS) occurs in dependent patients during the initial period of sudden onset abstinence. It is usually manifested by mild symptoms such as disorientation, agitation, and tachycardia, but, if untreated, can lead to severe confusion, seizures, and even cardiovascular collapse. Prevention of AWS has been shown to improve morbidity and mortality and shorten hospital and ICU stays. We examined the efficacy of ethanol as a method of prophylaxis. Our patient population was divided into two groups. Group 1 consisted of surgical patients receiving alcohol prophylaxis for AWS between January 2001 and July 2004 (n=124), as identified by retrospective chart review. We then developed a protocol for the initiation, dosage, and weaning of intravenous ethanol in patients at risk for AWS, based on blood alcohol levels and clinical assessment of withdrawal symptoms and signs. Group 2 consisted of all patients treated prospectively with this protocol during the subsequent year (n=76). Patients who did not fit inclusion criteria for the protocol were excluded from analysis, resulting in 92 and 68 patients in group 1 and group 2, respectively. We compared initiation criteria, efficacy, dosage, route, duration, and referral pattern to the substance abuse clinic before and after initiation of the protocol. Our initial use of intravenous ethanol was very variable in dosage, duration, and indication. The protocol decreased the duration of treatment between the two groups from 7 days to a mean of 3 days. The failure rate dropped from 20% to 7%. Referral to the substance abuse clinic rose from 7.6% to 20%. The only complication was asymptomatic hyponatremia in one patient. Intravenous ethanol is a viable option for AWS prophylaxis when administered in a systematic protocol.

Experience with an adult alcohol withdrawal syndrome practice guideline in internal medicine patients.

To standardize treatment of alcohol withdrawal syndrome (AWS) in internal medicine patients using an adult AWS practice guideline with a symptom-triggered management approach. Prospective interventional (pilot group) and retrospective (control group). University teaching hospital. Thirty-two internal medicine patients identified as being at risk for AWS and treated according to the AWS practice guideline who were compared with 49 internal medicine patients managed with nonstandardized approaches. Patients in the pilot group were assessed using the AWS type indicator. They received lorazepam, clonidine, or haloperidol, based on AWS type indicator assessment and adult AWS practice guideline criteria. Data collected and analyzed were drugs administered to control AWS symptoms, use of sitters and physical restraints, length of hospital stay, and discharge from hospital receiving tapered drug therapy. Pilot patients received 46.6% less benzodiazepine (p=0.001), 20% more clonidine (p=0.01), and 18.2% more haloperidol (p=0.002) than control patients. No drug therapy was required in 19% of pilot patients compared with 2% of controls (p=0.01). Significantly more control (71.4%) than pilot patients (18.8%) were discharged with tapered benzodiazepine therapy (p<or=0.01). No significant differences were found between groups for sitters, restraints, or hospital length of stay. This pilot project suggests that internal medicine patients at risk for AWS can be managed with a standardized, symptom-triggered approach using decreased amounts of benzodiazepine in combination with adjunctive agents to treat adrenergic hyperactivity and delirium. Further data are necessary to determine the impact of the practice guideline on patient outcome measurements.

Impact of an alcohol withdrawal syndrome practice guideline on surgical patient outcomes.

To standardize treatment of alcohol withdrawal syndrome (AWS) in surgical patients using an AWS practice guideline with a symptom-triggered approach. Prospective interventional (pilot group) and retrospective (comparison group). University teaching hospital. Thirty-eight trauma, orthopedic, and general surgery patients identified at risk for AWS in the pilot group, and 34 patients who were managed using nonstandardized approaches. At-risk patients in the pilot group were assessed using the AWS Type Indicator. They received lorazepam, clonidine, or haloperidol, based on AWS Type Indicator assessment and AWS practice guideline criteria. A standardized symptom-triggered approach to managing AWS was expected to decrease the use of benzodiazepines, avoid undertreatment of adrenergic hyperactivity and delirium, decrease the need for sitters and physical restraints, and reduce hospital length of stay. Pilot patients received a mean of 23 mg less benzodiazepine (p=0.01), 0.1 mg more clonidine (p=0.01), and 20 mg less haloperidol (p=0.06) than comparison patients. Pilot patients also required significantly fewer sitter hours (p=0.04) and hours of restraint use (p=0.09) than comparison patients. No significant differences were found between groups for length of stay (p=0.77). This pilot project suggests that trauma, orthopedic, and general surgery patients at risk for AWS can be safely and effectively managed with a standardized, symptom-triggered approach. Moreover, this approach decreased the amounts of benzodiazepines and haloperidol administered to patients at risk for AWS.