The alcohol withdrawal syndrome

Baclofen: a new drug for the treatment of alcohol dependence

Recent preclinical and clinical studies have suggested that baclofen, the prototypic gamma-aminobutyric acid B (GABA(B)) receptor agonist, is a promising pharmacological compound for use in the treatment of alcohol dependence. In particular, baclofen has been found to suppress symptoms of alcohol withdrawal syndrome with an efficacy comparable with that of the 'gold standard' diazepam. Moreover, baclofen has proven effective in the prevention of relapse due to its ability to reduce alcohol intake and craving in alcoholic patients. Baclofen proved to be manageable, producing no significant side effects and displaying no addictive properties. The efficacy of the drug in the management of both alcohol withdrawal syndrome and relapse prevention should entail a vastly simplified pharmacotherapy of alcohol dependence.

Ethanol withdrawal induces hyperalgesia mediated by PKCepsilon

Symptoms of ethanol withdrawal include heightened responses to sensory stimuli, as well as tremors and convulsions. We tested the hypothesis that repeated episodes of ethanol intake and withdrawal exacerbate the symptoms of alcohol-induced peripheral neuropathy. In contrast to the hyperalgesia produced when an alcohol (6.5%)-containing diet was fed continuously to male rats which took 4 weeks to develop (Dina et al., 2000), feeding alcohol (6.5%) in repeated cycles of 4 days of alcohol followed by 3 days without alcohol resulted in a withdrawal-induced hyperalgesia that began at the end of one weekly cycle and reached a maximum during the fourth cycle. For ethanol withdrawal to produce hyperalgesia, ethanol consumption needed to be terminated for a period of 2 days. Paradoxically, as the amount of alcohol consumed decreased, the hyperalgesia induced by withdrawal developed more rapidly, being maximal between 1.4 and 1.6% ethanol. These results suggest that continued exposure to ethanol also has a neuroprotective effect. Withdrawal-induced hyperalgesia, similar to the hyperalgesia induced by continuous, chronic alcohol intake, was inhibited reversibly by intrathecal administration of an antisense oligodeoxynucleotide to protein kinase C (PKC)epsilon.

Baclofen in the treatment of alcohol withdrawal syndrome: a comparative study vs diazepam

PURPOSE

Benzodiazepines are the drugs of choice in the treatment of alcohol withdrawal syndrome (AWS). Recent data have shown that baclofen may reduce AWS symptoms. At present, no comparative studies between baclofen and any benzodiazepine used in AWS treatment are available. Accordingly, the present study was designed to compare efficacy, tolerability and safety of baclofen versus diazepam in the treatment of AWS.

SUBJECTS AND METHODS

Thirty-seven patients with AWS were enrolled in the study and randomly divided into 2 groups. Baclofen (30 mg/day for 10 consecutive days) was orally administered to 18 patients (15 males, 3 females; median age: 46.5 years). Diazepam (0.5-0.75 mg/kg/day for 6 consecutive days, tapering the dose by 25% daily from day 7 to day 10) was orally administered to 19 patients (17 men, 2 women; median age: 42.0 years). The Clinical Institute Withdrawal Assessment (CIWA-Ar) was used to evaluate physical symptoms of AWS.

RESULTS

Both baclofen and diazepam significantly decreased CIWA-Ar score, without significant differences between the 2 treatments. When CIWA-Ar subscales for sweating, tremors, anxiety and agitation were evaluated singly, treatment with baclofen and diazepam resulted in a significant decrease in sweating, tremors and anxiety score, without significant differences between the 2 drug treatments. Both treatments decreased the agitation score, although diazepam was slightly more rapid than baclofen.

CONCLUSION

The efficacy of baclofen in treatment of uncomplicated AWS is comparable to that of the "gold standard" diazepam. These results suggest that baclofen may be considered as a new drug for treatment of uncomplicated AWS.

Alcohol and adult neurogenesis: Roles in neurodegeneration and recovery in chronic alcoholism

The concept of "structural plasticity" has emerged as a potential mechanism in neurodegenerative and psychiatric diseases such as drug abuse, depression, and dementia. Chronic alcoholism is a progressive neurodegenerative disease while the person continues to abuse alcohol, though clinical and imaging studies show that some recovery may occur with abstinence. The neural plasticity observed in chronic alcoholism coupled with conflicting reports on alcohol-induced hippocampal neuropathology make this disease ripe for reconsideration in terms of the phenomenon of adult neurogenesis. This review describes opposing neurogenic processes that occur with alcohol intoxication and abstinence following alcohol dependence and how these opposing events relate to neurodegeneration and recovery from chronic alcoholism.

Clinical predictors for delirium tremens in alcohol dependence

BACKGROUND AND AIMS

This study was aimed to find clinical predictors for developing delirium tremens (DT) in alcohol dependence.

METHODS

This cohort study was retrospectively carried out among patients who were diagnosed as having alcohol dependence between January 2001 and July 2004. Fifteen parameters were compared between patients who developed DT and ones who did not. We identified clinical predictors for DT by using multivariate analysis.

RESULTS

A total of one hundred and seventy-eight consecutive admission cases from 147 patients were analyzed. The mean age was 47.8 years, and 95.5% were male. Delirium tremens developed in 59 cases (33%) during hospitalization. On multiple logistic regression analysis, a previous history of DT (odds ratio (OR) 3.990; 95% CI 1.631, 9.759) and high pulse rate above 100 b.p.m. (OR 4.158; 95% CI 2.032, 8.511) were significant predictors for developing DT. When combined, DT developed in just 20.4% of cases without any predictors; however, if one predictor was present, DT developed in 45.6%, and if two predictors were present, DT developed in all cases (100%).

CONCLUSIONS

A simple assessment using the past history of DT and the pulse rate, which may be easily evaluated in clinical settings, can allow physicians to readily identify the patients who are at a high risk of developing DT during an alcohol dependence period and reserve more intensive therapies for the selected cases.

A Retrospective Chart Review Comparing Tiagabine and Benzodiazepines for the Treatment of Alcohol Withdrawal

Although benzodiazepines are the standard of care in the treatment of alcohol withdrawal, several studies have suggested that anticonvulsants may be equally effective at alleviating alcohol withdrawal symptoms and may pose less of a risk of causing rebound of symptoms which could contribute to relapse. This report compares treatment outcomes for patients (N=13) treated for alcohol withdrawal with either the anticonvulsant tiagabine or the benzodiazepines oxazepam and lorazepam. The Clinical Institute Withdrawal Assessment for Alcohol-revised (CIWA-Ar) was utilized to gauge alcohol withdrawal symptoms over the course of the study. When possible, follow-up data was obtained on alcohol use post-treatment. Both benzodiazepines and tiagabine appeared to reduce CIWA-Ar scores at about the same magnitude. There was a trend for tiagabine patients to have less post-detoxification drinking (Fisher exact test, p = 0.12). The reduction in alcohol withdrawal symptoms and decreased tendency to relapse observed in patients treated with the anticonvulsant tiagabine suggests that a double-blind, placebo controlled trial may be warranted.

Benzodiazepines for alcohol withdrawal

BACKGROUND

Alcohol withdrawal syndrome is a cluster of symptoms that occurs in alcohol-dependent people after cessation or reduction in alcohol use. This systematic review focuses on the evidence of benzodiazepines' use in the treatment of alcohol withdrawal symptoms.

OBJECTIVES

To evaluate the effectiveness and safety of benzodiazepines in the treatment of alcohol withdrawal.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2004), MEDLINE (1966 to October 2004) and EU-PSI PSI-Tri database with no language and publication restrictions. We also screened references of retrieved articles.

SELECTION CRITERIA

All randomized controlled trials examining the effectiveness and safety of a benzodiazepine in comparison with a placebo or other pharmacological intervention or other benzodiazepine were considered.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

Fifty-seven trials, with a total of 4,051 people were included. Despite the considerable number of randomized controlled trials, there was a very large variety of outcomes and of different rating scales and relatively limited quantitative synthesis of data was feasible. Benzodiazepines offered a large benefit against alcohol withdrawal seizures compared to placebo (relative risk [RR] 0.16; 95% confidence interval [CI] 0.04 to 0.69; p = 0.01). Benzodiazepines had similar success rates as other drugs (RR 1.02; 95% CI 0.92 to 1.12) or anticonvulsants in particular (RR 1.00; 95% CI 0.87 to 1.16) and offered a significant benefit for seizure control against non-anticonvulsants (RR 0.23; 95% CI 0.07 to 0.75; p = 0.02), but not against anticonvulsants (RR 1.99; 95% CI 0.46 to 8.65). Changes in Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scores at the end of treatment were similar with benzodiazepines versus other drugs, although some small studies showed isolated significant differences for other, less commonly, used scales. Data on other comparisons were very limited, thus making quantitative synthesis for various outcomes not very informative.

AUTHORS' CONCLUSIONS

Benzodiazepines are effective against alcohol withdrawal symptoms, in particular seizures, when compared to placebo. It is not possible to draw definite conclusions about the relative effectiveness and safety of benzodiazepines against other drugs in alcohol withdrawal, because of the large heterogeneity of the trials both in interventions and assessment of outcomes but the available data do not show prominent differences between benzodiazepines and other drugs in success rates.

Assessing the efficacy of medical treatments for alcohol use disorders

Alcohol use disorders (AUDs) are common health problems that have a significant impact on society as a whole. There is a need for more effective treatments. In the last two decades, evidence for the efficacy of pharmacological approaches to treatment has increased. Although it has long been clear that medications are needed for the treatment of the alcohol withdrawal syndrome, the important role of medications in the longer-term treatment of AUDs has only recently been appreciated. In particular, naltrexone, acamprosate and topiramate appear to be efficacious treatments, especially when combined with psychosocial interventions that emphasise compliance with medication and encourage treatment retention. The goal of this review is to bring together the existing literature supporting the usefulness of pharmacological treatments for the alcohol withdrawal syndrome, for longer-term treatment of AUDs, and for comorbid AUDs and other psychiatric disorders. In addition, opportunities for future research will be identified.

Temporally specific burst in cell proliferation increases hippocampal neurogenesis in protracted abstinence from alcohol

Adult neurogenesis is a newly considered form of plasticity that could contribute to brain dysfunction in psychiatric disease. Chronic alcoholism, a disease affecting over 8% of the adult population, produces cognitive impairments and decreased brain volumes, both of which are partially reversed during abstinence. Clinical data and animal models implicate the hippocampus, a region important in learning and memory. In a model of alcohol dependence (chronic binge exposure for 4 d), we show that adult neurogenesis is inhibited during dependence with a pronounced increase in new hippocampal neuron formation after weeks of abstinence. This increase is attributable to a temporally and regionally specific fourfold increase in cell proliferation at day 7 of abstinence, with a majority of those cells surviving and differentiating at percentages similar to controls, effects that doubled the formation of new neurons. Although increases in cell proliferation correlated with alcohol withdrawal severity, proliferation remained increased when diazepam (10 mg/kg) was used to reduce withdrawal severity. Indeed, those animals with little withdrawal activity still show a twofold burst in cell proliferation at day 7 of abstinence. Thus, alcohol dependence and recovery from dependence continues to alter hippocampal plasticity during abstinence. Because neurogenesis may contribute to hippocampal function and/or learning, memory, and mood, compensatory neurogenesis and the return of normal neurogenesis may also have an impact on hippocampal structure and function. For the first time, these data provide a neurobiological mechanism that may underlie the return of human cognitive function and brain volume associated with recovery from addiction.

Critical Care Aspects of Alcohol Abuse

The authors reviewed MEDLINE and references of major articles in the published literature over the last 30 years regarding the complications of alcohol abuse and discuss the critical care aspects of alcohol abuse. This article discusses the severe medical conditions associated with alcohol abuse that lead to admission to the medical intensive care unit. The clinical manifestations, pathophysiology, diagnostic studies, and management of these conditions are discussed in detail.

The role of corticotropin-releasing factor-like peptides in cannabis, nicotine, and alcohol dependence

The corticotropin-releasing factor (CRF)-like peptides, which include the mammalian peptides CRF, urocortin 1, urocortin 2, and urocortin 3, play an important role in orchestrating behavioral and physiological responses that may increase an organism's chance of survival when confronted with internal or external stressors. There is, however, evidence that a chronic overactivity of brain CRF systems under basal conditions may play a role in the etiology and maintenance of psychiatric disorders such as depression and anxiety disorders. In addition, there is evidence of a role for CRF-like peptides in acute and protracted drug abstinence syndromes and relapse to drug-taking behavior. This review focuses on the role of CRF-like peptides in the negative affective state associated with acute and protracted withdrawal from three widely abused drugs, cannabis, nicotine, and alcohol. In addition, we discuss the high comorbidity between stress-associated psychiatric disorders and drug dependence. A better understanding of the brain stress systems that may underlie psychiatric disorders, acute and protracted drug withdrawal, and relapse to drug-taking behavior may help in the development of new and improved pharmacotherapies for these widespread psychiatric disorders.

Neurobiological mechanisms in addictive and psychiatric disorders

The studies reviewed indicate that brain stress system play an important role in the acquisition and maintenance of drugs of abuse that target the brain's reward centers. In doing so, they may destabilize these areas, making the perception of pleasure more elusive and difficult to attain. Withdrawal from drugs of abuse leads to the activation of brain CRF systems that may produce the anxiogenic response associated with drug withdrawal. More research, however, is needed to investigate the role of brain stress systems and neuropeptides in other drug withdrawal symptoms such as anhedonia. A better understanding of the brain systems underlying drug withdrawal may help in the development of improved pharmacotherapies that can alleviate drug withdrawal symptoms. The second part of the article indicated that there is a very high comorbidity between depression and drug dependence. The reviewed studies suggest that depressed patients initiate drug-taking behavior to self-medicate the symptoms associated with their psychiatric disorder. Chronic use of drugs of abuse, however, may exacerbate the symptoms of pre-existing mental disorders and subsequently increase drug-taking behavior. Conversely, professional treatment of pre-existing psychiatric disorders may decrease the use of illicit substances.

The search for insight: Clients' psychological experiences of alcohol withdrawal in a voluntary, residential, health care setting

This study utilized a life history approach to describe clients' psychological experiences of the alcohol withdrawal process while voluntarily residing in a specialist alcohol withdrawal facility. Reflection on the past and anticipation of the future frequently occupied the thoughts of participants as they sought insight in to their lives. These insights were associated with a range of emotions that included embarrassment, shame, optimism, feelings of support and a sense of loss of control. The findings provide additional information on the human experience of alcohol withdrawal and, thus, increase empathy, understanding and knowledge. This increased understanding can be utilized to improve the quality of nursing care provided to this complex client group.

Suppression of Alcohol Delirium Tremens by Baclofen Administration: A Case Report

Delirium tremens (DT) is a clinical condition that appears in some patients affected by severe alcohol withdrawal syndrome (AWS). DT represents a serious complication, being characterized by elevated morbidity and mortality. Benzodiazepines are presently the drug of choice; however their use is related to several side effects. Baclofen is a stereoselective gamma-aminobutyric acid (GABAB) receptor agonist. Recent studies show that baclofen is able to suppress alcohol withdrawal symptoms. At present there are no data on the effects of baclofen administration in AWS complicated by DT. Here, we report a case of DT successfully treated with baclofen. This result indicates that the efficacy of baclofen in the treatment of DT should be examined in future clinical trials.

Risk factors for delirium tremens in trauma patients

BACKGROUND

The development of delirium tremens (DT) is associated with significant morbidity and mortality. This study identifies characteristics in trauma patients that are predictive of DT.

METHODS

Data from 1,856 trauma patients who either developed DT (n = 105) or had a positive blood alcohol concentration but did not develop DT (n = 1,751) were collected from the trauma registry of a Level I trauma center. Odds ratios were used to measure the association between predictors and DT as an outcome and between DT and length of stay as an outcome.

RESULTS

Of seven significant (p < 0.05) predictors of DT, four were retained after stepwise logistic regression: age >40, white race, burn as a mechanism of injury and, as a negative predictor, motor vehicle collision as a mechanism of injury. The DT group stayed an average of 6.5 and 5.2 days longer in the hospital and the intensive care unit, respectively, than those in the control group.

CONCLUSION

It is possible to determine which intoxicated trauma patients are at increased risk for DT using the above predictors. Patients who develop DT have worse outcomes than those who do not. Whether routine DT prophylaxis would improve outcomes among those at increased risk for DT is unknown, but deserves further study.

The effects of carbamazepine and lorazepam on single versus multiple previous alcohol withdrawals in an outpatient randomized trial

OBJECTIVE

Benzodiazepines are the mainstay of treatment for mild-to-moderate alcohol withdrawal in outpatient settings, but they can interact with alcohol, cause motor incoordination, or be abused. This study compared the therapeutic responses of the benzodiazepine lorazepam and the anticonvulsant carbamazepine for the outpatient treatment of acute alcohol withdrawal in terms of patients' previous detoxification histories, and compared the effects of these 2 medications on drinking behaviors in the immediate postdetoxification period.

DESIGN

This was a randomized double-blind trial comparing patient responses to carbamazepine and lorazepam across 2 levels of detoxification histories (0-1 or >or=2 previous medicated detoxifications).

SETTING

A university medical center substance abuse clinic in Charleston, SC.

PATIENTS

One hundred thirty-six patients in moderate alcohol withdrawal were randomized. Major exclusions were significant hepatic or hematologic abnormalities and use of medications that could alter withdrawal symptoms.

INTERVENTIONS

Patients received 600-800 mg of carbamazepine or 6-8 mg of lorazepam in divided doses on day 1 tapering to 200 mg of carbamazepine or 2 mg of lorazepam.

MAIN OUTCOME MEASURES

The Clinical Institute Withdrawal Assessment for Alcohol-Revised was used to assess alcohol withdrawal symptoms on days 1 through 5 and postmedication at days 7 and 12. Daily drinking was measured by patient report using a daily drinking log and a breath alcohol level with each visit. Side effects were recorded daily.

RESULTS

Carbamazepine and lorazepam were equally effective at decreasing the symptoms of alcohol withdrawal. In the post-treatment period, 89 patients drank on at least 1 day; on average, carbamazepine patients drank less than 1 drink per drinking day and lorazepam patients drank almost 3 drinks per drinking day (P =.003). Among those with multiple past detoxifications, the carbamazepine group drank less than 1 drink per day on average and the lorazepam group drank about 5 drinks per day on average (P =.033). Lorazepam-treated patients had a significant rebound of alcohol withdrawal symptoms post-treatment (P =.007) and the risk of having a first drink was 3 times greater (P =.04) than for carbamazepine-treated patients. Twenty percent of lorazepam-treated patients had dizziness, motor incoordination, or ataxia and did not recognize their impairment. Twenty percent of carbamazepine-treated patients reported pruritus but no rash.

CONCLUSIONS

Carbamazepine and lorazepam were both effective in decreasing the symptoms of alcohol withdrawal in relatively healthy, middle-aged outpatients. Carbamazepine, however, was superior to lorazepam in preventing rebound withdrawal symptoms and reducing post-treatment drinking, especially for those with a history of multiple treated withdrawals.

Somatic comorbidity of addicts: does hospitalization yield relevant findings?

The aim of this prospective study was to examine the severity and character of somatic comorbidity when addicted patients were admitted to hospital for detoxification. The study was conducted at a university-based psychiatric clinic. Somatic comorbidity was registered by laboratory, radiological and electrocardiographic parameters and by the amount of non-psychiatric consultations. Besides the number of patients with dual diagnosis interpreted as combination of addictive and psychiatric diseases was registered. A total of 111 consecutive patients (32 women) was divided into patients with alcohol dependence and patients with other addictive diseases including polydrug abuse and opiate dependence. Patients with alcohol dependence were characterized by an elevated heart rate and higher values for gamma-glutamyltransferase. No significant differences between groups could be found for the rate corrected QT interval and cardiothoracic ratio. Although viral liver disease was diagnosed in both groups patients with a history of injecting drug use were at greatest risk for hepatitis C. About one-third of all patients required consultant non-psychiatric treatment. Concomitant heart and pulmonary diseases were more pronounced in the alcohol dependence group. The findings emphasize that hospitalization of addicted patients yields relevant somatic morbidity which has an impact on cost and requires medically supervised detoxification programs.

Effects of nicotine on ethanol dependence and brain damage

Almost all alcoholics (80%-95%) smoke tobacco. When alcoholics binge, they achieve high, sustained blood alcohol levels, become physically dependent, and often suffer loss of cognition and other higher cortical functions. Nicotine could have a modulatory effect on ethanol drinking behavior and ethanol-induced brain damage through its cholinergic actions. To determine whether nicotine altered alcohol dependence, alcohol-induced brain damage, or both, a rat model of binge drinking was used to study the effects of nicotine on the alcohol withdrawal syndrome and its associated brain damage. After administration of the last dose of ethanol in a 4-day binge model, rats remained intoxicated for approximately 5 h, slowly returned to a neutral state, and entered a hyperexcited period, which peaked around 24 h and lasted a total of 60 h. Behavioral signs of withdrawal included splayed limbs, tremors, and seizures. Continuous transdermal nicotine did not alter the duration or severity of ethanol withdrawal. The 4-day binge ethanol treatment caused considerable brain damage in the perirhinal cortex, entorhinal cortex, ventral dentate gyrus, and olfactory bulb as visualized with amino cupric silver stain. Nicotine alone caused little or no brain damage and did not markedly alter binge ethanol-induced damage in cortical or hippocampal regions. In the olfactory bulb, nicotine reduced ethanol-induced brain damage. Although results of other studies seem to indicate that nicotine increases alcohol consumption, our findings indicate that nicotine does not markedly change the development of alcohol dependence or alcohol-induced cortical damage.

Alcohol withdrawal after open aortic surgery

This study was designed to test the hypothesis that unexpected alcohol withdrawal-like syndrome (AWLS) is more common following aortic, but not other, vascular or nonvascular procedures. All patients undergoing open aortic surgery at our institution in 1997 who survived at least 48 hr were identified, as were those undergoing carotid endarterectomy, infrainguinal bypass, and total colectomy. AWLS was defined as prolonged confusion or agitation and response to conventional treatment for withdrawal, providing that all other sources had been ruled out or a significant history was present. Our results show that, for unknown reasons, AWLS is more common after aortic surgery than after other vascular and high-stress, nonaortic intraabdominal procedures at our institution, and is associated with increased length of stay and morbidity. Because prophylaxis may improve outcome, better efforts to identify patients at risk are required.

Management of Acute Alcohol Withdrawal in the Inpatient Setting

Collaborative drug therapy management (CDTM) is a method for developing a patient-centered practice in which the pharmacist's activities are integrated with those of other health care providers. The goals of this continuing feature are to refine the concept of CDTM and provide patient-care applications from the authors' experience in Washington state. Questions or suggestions should be addressed to Timothy S. Fuller, FASHP, Fuller and Associates, 1948 Boyer Avenue East, Seattle, WA 98112-2924 (tel.206-860-8308). E-mail: timfuller@kendra.com

Moxonidine, a selective imidazoline-1 receptor agonist, suppresses the effects of ethanol withdrawal on the acoustic startle response in rats

BACKGROUND

There is a need for improved treatments for ethanol withdrawal in humans. Previously, ethanol withdrawal has been shown to enhance the acoustic startle response in rats. Because many ethanol withdrawal symptoms are caused by autonomic hyperactivity, we examined the effects of two antihypertensives, the imidazoline(I)(1) agonist moxonidine and the alpha(2)-adrenergic partial agonist clonidine, on the ethanol-withdrawal-enhanced acoustic startle response in rats. d-amphetamine-enhanced startle served as a positive control.

METHODS

Male, Long-Evans rats were made ethanol-dependent through unlimited access to liquid diet containing 6.7% v/v ethanol for 10 days. The concentration of ethanol was reduced to 3.3% v/v on the 11th day. On the 12th day, the rats received control diet. The acoustic startle response was tested 24 hours following the withdrawal of ethanol. Control rats were maintained on control liquid diet throughout the experiment.

RESULTS

As has been shown previously, withdrawal from the chronic ingestion of ethanol significantly enhanced the acoustic startle response. Pretreatment with moxonidine (0.01, 0.1, and 1.0 mg/kg, subcutaneously), but not clonidine (0.3, 1.0, and 3.0 mg/kg, subcutaneously), significantly attenuated the ethanol withdrawal-induced elevation of the acoustic startle response. Moxonidine did not suppress the elevation in the startle response caused by d-amphetamine.

CONCLUSIONS

These results indicate that I(1) receptors can play an important role in ethanol withdrawal and that moxonidine may be useful for the treatment of ethanol withdrawal in humans.

Alcohol withdrawal in the surgical patient: prevention and treatment

In the literature on AWS, there is repeated emphasis on performing a thorough preanesthesia assessment in patients with suspected chronic alcohol use. Because these patients are difficult to diagnose and to treat in surgical settings if complications arise, a multimodal approach is highly recommended (86). Ideally, AWS should be prevented by adequate prophylaxis. If AWS develops after surgery or trauma, immediate therapy is required. The symptoms of AWS can be controlled using the combination of a benzodiazepine (in Europe, also chlormethiazole) with haloperidol or clonidine. The drug regimens must be individualized and symptom-oriented to treat hallucinations and autonomic signs. Dosages are generally larger than those in detoxification units. Other approaches to modulate the neuroendocrine-immune axis in patients with an increased risk of postoperative infectious complications look promising but await controlled trials.

Medical causes of seizures

Seizures are commonly encountered in patients who do not have epilepsy. Factors that may provoke such seizures include organ failure, electrolyte imbalance, medication and medication withdrawal, and hypersensitive encephalopathy. There is usually one underlying cause, which may be reversible in some patients. A full assessment should be done to rule out primary neurological disease. Treatment of seizures in medically ill patients is aimed at correction of the underlying cause with appropriate short-term anticonvulsant medication. Phenytoin is ineffective in the management of seizures secondary to alcohol withdrawal, and in those due to theophylline or isoniazid toxicity. Control of blood pressure is important in patients with renal failure and seizures. Non-convulsive status epilepticus should be considered in any patient with confusion or coma of unclear cause, and electroencephalography should be done at the earliest opportunity. Most ill patients with secondary seizures do not have epilepsy, and this should be explained to patients and their families. Only those patients with recurrent seizures and uncorrectable predisposing factors need long-term treatment with anticonvulsant medication.