Intercurrent complications in chronic alcoholic men admitted to the intensive care unit following trauma

Cost-effectiveness analysis of deep brain stimulation for the treatment of alcohol use disorder and alcoholic liver disease

BACKGROUND

Alcohol use disorder (AUD) is a major public health concern and cause of mortality and morbidity. Alcohol-associated liver disease (ALD) is a debilitating complication of AUD, mitigated by abstinence from alcohol use. Deep brain stimulation (DBS) is emerging as a potential treatment for AUD. However, its cost-effectiveness compared to the standard medical treatment is unclear.

OBJECTIVE

To estimate the cost-effectiveness of DBS compared to medical management for patients with AUD and ALD.

METHODS

We utilized a decision analytic model based on published literature to conduct a cost-effectiveness analysis of costs and health outcomes for DBS and medical management in patients with AUD and ALD. We also carried out a threshold analysis to determine the probability of success necessary for DBS to be cost-effective. Costs were measured in 2024 US dollars and effectiveness in quality-adjusted life years (QALYs). We used a time horizon of 1-2 years and adopted a societal perspective.

RESULTS

Our results show that for AUD patients in general, DBS is not cost-effective at any DBS success rate. However, for advanced ALD patients, defined as fibrosis stage 3 or beyond DBS becomes cost-effective. For these patients, DBS is cost-effective over a two-year period at a $100,000 willingness-to-pay threshold at DBS success rates greater than 53 %. For advanced decompensated ALD patients, DBS is cost-effective over a one-year period at DBS success rate greater than 35 %.

CONCLUSION

Should it prove efficacious, DBS may be cost-effective for patients with AUD and ALD. Thus, future randomized controlled trials to evaluate its efficacy are warranted.

Incidence of Hospitalizations Involving Alcohol Withdrawal Syndrome in a Primary Care Population

Importance

Alcohol withdrawal syndrome (AWS) is an important cause and complication of hospitalizations. Although common and preventable, the incidence of AWS during hospitalizations is poorly described.

Objective

To evaluate the incidence and proportional incidence of hospitalizations involving AWS in an adult primary care population overall and across patient characteristics.

Design, Setting, and Participants

This retrospective cohort study used electronic health records and insurance claims from Kaiser Permanente Washington (KPWA) between July 1, 2018, and June 30, 2022. The study included adults with 1 or more primary care visits during this period or the year prior, where primary care included annual standardized alcohol screening using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C).

Exposures

Age, sex, race, Hispanic ethnicity, AUDIT-C scores, and comorbid diagnoses.

Main Outcome and Measures

Hospitalizations involving AWS were defined by diagnosis codes documented during hospitalizations (incidence numerator). Time enrolled in KPWA determined person-enrolled-years (incidence denominator). Proportional incidence was calculated as the incidence of hospitalizations involving AWS divided by the incidence of all-cause hospitalizations. Proportional incidence was also estimated for hospitalizations involving other common chronic conditions (chronic obstructive pulmonary disease, diabetes, heart failure, and hypertension), which were also defined using hospital diagnosis codes.

Results

Among 544 825 adults engaged in primary care (mean [SD] age, 47.0 [17.9] years; 310 069 [56.9%] female; 3656 [0.7%] American Indian or Alaska Native, 55 206 [10.1%] Asian, 25 406 [4.7%] Black, 5204 [1.0%] Native Hawaiian or Other Pacific Islander, 365 780 [67.1%] White, 19 791 [3.6%] multiracial, 15 963 [2.9%] other races, and 53 819 [9.9%] unknown race; 33 987 [6.2%] Hispanic, 414 269 [76.0%] not Hispanic, and 96 569 [17.7%] unknown ethnicity), incidence of hospitalizations involving AWS was 169 (95% CI, 159-179) per 100 000 person-enrolled-years overall but as high as 15 347 (95% CI, 13 502-17 331) in patients with other alcohol-attributable diagnoses. The proportional incidence of hospitalizations involving AWS was 2.3% overall, with variation by age, sex, and AUDIT-C scores (eg, 9%-11% in male patients aged 30-49 years and 23%-44% in patients with high-risk AUDIT-C scores of 7-12 points). In most cases, among adults younger than 60 years, proportional incidence of hospitalizations involving AWS matched or surpassed that of other common chronic conditions (chronic obstructive pulmonary disease, diabetes, heart failure, and hypertension).

Conclusions and Relevance

In this cohort study of a large primary care population served by an integrated health system, AWS hospitalizations were common, especially in male patients, younger age groups, and individuals with high-risk alcohol use. During hospitalizations, the burden of AWS was similar to or exceeded complications of other chronic diseases that receive greater medical attention.

Cost-Effectiveness Analysis of Deep Brain Stimulation for the Treatment of Alcohol Use Disorder and Alcoholic Liver Disease

Background

Alcohol use disorder (AUD) is a major public health concern and cause of mortality and morbidity. Alcohol-associated liver disease (ALD) is a debilitating complication of AUD, mitigated by abstinence from alcohol use. Deep brain stimulation (DBS) is emerging as a potential treatment for AUD. However, its cost-effectiveness compared to the standard medical treatment is unclear.

Objective

To estimate the cost-effectiveness of DBS compared to medical management for patients with AUD and ALD.

Methods

We utilized a decision analytic model based on published literature to conduct a cost-effectiveness analysis of costs and health outcomes for DBS and medical management in patients with AUD and ALD. We also carried out a threshold analysis to determine the probability of success necessary for DBS to be cost-effective. Costs were measured in 2024 US dollars and effectiveness in quality-adjusted life years (QALYs). We used a time horizon of 1-2 years and adopted a societal perspective.

Results

Our results show that for AUD patients in general, DBS is not cost-effective at any DBS success rate. However, for advanced ALD patients, defined as fibrosis stage 3 or beyond DBS becomes cost-effective. For these patients, DBS is cost-effective over a two-year period at a $100,000 willingness-to-pay threshold at DBS success rates greater than 53%. For advanced decompensated ALD patients, DBS is cost-effective over a one-year period at DBS success rate greater than 35%.

Conclusion

Should it prove efficacious, DBS may be cost-effective for patients with AUD and ALD. Thus, future randomized controlled trials to evaluate its efficacy are warranted.

Physical Activity, Alcohol, and Cigarette Use in Urological Cancer Patients over Time since Diagnosis

Urological cancers represent a substantial global public health concern, exerting far-reaching effects on both individuals and their families. There is an urgent need to comprehensively understand the transformations in patients' lifestyles and behaviors, given their critical role in the treatment process and overall well-being. This study, involving 128 urological cancer patients, aims to investigate changes in physical activity levels, problematic drinking behaviors assessed through the Alcohol Use Disorders Identification Test (AUDIT), and smoking habits assessed using the Fagerström Test for Nicotine Dependence (FTND) over four distinct time intervals over the subsequent three years from the time of diagnosis and among individuals diagnosed more than three years ago. The results reveal a significant decrease in physical activity levels between study intervals (p < 0.0001), declining from 69% to 45% between the first and second post-diagnosis assessments. Furthermore, the highest levels of problematic substance use, indicated by mean scores, were noted in the first year following diagnosis (AUDIT: 4.20, p = 0.01; FTND: 4.83, p = 0.08). Given the significant impact of physical activity on the prospects of recovery, it is imperative to delve more deeply into the factors contributing to this decline and devise targeted interventions for its improvement. In the context of substance use, it is essential to ascertain whether the initially high levels are a result of coping with the cancer diagnosis or represent a turning point at which patients modify their behaviors and cease their addiction. A more thorough understanding of this phenomenon would enhance the effectiveness of precisely focused interventions.

Pharmacological reversal of post-transcriptional alterations implicated in alcohol-induced alveolar macrophage dysfunction

Alcohol use disorders (AUD) cause alveolar macrophage (AM) immune dysfunction and increase risk of lung infections. Excessive alcohol use causes AM oxidative stress, which impairs AM phagocytosis and pathogen clearance from the alveolar space. Alcohol induces expression of NADPH oxidases (Noxes), primary sources of oxidative stress in AM. In contrast, alcohol decreases AM peroxisome proliferator-activated receptor gamma (PPARγ), a critical regulator of AM immune function. To explore the underlying molecular mechanisms for these effects of alcohol, we hypothesized that ethanol promotes CCAAT/enhancer-binding protein beta (C/EBPβ)-mediated suppression of Nox-related microRNAs (miRs), in turn enhancing AM Nox expression, oxidative stress, and phagocytic dysfunction. We also hypothesized that PPARγ activation with pioglitazone (PIO) would reverse alcohol-induced C/EBPβ expression and attenuate AM oxidative stress and phagocytic dysfunction. Cells from the mouse AM cell line (MH-S) were exposed to ethanol in vitro or primary AM were isolated from mice fed ethanol in vivo. Ethanol enhanced C/EBPβ expression, decreased Nox 1-related miR-1264 and Nox 2-related miR-107 levels, and increased Nox1, Nox2, and Nox 4 expression in MH-S cells in vitro and mouse AM in vivo. These alcohol-induced AM derangements were abrogated by loss of C/EBPβ, overexpression of miRs-1264 or -107, or PIO treatment. These findings identify C/EBPβ and Nox-related miRs as novel therapeutic targets for PPARγ ligands, which could provide a translatable strategy to mitigate susceptibility to lung infections in people with a history of AUD. These studies further clarify the molecular underpinnings for a previous clinical trial using short-term PIO treatment to improve AM immunity in AUD individuals.

Medication prescribing for alcohol use disorders during alcohol-related encounters in a Colorado regional healthcare system

RATIONALE

Investigations show that medications for alcohol use disorders (MAUD) reduce heavy drinking and relapses. However, only 1.6% of individuals with alcohol use disorders (AUD) receive MAUD across care settings. The epidemiology of MAUD prescribing in the acute care setting is incompletely described. We hypothesized that MAUD would be under prescribed in inpatient acute care hospital settings compared to the outpatient, emergency department (ED), and inpatient substance use treatment settings.

METHODS

We evaluated electronic health record (EHR) data from adult patients with an International Classification of Diseases, 10th revision (ICD-10) alcohol-related diagnosis in the University of Colorado Health (UCHealth) system between January 1, 2016 and 31 December, 2019. Data from patients with an ICD-10 diagnosis code for opioid use disorder and those receiving MAUD prior to their first alcohol-related episode were excluded. The primary outcome was prescribing of MAUD, defined by prescription of naltrexone, acamprosate, and/or disulfiram. We performed bivariate and multivariate analyses to identify independent predictors of MAUD prescribing at UCHealth.

RESULTS

We identified 48,421 unique patients with 136,205 alcohol-related encounters at UCHealth. Encounters occurred in the ED (42%), inpatient acute care (17%), inpatient substance use treatment (18%), or outpatient primary care (12%) settings. Only 2270 (5%) patients received MAUD across all settings. Female sex and addiction medicine consults positively predicted MAUD prescribing. In contrast, encounters outside inpatient substance use treatment, Hispanic ethnicity, and black or non-white race were negative predictors of MAUD prescribing. Compared to inpatient substance use treatment, inpatient acute care hospitalizations for AUD was associated with a 93% reduced odds of receiving MAUD.

CONCLUSIONS

AUD-related ED and inpatient acute care hospital encounters in our healthcare system were common. Nevertheless, prescriptions for MAUD were infrequent in this population, particularly in inpatient settings. Our findings suggest that the initiation of MAUD for patients with alcohol-related diagnoses in acute care settings deserves additional evaluation.

Pioglitazone Reverses Alcohol-Induced Alveolar Macrophage Phagocytic Dysfunction

Alcohol use disorders (AUD) increase susceptibility to respiratory infections by 2- to 4-fold in part because of impaired alveolar macrophage (AM) immune function. Alcohol causes AM oxidative stress, diminishing AM phagocytic capacity and clearance of microbes from the alveolar space. Alcohol increases AM NADPH oxidases (Noxes), primary sources of AM oxidative stress, and reduces peroxisome proliferator-activated receptor γ (PPARγ) expression, a critical regulator of AM immune function. To investigate the underlying mechanisms of these alcohol-induced AM derangements, we hypothesized that alcohol stimulates CCAAT/enhancer-binding protein β (C/EBPβ) to suppress Nox-related microRNAs (miRs), thereby enhancing AM Nox expression, oxidative stress, and phagocytic dysfunction. Furthermore, we postulated that pharmacologic PPARγ activation with pioglitazone would inhibit C/EBPβ and attenuate alcohol-induced AM dysfunction. AM isolated from human AUD subjects or otherwise healthy control subjects were examined. Compared with control AM, alcohol activated AM C/EBPβ, decreased Nox1-related miR-1264 and Nox2-related miR-107, and increased Nox1, Nox2, and Nox4 expression and activity. These alcohol-induced AM derangements were abrogated by inhibition of C/EBPβ, overexpression of miR-1264 or miR-107, or pioglitazone treatment. These findings define novel molecular mechanisms of alcohol-induced AM dysfunction mediated by C/EBPβ and Nox-related miRs that are amenable to therapeutic targeting with PPARγ ligands. These results demonstrate that PPARγ ligands provide a novel and rapidly translatable strategy to mitigate susceptibility to respiratory infections and related morbidity in individuals with AUD.

Prevalence and Variation of Clinically Recognized Inpatient Alcohol Withdrawal Syndrome in the Veterans Health Administration

OBJECTIVES

No prior study has evaluated the prevalence or variability of alcohol withdrawal syndrome (AWS) in general hospitals in the United States.

METHODS

This retrospective study used secondary data from the Veterans Health Administration (VHA) to estimate the documented prevalence of clinically recognized AWS among patients engaged in VHA care who were hospitalized during fiscal year 2013. We describe variation in documented inpatient AWS by geographic region, hospital, admitting specialty, and inpatient diagnoses using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and/or procedure codes recorded at hospital admission, transfer, or discharge.

RESULTS

Among 469,082 eligible hospitalizations, the national prevalence of documented inpatient AWS was 5.8% (95% confidence interval [CI] 5.2%-6.4%), but there was marked variation by geographic region (4.3%-11.2%), hospital (1.4%-16.1%), admitting specialty (0.7%-19.0%), and comorbid diagnoses (1.3%-38.3%). AWS affected a high proportion of psychiatric admissions (19.0%, 95% CI 17.5%-20.4%) versus Medical (4.4%, 95% CI 4.0%-4.8%) or surgical (0.7%, 95% CI 0.6%-0.8%); though by volume, medical admissions represented the majority of hospitalizations complicated by AWS (n = 13,478 medical versus n = 12,305 psychiatric and n = 595 surgical). Clinically recognized AWS was also common during hospitalizations involving other alcohol-related disorders (38.3%, 95% CI 35.8%-40.8%), other substance use conditions (19.3%, 95% CI 17.7%-20.9%), attempted suicide (15.3%, 95% CI 13.0%-17.6%), and liver injury (13.9%, 95% CI 12.6%-15.1%).

CONCLUSIONS

AWS was commonly recognized and documented during VHA hospitalizations in 2013, but varied considerably across inpatient settings. This clinical variation may, in part, reflect differences in quality of care and warrants further, more rigorous investigation.

Impact of blood alcohol concentration on hematologic and serum chemistry parameters in trauma patients: Analysis of data from a high-volume level 1 trauma center

Background

Alcohol (EtOH) intoxication is common among trauma patients. While providers are familiar with the clinical aspects of acute EtOH intoxication, few studies have investigated the effects that EtOH levels may have on common laboratory markers. The aim of this study was to identify hematologic and serum chemistry parameters that may be affected by the blood alcohol concentration (BAC), hypothesizing that BAC influences both comprehensive blood count (CBC) and comprehensive serum chemistry (CSC) components.

Methods

We performed an IRB-exempt institutional registry review of all trauma patients who had serum EtOH levels measured between January 2009 and June 2015. Data for each patient included: patient demographics, BAC determinations (g/dL), injury mechanism/severity information (ISS), hematologic parameters included in a CBC (hemoglobin, hematocrit, white blood cell [WBC] count, and platelet count), and CSC panel components (sodium, potassium, chloride, bicarbonate, blood urea nitrogen [BUN], creatinine, glucose, and hepatic function tests). Laboratory markers were contrasted across predefined categories of BAC: <0.10%, 10%-15%, 15%-20%, and >20%. Statistical comparisons were performed using SPSS 18 Software, employing analysis-of-covariance with adjustments performed for the patient demographics and injury characteristics. Statistical significance was set at α = 0.005.

Results

A total of 2167 patient records were analyzed. After adjusting for patient age, gender, and ISS, increasing BAC correlated with 4.8% increase in hemoglobin and 32.5% higher hematocrit (both P < 0.001), as well as a 27.8% decrease in WBC count. There were also statistically significant differences between low (<0.10%) and high (>0.20%) BAC groups across multiple CSC parameters, with largest impact on BUN (32.2% decrease); creatinine (31.5% decrease); and glucose (13.6% decrease) values. Elevated BAC (>0.20 g/dL) was also associated with 81.8% increase in total bilirubin, and hepatic transaminases were elevated among patients with BAC >0.10.

Conclusion

Due to the paucity of literature relating to the effects of BAC on serum hematologic and biochemical markers in acute trauma, this study provides a foundation for further exploration of these relationships and their clinical impact. More specifically, we found that BAC levels significantly influenced key laboratory markers, suggesting that acute EtOH intoxication may lead to hematologic and CSC changes that are potentially important in acute trauma management by frontline clinical staff.

Correlation between Alcohol Use Disorders, Blood Alcohol Content, and Length of Stay in Trauma Patients

Background:

Patients with an alcohol use disorder (AUD) have an increased risk of developing complications during their hospital stays; however, how AUD impacts the length of stay (LOS) and the utilization of hospital resources remains inconclusive.

Aim:

This study aimed to identify the associations between AUD, defined by self-reported alcohol consumption, blood alcohol content (BAC), and hospital LOS (HLOS) including intensive care unit (ICU) LOS in the trauma patient population.

Study Design:

We conducted a retrospective study analyzing data obtained from 2010 to 2018 at a university-based, level-one trauma emergency department. We identified 1689 adult trauma patients who completed the AUDs identification test (AUDIT) and were admitted to the hospital. We retrieved BAC, age, gender, LOS, and injury severity score (ISS) from the patient charts. The independent samples' median test was used to assess the association of HLOS and ICULOS with ISS, BAC levels, or AUDIT scores.

Results:

ISS was directly associated with higher HLOS (P < 0.001) and ICULOS (P < 0.001); however there was no statistically significant association between AUDIT scores and ICULOS (P = 0.21) or HLOS (P = 0.86). There was also no statistically significant association between BAC and HLOS (P = 0.09) or ICULOS (P = 0.07).

Conclusions:

Our study found no associations between AUDIT, BAC, and both hospital and ICU LOS in trauma patients even though the literature supported an increased risk of medical complications in the AUD patients.

Anti-inflammatory Effects of Alcohol Are Associated with JNK-STAT3 Downregulation in an In Vitro Inflammation Model in HepG2 Cells

Background

In several preclinical and in vitro models of acute inflammation, alcohol (ethanol, EtOH) has been described as an immunomodulatory agent. Similarly, in different pathologies, clinical observations have confirmed either pro- or anti-inflammatory effects of EtOH. The liver plays an important role in immunity and alcohol metabolism; therefore, we analysed dose- and time-dependent effects of EtOH on the inflammatory response of human liver cells in an in vitro model of acute inflammation.

Methods

HepG2 cells were stimulated with IL-1β and subsequently exposed to EtOH in a low or high dose (85 mM, LoD or 170 mM, HiD) for 1 h (acute exposure) or 72 h (prolonged exposure). IL-6 and TNF-α release was determined by ELISA. Cell viability, adhesion of isolated neutrophils to HepG2 monolayers, their ICAM-1 expression, and the activation of stress-induced protein kinase/c-Jun N-terminal kinase (SAPK/JNK) or signal transducer and activator of transcription 3 (STAT3) were analysed.

Results

In this experimental design, EtOH did not markedly change the cell viability. Acute and prolonged exposure to EtOH significantly reduced dose-independent IL-1β-induced IL-6 and TNF-α release, as well as adhesion capacity to pretreated HepG2 cells. Acute exposure to EtOH significantly decreased the percentage of ICAM-1-expressing cells. IL-1β stimulation notably increased the activation of SAPK/JNK. However, low-dose EtOH exposure reduced this activation considerably, in contradiction to high-dose EtOH exposure. Acute exposure to LoD EtOH significantly diminished the IL-1β-induced STAT3 activation, whereas an acute exposure of cells to either HiD EtOH or in a prolonged setting showed no effects on STAT3 activation.

Conclusion

EtOH exerts anti-inflammatory potential in this in vitro model of hepatic inflammation. These effects are associated with the reduced activation of JNK/STAT3 by EtOH, particularly in the condition of acute exposure to low-dose EtOH.

Use of Electronic Health Record Data to Estimate the Probability of Alcohol Withdrawal Syndrome in a National Cohort of Hospitalized Veterans

OBJECTIVES

Inpatient alcohol withdrawal syndrome (AWS) is common and early treatment improves outcomes, but no prior study has used electronic health record (EHR) data, available at admission, to predict the probability of inpatient AWS. This study estimated the probability of inpatient AWS using prior-year EHR data, hypothesizing that documented alcohol use disorder (AUD) and AWS would be strongly associated with inpatient AWS while exploring associations with other patient characteristics.

METHODS

The study investigated patients hospitalized ≥24 hours on medical services in the Veterans Health Administration during 2013 using EHR data extracted from the Veterans Health Administration Corporate Data Warehouse. ICD-9-CM diagnosis code, demographic, and healthcare utilization data documented in the year before admission defined prior-year AUD, AWS, and other factors associated with inpatient AWS. The primary outcome, inpatient AWS, was defined by inpatient ICD-9-CM codes.

RESULTS

The unadjusted probability of AWS was 5.0% (95% CI 4.5%-5.4%) among 209,151 medical inpatients overall, 26.4% (95% CI 24.4%-28.4%) among those with prior-year AUD, and 62.5% (95% CI 35.2%-39.7%) among those with prior-year AWS. Of those with AWS, 86% had documented prior-year AUD and/or AWS. Other patient characteristics associated with increased probability of inpatient AWS (P < 0.001) were: male sex, single relationship status, homelessness, seizure, and cirrhosis.

CONCLUSIONS

Although inpatient providers often use history to predict AWS, this is the first study in hospitalized patients to inform and validate this practice, showing that prior-year diagnosis of AUD and/or AWS in particular, can identify the majority of inpatients who should be monitored for AWS.

Epidural analgesia in ICU chest trauma patients with fractured ribs: retrospective study of pain control and intubation requirements

BACKGROUND

Nonintubated chest trauma patients with fractured ribs admitted to the intensive care unit (ICU) are at risk for complications and may require invasive ventilation at some point. Effective pain control is essential. We assessed whether epidural analgesia (EA) in patients with fractured ribs who were not intubated at ICU admission decreased the need for invasive mechanical ventilation (IMV). We also looked for risk factors for IMV.

STUDY DESIGN AND METHODS

This retrospective, observational, multicenter study conducted in 40 ICUs in France included consecutive patients with three or more fractured ribs who were not intubated at admission between July 2013 and July 2015.

RESULTS

Of the 974 study patients, 788 were included in the analysis of intubation predictors. EA was used in 130 (16.5%) patients, and 65 (8.2%) patients required IMV. Factors independently associated with IMV were chronic respiratory disease (P = 0.008), worse SAPS II (P < 0.0001), flail chest (P = 0.02), worse Injury Severity Score (P = 0.0003), higher respiratory rate at admission (P = 0.02), alcohol withdrawal syndrome (P < 0.001), and noninvasive ventilation (P = 0.04). EA was not associated with decreases in IMV requirements, median numerical rating scale pain score, or intravenous morphine requirements from day 1 to day 7.

CONCLUSIONS

EA was not associated with a lower risk of IMV in chest trauma patients with at least 3 fractured ribs, moderate pain, and no intubation on admission. Further studies are needed to clarify the optimal pain control strategy in chest trauma patients admitted to the ICU, notably those with severe pain or high opioid requirements.

The Utility of Carbohydrate-Deficient Transferrin in Identifying Chronic Alcohol Users in the Injured Patient: Expanding the Toolkit

BACKGROUND

Alcohol use remains abundant in patients with traumatic injury. Previous studies have suggested that serum carbohydrate-deficient transferrin (%dCDT) levels, relative to blood alcohol levels (BALs), may better differentiate episodic binge drinkers from sustained heavy consumers in admitted patients with traumatic injury. We characterized %dCDT levels and BAL levels to differentiate binge drinkers from sustained heavy consumers in admitted trauma patients and their associations with outcomes.

METHODS

This prospective, cross-sectional, observational study assessed %dCDT and BAL levels in admitted male and female patients with traumatic injury (≥18 y) at an American College of Surgeons Committee on Trauma level-1 center from July 2014 to June 2016. We designated patients with %dCDT levels ≥1.7% (CDT+) as chronic alcohol users and dichotomized acutely intoxicated patients using three different BAL-level thresholds. Primary outcomes included in-hospital complications, along with prolonged ventilation and intensive care unit length of stay, both defined as the top decile. Secondary outcomes included rates of drug or alcohol withdrawal and all-cause mortality. Analyses were adjusted for clinical factors.

RESULTS

We studied 715 patients (77.5% men, 60.6% ≤ 40 y of age, median Injury Severity Score: 14, 41.7% motor vehicle crashes, 17.9% gunshot wounds, 11.1% falls). While 31.0% were CDT+, 48.7% were BAL>0. After adjusting for CDT levels, BAL levels >0, >100, or >200 were not associated with adverse outcomes. However, CDT+ relative to patients with CDT were associated with complications (adjusted odds ratio: 1.96 [1.24-3.09]), prolonged ventilation days (3.23 [1.08-9.65]), and prolonged intensive care unit stays (2.83 [1.20-6.68]).

CONCLUSIONS

In this 2-year prospective, cross-sectional, and observational study, we found that %dCDT levels, relative to BAL levels, may better stratify admitted patients with traumatic injury into acute versus chronic alcohol users, identifying those at higher risk for in-hospital complications.

Alcohol Use Disorder Is Bad for Broken Ribs: A Nationwide Analysis of 19,638 Patients With Rib Fractures

BACKGROUND

Alcohol use disorder (AUD) has deleterious effects on many organ systems. The aim of our study was to assess the impact of AUD on outcomes in patients with rib fractures. We hypothesized that AUD is associated with increased risk adverse outcomes.

METHODS

We performed a 2013-2014 retrospective analysis of all adult trauma patients diagnosed with rib fractures from the American College of Surgeons-Trauma Quality Improvement Program database. We excluded patients who were acutely intoxicated with alcohol. Patients were stratified into two groups: AUD + and AUD -. A 1:1 ratio propensity score matching for demographics, admission vitals, injury severity, smoking status, operative intervention, and number of rib fractures was performed. Outcome measures were in-hospital complications, mortality, hospital and intensive care unit length of stay, and ventilator days.

RESULTS

We matched 19,638 patients (AUD +:9,819, AUD -:9819). Mean age was 53 ± 22y, and median injury severity score was 15[10-20]. Matched groups were similar in age (P = 0.18), smoking status (P = 0.82), injury severity score (P = 0.28), chest Abbreviated Injury Scale (P = 0.24), and number of rib fractures (2[1-4] versus 2[1-4], P = 0.86). Alcoholic patients had higher rates of pneumonia (18.1% versus 9.2%, P < 0.01), unplanned intubation (18.5% versus 9.7, P < 0.001), sepsis (10.8% versus 6.3%, P < 0.001), acute respiratory distress syndrome (12.2% versus 7.4%, P < 0.001), and mortality (8.0 versus 5.7%, P < 0.001). Patients with AUD spent more days in the hospital and intensive care unit . There was no difference in ventilator days between the two groups.

CONCLUSIONS

Patients with AUD and rib fractures had higher rates of adverse events than patients without AUD. Early identification of patients with rib fractures with AUD may allow better resource allocation and help improve outcomes.

LEVEL OF EVIDENCE

Level III prognostic.

Intermittent hypoxia training: Powerful, non-invasive cerebroprotection against ethanol withdrawal excitotoxicity

Ethanol intoxication and withdrawal exact a devastating toll on the central nervous system. Abrupt ethanol withdrawal provokes massive release of the excitatory neurotransmitter glutamate, which over-activates its postsynaptic receptors, causing intense Ca2+ loading, p38 mitogen activated protein kinase activation and oxidative stress, culminating in ATP depletion, mitochondrial injury, amyloid β deposition and neuronal death. Collectively, these mechanisms produce neurocognitive and sensorimotor dysfunction that discourages continued abstinence. Although the brain is heavily dependent on blood-borne O2 to sustain its aerobic ATP production, brief, cyclic episodes of moderate hypoxia and reoxygenation, when judiciously applied over the course of days or weeks, evoke adaptations that protect the brain from ethanol withdrawal-induced glutamate excitotoxicity, mitochondrial damage, oxidative stress and amyloid β accumulation. This review summarizes evidence from ongoing preclinical research that demonstrates intermittent hypoxia training to be a potentially powerful yet non-invasive intervention capable of affording robust, sustained neuroprotection during ethanol withdrawal.

Age and Number of Surgeries Increase Risk for Complications in Polytrauma Patients with Operative Maxillofacial Fractures

BACKGROUND

Poly-trauma patients often sustain complex head/neck injuries requiring prolonged hospitalizations and multiple operations. Few studies have evaluated the associated injury patterns and risk factors for poor clinical outcomes.

METHODS

Consecutive poly-trauma patients with operative maxillofacial fractures treated at a level 1 trauma medical center between 1995 and 2013 were evaluated. Concomitant head/neck injuries to identify potential injury patterns were numerated. Lastly, a multivariate analysis was performed to determine independent risk factors for complications during the acute hospitalization period.

RESULTS

Totally, 232 poly-trauma patients presented with operative maxillofacial fractures, while 38.8% of patients had a secondary maxillofacial fracture, 16.4% had intracranial hemorrhage, 23.7% had skull fractures, and 12.1% had spinal fractures. The rate of complication during admission was 28.3%. Multivariate analysis revealed advanced patient age and increased number of operations to predict the rate of complication. Patients requiring more than one operation had a 1.8-fold increase in complication rate (p<0.01) and older patients had a 4.5% increase in complication rate (p<0.05) for every year of increased age.

CONCLUSION

Poly-trauma patients have a high incidence of secondary maxillofacial fractures, concomitant head/neck injury, and inpatient complication rate. Knowledge of associated injury patterns can help increased awareness and can guide physician decision-making to avoid missed/delayed injuries.

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

STUDY OBJECTIVE

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.

DESIGN

Retrospective pre- and postprotocol implementation study.

SETTING

A 36-bed closed medical ICU (MICU) at a large tertiary care teaching hospital in an urban setting.

PATIENTS

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.

MEASUREMENTS AND MAIN RESULTS

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).

CONCLUSION

Implementation of YAWP was associated with a decreased risk of MICU intubation in patients at risk for AWS.

Identifying chronic heavy alcohol use in emergency general surgery patients: a pilot study

Background

Chronic heavy alcohol (CHA) use has been associated with perioperative complications. Emergency general surgery (EGS) patients are not routinely screened for CHA. If screened, it is usually for hazardous use of alcohol, using a survey such as the Alcohol Use Disorders Identification Test (AUDIT). This study screened EGS patients for CHA use using serum carbohydrate-deficient transferrin (%dCDT) level, a biomarker that has been validated as an indicator for CHA use, as well as the AUDIT. The purpose of this study was to determine the percent of EGS patients with CHA (as indicated by elevated %dCDT), and the relationship between %dCDT and AUDIT. Secondary aims included comparing the characteristics of EGS patients with and without CHA use, and evaluating the association of CHA use with negative clinical outcomes.

Methods

EGS patients aged 21 and older admitted to the general surgery inpatient service of a tertiary hospital from July 2014 to June 2016 were invited to participate in this study. %dCDT levels above 1.7% were considered positive for CHA use, as were AUDIT scores ≥8.

Results

195 EGS patients were screened for inclusion and 91 (46.7%) agreed to participate. 14 (15.4%) were positive for hazardous alcohol use on AUDIT and 5 (5.5%) were positive for CHA by %dCDT. Positive predictive value of AUDIT for CHA was 21.4%. There was no correlation between positive scores on AUDIT and %dCDT.

Discussion

Identifying at risk patients early on in their hospital course may allow clinicians to institute treatments to mitigate and/or circumvent complications in such patients. This pilot study determined that 17.6% of participating EGS patients were positive for some type of alcohol misuse, but only 5.5% had CHA. Further research is needed to determine whether routine use of %dCDT would be beneficial in reducing perioperative complications in this patient population.

Level of evidence

III (diagnostic test).

A comparison of alcohol positive and alcohol negative trauma patients requiring an emergency laparotomy

BACKGROUND

The effect of alcohol exposure on patients undergoing a laparotomy for trauma is unknown. The purpose of this study was to compare outcomes of morbidity and mortality between alcohol positive and alcohol negative trauma patients who required emergent laparotomies using the National Trauma Data Bank (NTDB).

METHODS

A retrospective database analysis was performed using 28,354 NTDB incident trauma cases, from 2007 through 2012, who had been tested for alcohol and who required abdominal operations (using ICD-9-CM procedure codes) within 24h of presentation. Variables used: age, gender, admission year, alcohol presence, ISS, GCS, injury type & mechanism, discharge status, hospital LOS, ICU stay, ventilator use, and hospital complications.

RESULTS

In adjusted analyses, there were no statistically significant differences between the alcohol positive and alcohol negative cohorts when evaluating in-hospital mortality (OR, 0.93; 95% CI: 0.84-1.03), likelihood of earlier hospital discharge (HR, 1.02; 95% CI: 0.99-1.05), and the all-inclusive category of in-hospital complications (OR, 1.04; 95% CI: 0.97-1.12).

CONCLUSIONS

After adjusting for age, gender, admission year, ISS, GCS, and injury mechanism, there were no major differences between the alcohol positive and alcohol negative cohorts when it came to in-hospital mortality, likelihood of earlier hospital discharge, and most of the in-hospital complications measured among adult trauma patients requiring emergency laparotomies.

A 5-Year Follow-Up of a Cohort of Italian Alcoholics: Hospital Admissions and Overall Survival

BACKGROUND

Alcohol use disorders (AUDs), including alcohol dependence and alcohol abuse defined according to specific DSM-IV and ICD-10 criteria, can be potentially lethal, because they are associated with several medical and psychiatric conditions. This study aimed to describe the causes of hospitalization of a large cohort of subjects with alcohol dependence (alcoholics) enrolled in Florence (Italy) over a 5-year follow-up period and to evaluate the effect of hospitalization on overall survival.

METHODS

One thousand one hundred and thirty alcoholics, newly diagnosed from 1997 to 2001, were linked to the Regional Mortality Registry for update of vital status as of December 31, 2006, and to the Hospital Discharge electronic archives of the Regional Health System of Tuscany to verify hospital admissions (HAs) during the 5-year postcohort enrollment follow-up. Kaplan-Meier survival and Cox regression analyses were performed to evaluate any association of HA with overall survival.

RESULTS

A total of 3,916 new hospitalizations occurred during the 5-year follow-up. Most alcoholics (70.6%) reported at least 1 new hospitalization, with a first hospitalization rate of 61.7 per 100 person-years in the first year of follow-up. The mean number of hospitalizations per admitted subject was 4.87 (SD 7.4), and mean length of hospital stay was 8.5 days (SD 11.3). The main causes of hospitalization were mental disorders and diseases of the digestive system, as well as accidents or violence. Among those alcoholics alive after 1 year of follow-up, a significantly increased risk of dying in the following years could be predicted by early hospitalization in the 12 months preceding (hazard ratio [HR] 1.73; 95% confidence interval [CI] 1.15 to 2.60) or following (HR 3.59; 95% CI 2.31 to 5.61) enrollment in the cohort.

CONCLUSIONS

Our results confirm the association of AUDs with several serious medical conditions. This fact may be responsible for a high impact on health resource utilization and high social costs. Early hospitalization significantly predicts vital status at 5 years.

Influence of Volatile Anesthesia on the Release of Glutamate and other Amino Acids in the Nucleus Accumbens in a Rat Model of Alcohol Withdrawal: A Pilot Study

Background

Alcohol withdrawal syndrome is a potentially life-threatening condition, which can occur when patients with alcohol use disorders undergo general anesthesia. Excitatory amino acids, such as glutamate, act as neurotransmitters and are known to play a key role in alcohol withdrawal syndrome. To understand this process better, we investigated the influence of isoflurane, sevoflurane, and desflurane anesthesia on the profile of excitatory and inhibitory amino acids in the nucleus accumbens (NAcc) of alcohol-withdrawn rats (AWR).

Methods

Eighty Wistar rats were randomized into two groups of 40, pair-fed with alcoholic or non-alcoholic nutrition. Nutrition was withdrawn and microdialysis was performed to measure the activity of amino acids in the NAcc. The onset time of the withdrawal syndrome was first determined in an experiment with 20 rats. Sixty rats then received isoflurane, sevoflurane, or desflurane anesthesia for three hours during the withdrawal period, followed by one hour of elimination. Amino acid concentrations were measured using chromatography and results were compared to baseline levels measured prior to induction of anesthesia.

Results

Glutamate release increased in the alcohol group at five hours after the last alcohol intake (p = 0.002). After 140 min, desflurane anesthesia led to a lower release of glutamate (p < 0.001) and aspartate (p = 0.0007) in AWR compared to controls. GABA release under and after desflurane anesthesia was also significantly lower in AWR than controls (p = 0.023). Over the course of isoflurane anesthesia, arginine release decreased in AWR compared to controls (p < 0.001), and aspartate release increased after induction relative to controls (p_20min = 0.015 and p_40min = 0.006). However, amino acid levels did not differ between the groups as a result of sevoflurane anesthesia.

Conclusions

Each of three volatile anesthetics we studied showed different effects on excitatory and inhibitory amino acid concentrations. Under desflurane anesthesia, both glutamate and aspartate showed a tendency to be lower in AWR than controls over the whole timecourse. The inhibitory amino acid arginine increased in AWR compared to controls, whereas GABA levels decreased. However, there were no significant differences in amino acid concentrations under or after sevoflurane anesthesia. Under isoflurane, aspartate release increased in AWR following induction, and from 40 min to 140 min arginine release in controls was elevated. The precise mechanisms through which each of the volatile anesthetics affected amino acid concentrations are still unclear and further experimental research is required to draw reliable conclusions.

Metabolic Consequences of Chronic Alcohol Abuse in Non-Smokers: A Pilot Study

An alcohol use disorder (AUD) is associated with an increased susceptibility to respiratory infection and injury and, upon hospitalization, higher mortality rates. Studies in model systems show effects of alcohol on mitochondrial function, lipid metabolism and antioxidant systems. The present study applied high-resolution metabolomics to test for these changes in bronchoalveolar lavage fluid (BALF) of subjects with an AUD. Smokers were excluded to avoid confounding effects and compliance was verified by cotinine measurements. Statistically significant metabolic features, differentially expressed by control and AUD subjects, were identified by statistical and bioinformatic methods. The results show that fatty acid and acylcarnitine concentrations were increased in AUD subjects, consistent with perturbed mitochondrial and lipid metabolism. Decreased concentrations of methyl-donor compounds suggest altered one-carbon metabolism and oxidative stress. An accumulation of peptides suggests proteolytic activity, which could reflect altered epithelial barrier function. Two metabolites of possible microbial origin suggest subclinical bacterial infection. Furthermore, increased diacetylspermine suggests additional metabolic perturbations, which could contribute to dysregulated alveolar macrophage function and vulnerability to infection. Together, the results show an extended metabolic consequence of AUD in the bronchoalveolar space.

Analysis of perioperative morbidity and mortality in shoulder arthroplasty patients with preexisting alcohol use disorders

BACKGROUND

Shoulder arthroplasty is becoming increasingly popular in the United States. Given the high prevalence of alcohol abuse and its implications in postoperative morbidity and the increasing incidence of shoulder arthroplasty, it is prudent to explore the effect of alcohol use disorders (AUDs) in this patient population. In this study, we considered numerous outcome variables, including perioperative complications, in-hospital death, prolonged hospital stay, and nonroutine discharge.

METHODS

Using the Nationwide Inpatient Sample, we performed a retrospective cohort study to identify a population of 422,371 adults (≥18 years old) undergoing total shoulder arthroplasty or hemiarthroplasty between January 1, 2002, and December 31, 2011. We then further subdivided this cohort into those who were classified as having AUDs and those who did not. Comparisons of early postoperative outcome measures were performed by bivariate and multivariable analyses with logistic regression modeling.

RESULTS

Compared with those without AUDs, patients undergoing shoulder arthroplasty with a preexisting AUD have a greater likelihood to experience death, pneumonia, deep venous thrombosis, acute renal failure, transfusion, prolonged length of stay, and nonroutine discharge irrespective of age, gender, race, and other medical comorbidities. Patients with a preexisting AUD are 2.7 times more likely to experience perioperative complications after shoulder arthroplasty.

CONCLUSION

Patients undergoing shoulder arthroplasty with a preexisting AUD have a greater likelihood of perioperative complications and health care resource utilization after shoulder arthroplasty. Presurgical alcohol screening may prove effective in identifying at-risk patients, and providing interventions before surgery may effectively limit the complication profile.

The "Prediction of Alcohol Withdrawal Severity Scale" (PAWSS): systematic literature review and pilot study of a new scale for the prediction of complicated alcohol withdrawal syndrome

BACKGROUND

To date, no screening tools for alcohol withdrawal syndromes (AWS) have been validated in the medically ill. Although several tools quantify the severity of AWS (e.g., Clinical Institute Withdrawal Assessment for Alcohol [CIWA]), none identify subjects at risk of AWS, thus missing the opportunity for timely prophylaxis. Moreover, there are no validated tools for the prediction of complicated (i.e., moderate to severe) AWS in the medically ill.

OBJECTIVES

Our goals were (1) to conduct a systematic review of the published literature on AWS to identify clinical factors associated with the development of AWS, (2) to use the identified factors to develop a tool for the prediction of alcohol withdrawal among patients at risk, and (3) to conduct a pilot study to assess the validity of the tool.

METHODS

For the creation of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS), we conducted a systematic literature search using PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines for clinical factors associated with the development of AWS, using PubMed, PsychInfo, MEDLINE, and Cochrane Databases. Eligibility criteria included: (i) manuscripts dealing with human subjects, age 18 years or older, (ii) manuscripts directly addressing descriptions of AWS or its predisposing factors, including case reports, naturalistic case descriptions, and all types of clinical trials (e.g., randomized, single-blind, or open label studies), (iii) manuscripts describing characteristics of alcohol use disorder (AUD), and (iv) manuscripts dealing with animal data (which were considered only if they directly dealt with variables described in humans). Obtained data were used to develop the Prediction of Alcohol Withdrawal Severity Scale, in order to assist in the identification of patients at risk for complicated AWS. A pilot study was conducted to assess the new tool's psychometric qualities on patients admitted to a general inpatient medicine unit over a 2-week period, who agreed to participate in the study. Blind to PAWSS results, a separate group of researchers retrospectively examined the medical records for evidence of AWS.

RESULTS

The search produced 2802 articles describing factors potentially associated with increased risk for AWS, increased severity of withdrawal symptoms, and potential characteristics differentiating subjects with various forms of AWS. Of these, 446 articles met inclusion criteria and underwent further scrutiny, yielding a total of 233 unique articles describing factors predictive of AWS. A total of 10 items were identified as correlated with complicated AWS (i.e., withdrawal hallucinosis, withdrawal-related seizures, and delirium tremens) and used to construct the PAWSS. During the pilot study, a total of 68 subjects underwent evaluation with PAWSS. In this pilot sample the sensitivity, specificity, and positive and negative predictive values of PAWSS were 100%, using the threshold score of 4.

DISCUSSION

The results of the literature search identified 10 items which may be correlated with risk for complicated AWS. These items were assembled into a tool to assist in the identification of patients at risk: PAWSS. The results of this pilot study suggest that PAWSS may be useful in identifying risk of complicated AWS in medically ill, hospitalized individuals. PAWSS is the first validated tool for the prediction of severe AWS in the medically ill and its use may aid in the early identification of patients at risk for complicated AWS, allowing for prophylaxis against AWS before severe alcohol withdrawal syndromes develop.

Alcohol, nicotine, and iatrogenic withdrawals in the ICU

OBJECTIVES

The neurophysiology, risk factors, and screening tools associated with alcohol withdrawal syndrome in the ICU are reviewed. Alcohol withdrawal syndrome assessment and its treatment options are discussed. Description of nicotine withdrawal and related publications specific to the critically ill are also reviewed. A brief comment as to sedative and opiate withdrawal follows.

DATA AND SUMMARY

The role of currently published alcohol withdrawal syndrome pharmacologic strategies (benzodiazepines, ethanol, clomethiazole, antipsychotics, barbiturates, propofol, and dexmedetomidine) is detailed. Studies on nicotine withdrawal management in the ICU focus mainly on the safety (mortality) of nicotine replacement therapy. Study characteristics and methodological limitations are presented.

CONCLUSION

We recommend a pharmacologic regimen titrated to withdrawal symptoms in ICU patients with alcohol withdrawal syndrome. Benzodiazepines are a reasonable option; phenobarbital appears to confer some advantages in combination with benzodiazepines. Propofol and dexmedetomidine have not been rigorously tested in comparative studies of drug withdrawal treatment; their use as additional or alternative strategies for managing withdrawal syndromes in ICU patients should therefore be individualized to each patient. Insufficient data preclude recommendations as to nicotine replacement therapy and management of iatrogenic drug withdrawal in ICU patients.

Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit

OBJECTIVE

To revise the "Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult" published in Critical Care Medicine in 2002.

METHODS

The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task force with expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients. The task force, divided into four subcommittees, collaborated over 6 yr in person, via teleconferences, and via electronic communication. Subcommittees were responsible for developing relevant clinical questions, using the Grading of Recommendations Assessment, Development and Evaluation method (http://www.gradeworkinggroup.org) to review, evaluate, and summarize the literature, and to develop clinical statements (descriptive) and recommendations (actionable). With the help of a professional librarian and Refworks database software, they developed a Web-based electronic database of over 19,000 references extracted from eight clinical search engines, related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The group also used psychometric analyses to evaluate and compare pain, agitation/sedation, and delirium assessment tools. All task force members were allowed to review the literature supporting each statement and recommendation and provided feedback to the subcommittees. Group consensus was achieved for all statements and recommendations using the nominal group technique and the modified Delphi method, with anonymous voting by all task force members using E-Survey (http://www.esurvey.com). All voting was completed in December 2010. Relevant studies published after this date and prior to publication of these guidelines were referenced in the text. The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2), and either in favor of (+) or against (-) an intervention. A strong recommendation (either for or against) indicated that the intervention's desirable effects either clearly outweighed its undesirable effects (risks, burdens, and costs) or it did not. For all strong recommendations, the phrase "We recommend …" is used throughout. A weak recommendation, either for or against an intervention, indicated that the trade-off between desirable and undesirable effects was less clear. For all weak recommendations, the phrase "We suggest …" is used throughout. In the absence of sufficient evidence, or when group consensus could not be achieved, no recommendation (0) was made. Consensus based on expert opinion was not used as a substitute for a lack of evidence. A consistent method for addressing potential conflict of interest was followed if task force members were coauthors of related research. The development of this guideline was independent of any industry funding.

CONCLUSION

These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.

Alcohol withdrawal and delirium tremens in the critically ill: a systematic review and commentary

INTRODUCTION

Alcohol withdrawal is common among intensive care unit (ICU) patients, but no current practice guidelines exist. We reviewed published manuscripts for prevalence, risk factors, screening tools, prophylactic and treatment strategies, and outcomes for alcohol withdrawal syndrome (AWS) and delirium tremens (DT) in the critically ill.

METHODS

The following databases: PubMed, MEDLINE, Embase, Cochrane Database of Systematic Reviews and Central Register of Controlled Trials, CINAHL, Scopus, Web of Knowledge, pain, anxiety and delirium (PAD) Guidelines REFWORKS, International Pharmaceutical Abstracts and references for published papers were searched. Publications with high or moderate Grading of Recommendations Assessment, Development and Evaluation (GRADE) and Oxford levels of evidence were included.

RESULTS

Reported AWS rates range from <1 % in 'all ICU comers' to 60 % in highly selected alcohol-dependent ICU patients. Alcohol dependence and a history of withdrawal are significant risk factors for AWS occurrence. No screening tools for withdrawal have been validated in the ICU. The benefit of alcohol withdrawal prophylaxis is unproven, and proposed regimens appear equivalent. Early and aggressive titration of medication guided by symptoms is the only feature associated with improved treatment outcome.

CONCLUSIONS

Treatment of AWS is associated with higher ICU complication rates and resource utilization. The optimal means of identification, prevention and treatment of AWS in order to establish evidence-based guidelines remain to be determined.

Chronic alcohol exposure, infection, extended circulating white blood cells differentiated by flow cytometry and neutrophil CD64 expression: a prospective, descriptive study of critically ill medical patients

Background

A history of prolonged and excessive consumption of alcohol increases the risk for infections. The goal of this study was to investigate circulating white blood cells (WBC) differentiated by flow cytometry and neutrophil CD64 expression in excessive alcohol drinkers versus abstinent or moderate drinkers, and in those with or without infection, in medical patients admitted to the intensive care unit (ICU).

Methods

All patients admitted between September 2009 and March 2010 with an ICU-stay of 3 days or more were eligible for inclusion. Upon admission, hematological exams were conducted by flow cytometry.

Results

Overall, 281 adult were included, with 37% identified as at-risk drinkers. The only significant difference found in circulating WBC between at-risk and not-at-risk drinkers was a lower number of B lymphocytes in at-risk drinkers (P = 0.002). Four groups of patients were defined: not-at-risk drinkers with no infection (n = 66); not-at-risk drinkers with infection (n = 112); at-risk drinkers with no infection (n = 53); and at-risk drinkers with infection (n = 50). Whilst the presence of infection significantly reduced levels of noncytotoxic and cytotoxic T lymphocytes and significantly increased levels of CD16^– monocytes in not-at-risk drinkers, with variation related to infection severity, infection had no effect on any of the variables assessed in at-risk drinkers. Post-hoc comparisons showed that B-lymphocyte, noncytotoxic, and cytotoxic T lymphocyte and CD16^– counts in at-risk drinkers were similar to those in not-at-risk drinkers with infection and significantly lower than those in not-at-risk drinkers without infection. Neutrophil CD64 index varied significantly between groups, with variations related to infection, not previous alcohol consumption.

Conclusions

These results show that chronic alcohol exposure has an impact on the immune response to infection in critically ill medical patients. The absence of significant variations in circulating WBC seen in at-risk drinkers according to the severity of infection is suggestive of altered immune response.

Chronic-alcohol-abuse-induced oxidative stress in the development of acute respiratory distress syndrome

Chronic alcohol ingestion increases the risk of developing acute respiratory distress syndrome (ARDS), a severe form of acute lung injury, characterized by alveolar epithelial and endothelial barrier disruption and intense inflammation. Alcohol abuse is also associated with a higher incidence of sepsis or pneumonia resulting in a higher rate of admittance to intensive care, longer inpatient stays, higher healthcare costs, and a 2-4 times greater mortality rate. Chronic alcohol ingestion induced severe oxidative stress associated with increased ROS generation, depletion of the critical antioxidant glutathione (GSH), and oxidation of the thiol/disulfide redox potential in the alveolar epithelial lining fluid and exhaled breath condensate. Across intracellular and extracellular GSH pools in alveolar type II cells and alveolar macrophages, chronic alcohol ingestion consistently induced a 40-60 mV oxidation of GSH/GSSG suggesting that the redox potentials of different alveolar GSH pools are in equilibrium. Alcohol-induced GSH depletion or oxidation was associated with impaired functions of alveolar type II cells and alveolar macrophages but could be reversed by restoring GSH pools in the alveolar lining fluid. The aims of this paper are to address the mechanisms for alcohol-induced GSH depletion and oxidation and the subsequent effects in alveolar barrier integrity, modulation of the immune response, and apoptosis.

Prevention and therapy of alcohol withdrawal on intensive care units: systematic review of controlled trials

BACKGROUND

Alcohol withdrawal syndrome (AWS) occurs in 16 to 31% of intensive care unit (ICU) patients after cessation of sedation. There exist many preventive and therapeutic strategies, but no systematic review (SR) has been published on this topic so far. We aimed to perform a synopsis of all controlled trials of AWS prevention and therapy in ICU published between 1971 and 30 March 2011 following the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) statement.

METHODS

We performed a MEDLINE search with the terms "alcohol" AND "ICU" as well as "alcohol withdrawal" AND "intensive care." All publications that matched our eligibility criteria were analyzed according to our predefined criteria.

RESULTS

We identified 6 controlled trials about AWS prevention and 8 about AWS therapy in ICUs. For AWS prevention, benzodiazepines (BZO), ethanol (EtOH), and clonidine were evaluated as single agents, and BZO, clonidine, clomethiazol and haloperidol were studied in drug combinations. All evaluated single agents and combinations were found to be effective for AWS prevention. Clomethiazol was found to be associated with a higher tracheobronchitis rate and thus disadvised for critically ill patients. For AWS therapy, BZO, gamma-hydroxybutyric acid (GHB), and clomethiazol were evaluated in randomized controlled trials as single agents and phenobarbital, clonidine, and haloperidol as adjuncts. All evaluated regimens were found to be effective for AWS therapy. Overall, in the ICU, BZO were found to be superior to GHB and clomethiazol regarding safety and efficacy. Furthermore, 4 cohort trials with historical control groups evaluated the effect of the implementation of a standardized protocol of BZO therapy for AWS in ICUs. All of these 4 studies found better outcome for the intervention groups.

CONCLUSIONS

Based on the evidence of this SR, EtOH or BZO can be advised for AWS prevention on ICU patients with alcohol dependence, but EtOH is not allowed for therapy of AWS. AWS therapy should be standardized and based on symptom-triggered BZO administration. Alpha2-agonists and haloperidol should be added for autonomic and productive psychotic symptoms.

Health care-associated infections in surgical patients undergoing elective surgery: are alcohol use disorders a risk factor?

BACKGROUND

Health care-associated infections (HAI) result in 100,000 deaths/year. Alcohol use disorders (AUD) increase the risk of community-acquired infections and HAI. Small studies have shown that AUD increase the risk of HAI and surgical site infections (SSI). We sought to determine the risk of HAI and SSI in surgical patients undergoing elective inpatient joint replacement, coronary artery bypass grafting, laparoscopic cholecystectomy, colectomy, and hernia repair.

STUDY DESIGN

The Nationwide Inpatient Sample was analyzed (years 2007 and 2008). HAI were defined as health care-associated pneumonia, sepsis, SSI, and urinary tract infection. Primary outcomes were risk of HAI and SSI in patients with AUD. Secondary outcomes were mortality and hospital length of stay in patients with HAI and SSI, alpha = 10(-6).

RESULTS

There were 1,275,034 inpatient admissions analyzed; 38,335 (3.0%) cases of HAI were documented, and 5,756 (0.5%) cases of SSI were identified. AUD was diagnosed in 11,640 (0.9%) of cases. Multivariable analysis demonstrated that AUD was an independent predictor of developing HAI: odds ratio (OR) 1.70, p < 10(-6), and this risk was independent of type of surgery. By multivariable analysis, the risk of SSI in patients with AUD was also higher: OR 2.73, p < 10(-6). Hospital mortality in patients with HAI or SSI was not affected by AUD. However, hospital length of stay was longer in patients with HAI who had AUD (multivariable analysis 2.4 days longer, p < 10(-6)). Among patients with SSI, those with AUD did not have longer hospital length of stay.

CONCLUSIONS

Patients with AUD who undergo a variety of elective operations have an increased risk of infectious postoperative morbidity.

Three-year mortality among alcoholic patients after intensive care: a population-based cohort study

INTRODUCTION

Alcoholic patients comprise a large proportion of patients in intensive care units (ICUs). However, data are limited on the impact of alcoholism on mortality after intensive care.

METHODS

We conducted a cohort study among 16,848 first-time ICU patients between 2001 and 2007 to examine 30-day and 3-year mortality among alcoholic patients. Alcoholic patients with and without complications of alcohol misuse (for example, alcoholic liver disease) were identified from previous hospital contacts for alcoholism-related conditions or redemption of a prescription for alcohol deterrents. Data on medication use, demographics, hospital diagnoses, and comorbidity were obtained from medical databases. We computed 30-day and 3-year mortality and mortality rate ratios (MRRs) by using Cox regression analysis, controlling for covariates.

RESULTS

In total, 1,229 (7.3%) ICU patients were current alcoholics. Among alcoholic patients without complications of alcoholism (n=785, 4.7% of the cohort), 30-day mortality was 15.9% compared with 19.7% among nonalcoholic patients. Compared with nonalcoholic patients, the adjusted 30-day MRR was 1.04 (95% confidence interval (CI), 0.87 to 1.25). Three-year mortality was 36.2% compared with 40.9% among nonalcoholic patients, corresponding to an adjusted 3-year MRR of 1.16 (95% CI, 1.03 to 1.31). For alcoholic patients with complications (n=444, 2.6% of the cohort), 30-day mortality was 33.6%, and 3-year mortality was 64.5%, corresponding to adjusted MRRs, with nonalcoholics as the comparator, of 1.64 (95% CI, 1.38 to 1.95) and 1.67 (95% CI, 1.48 to 1.90), respectively.

CONCLUSIONS

Alcoholic ICU patients with chronic complications of alcoholism have substantially increased 30-day and 3-year mortality. In contrast, alcoholics without complications have no increased 30-day and only slightly increased 3- year mortality.

Risk Factors for Delirium in Trauma Patients: The Impact of Ethanol Use and Lack of Insurance

The purpose of this study was to examine independent risk factors, and in particular the impact of alcohol on the development of delirium, in a cohort of trauma patients screened for ethanol ingestion on admission to hospital. The National Trauma Databank (v. 7.0) was used to identify all patients 18 years or older screened for ethanol on admission. Patients who developed delirium were compared with those who did not. Stepwise logistic regression analysis was used to identify independent risk factors for the development of delirium. A total of 504,839 patients with admission ethanol levels were identified. Of those, 2,909 (0.6%) developed delirium. Patients developing delirium were significantly older, more frequently male, and more likely to sustain thermal injuries and falls. Patients developing delirium had more comorbidities including chronic ethanol use (19.1% vs 4.5%, P < 0.001) and cardiovascular disease (21.5% vs 12.2%, P < 0.001). On admission, patients developing delirium were more likely to be intoxicated with ethanol (55.4% vs 26.5%, P < 0.001) and were more likely to be uninsured (17.8% vs 0.9%, P < 0.001). A stepwise logistic regression model identified lack of insurance, positive ethanol on admission, chronic ethanol use, Intensive Care Unit admission, age ≥ 55 years, burns, Medicare insurance, falls, and history of cardiovascular disease as independent risk factors for the development of delirium. The incidence of delirium in this trauma patient cohort was 0.6 per cent. The above risk factors were independently associated with the development of delirium. This data may be helpful in designing interventions to prevent delirium.

Delayed treatment of delirium increases mortality rate in intensive care unit patients

Delirium in the intensive care unit (ICU) is a serious complication associated with a poor outcome in critically ill patients. In this prospective observational study of the effect of a delay in delirium therapy on mortality rate, 418 ICU patients were regularly assessed using the Delirium Detection Score (DDS). The departmental standard required that if delirium was diagnosed (DDS >7), therapy should be started within 24 h. In total, 204 patients (48.8%) were delirious during their ICU stay. In 184 of the delirious patients (90.2%), therapy was started within 24 h; in 20 patients (9.8%), therapy was delayed. During their ICU stay, patients whose delirium treatment was delayed were more frequently mechanically ventilated, had more nosocomial infections (including pneumonia) and had a higher mortality rate than patients whose treatment was not delayed. Thus, it would appear that a delay in initiating delirium therapy in ICU patients was associated with increased mortality.

Alcohol screening and risk of postoperative complications in male VA patients undergoing major non-cardiac surgery

BACKGROUND

Patients who misuse alcohol are at increased risk for surgical complications. Four weeks of preoperative abstinence decreases the risk of complications, but practical approaches for early preoperative identification of alcohol misuse are needed.

OBJECTIVE

To evaluate whether results of alcohol screening with the Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) questionnaire-up to a year before surgery-were associated with the risk of postoperative complications.

DESIGN

This is a cohort study.

SETTING AND PARTICIPANTS

Male Veterans Affairs (VA) patients were eligible if they had major noncardiac surgery assessed by the VA's Surgical Quality Improvement Program (VASQIP) in fiscal years 2004-2006, and completed the AUDIT-C alcohol screening questionnaire (0-12 points) on a mailed survey within 1 year before surgery.

MAIN OUTCOME MEASURE

One or more postoperative complication(s) within 30 days of surgery based on VASQIP nurse medical record reviews.

RESULTS

Among 9,176 eligible men, 16.3% screened positive for alcohol misuse with AUDIT-C scores ≥ 5, and 7.8% had postoperative complications. Patients with AUDIT-C scores ≥ 5 were at significantly increased risk for postoperative complications, compared to patients who drank less. In analyses adjusted for age, smoking, and days from screening to surgery, the estimated prevalence of postoperative complications increased from 5.6% (95% CI 4.8-6.6%) in patients with AUDIT-C scores 1-4, to 7.9% (6.3-9.7%) in patients with AUDIT-Cs 5-8, 9.7% (6.6-14.1%) in patients with AUDIT-Cs 9-10 and 14.0% (8.9-21.3%) in patients with AUDIT-Cs 11-12. In fully-adjusted analyses that included preoperative covariates potentially in the causal pathway between alcohol misuse and complications, the estimated prevalence of postoperative complications increased significantly from 4.8% (4.1-5.7%) in patients with AUDIT-C scores 1-4, to 6.9% (5.5-8.7%) in patients with AUDIT-Cs 5-8 and 7.5% (5.0-11.3%) among those with AUDIT-Cs 9-10.

CONCLUSIONS

AUDIT-C scores of 5 or more up to a year before surgery were associated with increased postoperative complications.

Alcohol intoxication/dependence, ethnicity and utilisation of health care resources in a level I trauma center

OBJECTIVE

To evaluate the potential influence of acute intoxication and dependence to alcohol on extrautilisation of health care resources by ethnic minority trauma patients in a level I trauma center.

METHODS

We analysed the data of 1493 patients enrolled in a study that evaluated the effectiveness of brief alcohol intervention among ethnic minority trauma patients. The database included detailed demographic, injury-related and drinking-related characteristics (including acute intoxication and alcohol dependency status). Patients were categorised into the following groups: non-intoxicate/nondependent(NI/ND), non-intoxicated/dependent (NI/D), intoxicated/non-dependent (I/ND) and intoxicated/dependent (I/D). We compared utilisation of several diagnostic and therapeutic procedures among these four categories. We placed special emphasis on ethnicity as a potential effect modifier.

RESULTS

Relative to NI/ND trauma patients, I/ND patients (relative risk (RR): 1.8, 95% CI: 1.2–2.8) and I/D patients (RR: 2.4, 95% CI: 1.6–3.6) had significantly higher chance of being evaluated by abdominal ultrasound during the first 24 h of hospital arrival. Similar pattern was observed for head CT scan (with the corresponding RRs of 2.1 and 2.6, respectively). Chance of admission to the intensive care unit (ICU)was not associated with intoxication/dependence status. Length of hospital stay was negatively associated with drinking status with the shortest length of stay for I/D. Including ethnicity in the models,did not change the results and conclusions.

DISCUSSION

Acute intoxication and dependence to alcohol are both associated with more frequent utilisation of selected health care resources and the utilisation pattern was not associated with patient ethnicity. This emphasises on the importance of routine screening for drinking problems among all trauma patients, regardless of their blood alcohol level in the ED.

Alcohol-use disorders in the critically ill patient

Alcohol abuse and dependence, referred to as alcohol-use disorders (AUDs), affect 76.3 million people worldwide and account for 1.8 million deaths per year. AUDs affect 18.3 million Americans (7.3% of the population), and up to 40% of hospitalized patients have AUDs. This review discusses the development and progression of critical illness in patients with AUDs. In contrast to acute intoxication, AUDs have been linked to increased severity of illness in a number of studies. In particular, surgical patients with AUDs experience higher rates of postoperative hemorrhage, cardiac complications, sepsis, and need for repeat surgery. Outcomes from trauma are worse for patients with chronic alcohol abuse, whereas burn patients who are acutely intoxicated may not have worse outcomes. AUDs are linked to not only a higher likelihood of community-acquired pneumonia and sepsis but also a higher severity of illness and higher rates of nosocomial pneumonia and sepsis. The management of sedation in patients with AUDs may be particularly challenging because of the increased need for sedatives and opioids and the difficulty in diagnosing withdrawal syndrome. The health-care provider also must be watchful for the development of dangerous agitation and violence, as these problems are not uncommonly seen in hospital ICUs. Despite studies showing that up to 40% of hospitalized patients have AUDs, relatively few guidelines exist on the specific management of the critically ill patient with AUDs. AUDs are underdiagnosed, and a first step to improving patient outcomes may lie in systematically and accurately identifying AUDs.

Perioperative management of patients with alcohol, tobacco and drug dependency

PURPOSE OF REVIEW

One in five patients in the perioperative setting has a alcohol use disorder (AUD), one in three patients has a nicotine use disorder (NUD) and one in 10 patients has a drug use disorder (DUD) with a high risk of dependency. Patients with dependencies challenge physicians with various complications within the perioperative setting.

RECENT FINDINGS

Adequate treatment of alcohol, nicotine and drug dependency during the perioperative and intraoperative course requires established screening tools in order to evaluate patients' susceptibility to developing complications. Particularly in these patients, secondary prevention and early treatment is warranted.

SUMMARY

Alcohol, nicotine and drug dependency are very treatable. Numerous effective therapeutic options are available and should be offered to patients. Intensive care treatment can be shortened or even avoided by initiating preventive measures. A multimodal approach includes implementation of screening tools, motivational interviewing, preoperative abstinence, individual anaesthesiological treatment, stress reduction preventing delirium and postoperative infection, prevention and treatment of withdrawal syndrome, replacement therapies and provision of preoperative or postoperative detoxification. The implementation rate is very low and urgently requires strategies for improvement.

The perioperative von Willebrand factor activity and factor VIII levels among alcohol use disorder patients undergoing total knee or hip replacement

Alcohol use disorder patients have a five-fold higher risk of postoperative bleeding complications. We measured the perioperative von Willebrand factor and factor VIII levels in consecutive patients with alcohol use disorder. In one university hospital, 105 patients scheduled for arthroplasty were screened, and 25 fulfilled inclusion criteria. Postoperatively, we found significantly decreased von Willebrand factor ristocetin cofactor values over time among alcohol use disorder patients and significantly different time courses of factor VIII levels between patients with and without a diagnosed alcohol use disorder. Blood loss was significantly increased among alcohol use disorder patients on their first postoperative day.