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Huang J, Ahmed IM, Wang T, Xie C. Beyond the Liver: Neurologic Manifestations of Alcohol Use. Clin Liver Dis 2024; 28:681-697. [PMID: 39362715 DOI: 10.1016/j.cld.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2024]
Abstract
Alcohol use, while commonly associated with liver damage, also has significant neurologic implications, which often mimic hepatic encephalopathy and complicate diagnosis and management. Alcohol mediates its acute central nervous system effects by altering neurotransmitter balance, notably between gamma-aminobutyric acid and glutamate. Its chronic neurotoxicity, compounded by thiamine deficiency, results in chronic neurologic complications. Clinically, alcohol-related neurologic disorders present a spectrum from acute intoxication and withdrawal to chronic conditions like Korsakoff syndrome, dementia, cerebellar degeneration, and peripheral neuropathy. This review underscores differentiating these conditions from hepatic encephalopathy and highlights the importance of history-taking and physical examination in clinical practice.
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Affiliation(s)
- Jiannan Huang
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, 1400 West 22nd Street, Sioux Falls, SD 57105, USA
| | - Ibrahim Munaf Ahmed
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, 1400 West 22nd Street, Sioux Falls, SD 57105, USA
| | - Tian Wang
- Department of Neurology, Georgetown University, Washington, DC, USA; Georgetown University Medical Center, Comprehensive Epilepsy Center, MedStar Georgetown University Hospital, MedStar Southern Maryland Hospital Center, 10401 Hospital Drive, Suite 102, Clinton, MD 20735, USA
| | - Chencheng Xie
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, 1400 West 22nd Street, Sioux Falls, SD 57105, USA; Division of Hepatology, Avera McKennan Hospital & University Health Center, 1315 South Cliff Avenue, Suite 1200 Plaza 3, Sioux Falls, SD 57105, USA.
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Norris M, Mak H, Fong CT, Walters AM, Hoang CV, Lele AV. Evaluation of the Use of Phenobarbital and Benzodiazepines in the Management of Alcohol Withdrawal Syndrome in Patients Requiring Neurological/Neurosurgical Critical Care: A Propensity-Matched Analysis. Cureus 2024; 16:e61952. [PMID: 38978925 PMCID: PMC11230610 DOI: 10.7759/cureus.61952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2024] [Indexed: 07/10/2024] Open
Abstract
Objective There is growing interest in the use of phenobarbital for alcohol withdrawal syndrome in critically ill patients, though experience in neurologically injured patients is limited. The purpose of this study was to compare the safety and effectiveness of phenobarbital-containing alcohol withdrawal regimens versus benzodiazepine monotherapy in the neurocritical care unit. Methods We conducted a retrospective cohort study of adult patients admitted to the neurocritical care unit from January 2014 through November 2021 who received pharmacologic treatment for alcohol withdrawal. Treatment groups were defined as benzodiazepine monotherapy versus phenobarbital alone or in combination with benzodiazepines. The primary outcome was the percentage of patients requiring intubation after receiving alcohol withdrawal treatment. Secondary outcomes included all-cause, in-hospital mortality, intensive care unit length of stay, discharge disposition, change in Glasgow Coma Scale (GCS) score, and the use of adjunctive agents. Results We analyzed data from 156 patients, with 77 (49%) in the benzodiazepine group and 79 (51%) in the phenobarbital combination group. The groups were well-balanced for baseline characteristics, though more males (67, 85%) were in the phenobarbital group. Only three (1.9%) patients received phenobarbital monotherapy, and the rest (153, 98.1%) received combination therapy. The percentage of patients requiring mechanical ventilation was significantly higher in the phenobarbital combination group compared to benzodiazepine monotherapy (39% (n=31) versus 13% (n=10); OR: 4.33, 95% CI: 1.94-9.66; p<0.001). The use of adjunctive propofol and dexmedetomidine was higher in the phenobarbital group (propofol 35% (n= 28) versus 9% (n=7) and dexmedetomidine 30% (n=24) versus 5% (n=4), respectively). Patients in the phenobarbital group also had lower GCS scores and higher Clinical Institute Withdrawal Assessment of Alcohol (CIWA-Ar) scores during their intensive care unit admission, possibly suggesting more severe alcohol withdrawal. There was no difference in intensive care unit length of stay, all-cause, in-hospital mortality, discharge disposition, or therapeutic adjuncts. Conclusions Combination therapy of phenobarbital plus benzodiazepines was associated with higher odds of requiring mechanical ventilation. Few patients received phenobarbital monotherapy. Additional studies are needed to better compare the effects of phenobarbital monotherapy versus benzodiazepines in neurocritical patients.
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Affiliation(s)
| | - Hannah Mak
- Pharmacy, Harborview Medical Center, Seattle, USA
| | - Christine T Fong
- Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, USA
| | - Andrew M Walters
- Anesthesiology and Pain Medicine, Harborview Medical Center, Seattle, USA
| | | | - Abhijit V Lele
- Anesthesiology and Pain Medicine, Harborview Medical Center, Seattle, USA
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Kurtz P, van den Boogaard M, Girard TD, Hermann B. Acute encephalopathy in the ICU: a practical approach. Curr Opin Crit Care 2024; 30:106-120. [PMID: 38441156 DOI: 10.1097/mcc.0000000000001144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW Acute encephalopathy (AE) - which frequently develops in critically ill patients with and without primary brain injury - is defined as an acute process that evolves rapidly and leads to changes in baseline cognitive status, ranging from delirium to coma. The diagnosis, monitoring, and management of AE is challenging. Here, we discuss advances in definitions, diagnostic approaches, therapeutic options, and implications to outcomes of the clinical spectrum of AE in ICU patients without primary brain injury. RECENT FINDINGS Understanding and definitions of delirium and coma have evolved. Delirium is a neurocognitive disorder involving impairment of attention and cognition, usually fluctuating, and developing over hours to days. Coma is a state of unresponsiveness, with absence of command following, intelligible speech, or visual pursuit, with no imaging or neurophysiological evidence of cognitive motor dissociation. The CAM-ICU(-7) and the ICDSC are validated, guideline-recommended tools for clinical delirium assessment, with identification of clinical subtypes and stratification of severity. In comatose patients, the roles of continuous EEG monitoring and neuroimaging have grown for the early detection of secondary brain injury and treatment of reversible causes. SUMMARY Evidence-based pharmacologic treatments for delirium are limited. Dexmedetomidine is effective for mechanically ventilated patients with delirium, while haloperidol has minimal effect of delirium but may have other benefits. Specific treatments for coma in nonprimary brain injury are still lacking.
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Affiliation(s)
- Pedro Kurtz
- D'Or Institute of Research and Education
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Mark van den Boogaard
- Radboud University Medical Center, Department of Intensive Care, Nijmegen, The Netherlands
| | - Timothy D Girard
- Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) in the Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Bertrand Hermann
- Medical Intensive Care Unit, Hôpital Européen Georges Pompidou, Assistance Publique des Hôpitaux de Paris - Centre (APHP-Centre)
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP), Université Paris Cité, Paris, France
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Liu TT, Frost ED, Donlon J, Gandhi RM, Mohammadi T, Murray BP, Shad MU, Koola MM. Surge of Midazolam Use in the Midst of Lorazepam Shortage. J Clin Psychopharmacol 2023; 43:520-526. [PMID: 37930205 DOI: 10.1097/jcp.0000000000001763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
BACKGROUND Lorazepam is a widely prescribed benzodiazepine that is used to manage anxiety, insomnia, and status epilepticus and is used for pre-anesthetic care as well as several off-label indications including aggression, alcohol withdrawal, panic disorder, chemotherapy-associated anticipatory nausea, and catatonia. Recent increases in demand, manufacturing changes, and quality control issues have resulted in a shortage of injectable and oral lorazepam, prompting clinicians to use alternatives. One such alternative is midazolam, a drug that has been used primarily in the intensive care unit and anesthesia settings. PROCEDURES This article examines the significant pharmacologic differences between lorazepam and midazolam. In addition, this article provides dosage guidelines based on the current scientific knowledge and recommendations for conversion equivalencies. RESULTS The clinical preference for lorazepam can be attributed to its simpler metabolism with no active metabolites, better suitability for patients with less severe hepatic and renal impairment, less risk of adverse reactions, fewer drug-drug interactions, and greater desirability for special populations. In periods of shortages, midazolam has been shown to be effective for a number of off-label uses. To manage conditions that have not been extensively studied, clinicians may opt to use conversion equivalencies, with the caveat that guidelines may vary greatly between institutions and online sources; therefore, it would be best to start low and titrate slowly. CONCLUSIONS Our goal is to aid clinicians in safely and effectively prescribing midazolam during the shortage of injectable lorazepam so that patients are provided the same effects and benefits.
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Affiliation(s)
- Tonia T Liu
- From the Cooper Medical School of Rowan University, Camden, NJ
| | - Emma D Frost
- Department of Neurology, Cooper Neurological Institute, Cooper University Health Care, Camden, NJ
| | - Jack Donlon
- From the Cooper Medical School of Rowan University, Camden, NJ
| | - Roshni M Gandhi
- From the Cooper Medical School of Rowan University, Camden, NJ
| | | | | | - Mujeeb U Shad
- Department of Psychiatry, University of Nevada, Las Vegas, NV
| | - Maju Mathew Koola
- Department of Psychiatry and Behavioral Health, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, NJ
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Chionatos RA, Lerner DP, Burns JD, Ramineni A. Alcohol-related posterior reversible encephalopathy syndrome: a case report of a patient managed with a benzodiazepine-sparing regimen for alcohol withdrawal. Neurocase 2023; 29:75-80. [PMID: 38700146 DOI: 10.1080/13554794.2024.2346365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 04/15/2024] [Indexed: 05/05/2024]
Abstract
We report a case of posterior reversible encephalopathy syndrome (PRES) during treatment for alcohol withdrawal syndrome with gabapentin and clonidine. The patient developed severe hypertension, confusion and tremor, culminating in bilateral vision loss and a seizure. Imaging revealed posterior cerebral edema. Treatment with benzodiazepines, antihypertensives, and anti-seizure medications led to resolution. One year later, imaging showed resolution of the findings. We review the associated literature and propose the recognition of a PRES sub-entity, Alcohol-Related PRES (ARPRES), which can appear in the setting of alcohol withdrawal syndrome, chronic alcohol use, and acute alcohol intoxication, with or without hypertension.
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Affiliation(s)
- Rafail A Chionatos
- Department of Neurology, Tufts University School of Medicine, Boston, USA
| | - David P Lerner
- Department of Neurology, Brookdale University Hospital and Medical Center, Brooklyn, USA
| | - Joseph D Burns
- Department of Neurology, Tufts University School of Medicine, Boston, USA
- Department of Neurology, Lahey Hospital and Medical Center, Burlington, USA
- Department of Neurosurgery, Tufts University School of Medicine, Boston, USA
| | - Anil Ramineni
- Department of Neurology, Tufts University School of Medicine, Boston, USA
- Department of Neurology, Lahey Hospital and Medical Center, Burlington, USA
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Hilbert MT, Henkel ND, Spetz SL, Malaiyandi DP. The Rising Status of Phenobarbital: A Case for Use in Severe Refractory Hyperactive Poststroke Delirium. Neurologist 2023; 28:123-125. [PMID: 35534002 DOI: 10.1097/nrl.0000000000000441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Up to 48% of patients who have had a stroke will experience poststroke delirium (PSD) that can be hyperactive, hypoactive, or mixed. Literature on treatment of the hyperactive subtype is specifically lacking. This case report describes the rapid resolution of severe refractory hyperactive PSD with phenobarbital. CASE REPORT A 58-year-old man with a left middle cerebral artery stroke presented with severe hyperactive PSD of 12 days duration, refractory to antipsychotics, alpha-2 agonists, gabapentin, therapeutic valproic acid, benzodiazepines, and ketamine infusion. An oral dose of phenobarbital 30.4 mg, followed by oral maintenance therapy was initiated on day 13 of admission with dramatic improvement. As his Richmond Agitation-Sedation score trended downwards to 0, he was able to cooperate with therapies. This allowed for discharge to a skilled nursing facility for rehabilitation and subsequently home 2 weeks later. CONCLUSION Hyperactive PSD is a common complication of stroke with little evidence to guide treatment strategies. This report suggests that phenobarbital, because of its varied mechanisms of action and unique neurochemistry, may be an unrecognized potential therapy.
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Affiliation(s)
- Morgan T Hilbert
- Department of Pharmacy, ProMedica Toledo Hospital/Russell J. Ebeid Children's Hospital
| | - Nicholas D Henkel
- Department of Neurosciences and Neurological Disorders, University of Toledo
| | - Samantha L Spetz
- Department of Pharmacy, ProMedica Toledo Hospital/Russell J. Ebeid Children's Hospital
| | - Deepa P Malaiyandi
- Division of Neurocritical Care, Department of Neurology, University of Toledo College of Medicine
- Department of Neurology, ProMedica Toledo Hospital, Toledo, OH
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Pham C, Goldenberg-Sandau A, Sensenig R, Chau T, Igneri L, Solomon D, Chuang L. Phenobarbital for the Management of Alcohol Withdrawal Syndrome in Critically Ill, Surgical-Trauma Patients. J Surg Res 2023; 283:965-972. [PMID: 36915025 DOI: 10.1016/j.jss.2022.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 11/09/2022] [Accepted: 11/16/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION While benzodiazepines (BZD) are the standard of care therapy for the management alcohol withdrawal syndrome (AWS), phenobarbital (PHB) is often used as an alternative agent. The objective of this study is to assess the use of PHB therapy for the management of AWS in trauma-surgical intensive care unit (TSCU) patients. MATERIALS AND METHODS This is an institutional review board-approved single-center, retrospective study conducted at a large academic medical center. Patients aged ≥ 18 y admitted to the TSCU receiving PHB therapy for primary management of AWS were included. The primary outcome evaluated was the incidence of AWS-related complications (AWSRC) defined as severe agitation, delirium tremens, or seizures following initiation of PHB. Secondary outcomes included the incidence of oversedation and duration of mechanical ventilation. RESULTS Sixty patients were included in this study. AWSRC following initiation of PHB occurred in 65% of patients. Median time to initiation of PHB (42 versus 18 h, P = 0.001) and rates of oversedation (79.5% versus 28.6%, P < 0.001) were significantly greater among patients who experienced AWSRC compared to those who did not. Univariate analysis revealed use of BZD therapy for ≥ 24 h prior to PHB initiation, time from hospital admission to PHB initiation ≥ 24 h, presence of AWS symptoms at baseline, and baseline MINDS score > 6 were risk factors for AWSRC. CONCLUSIONS Delays in initiation of PHB appear to be associated with an increased risk for developing AWSRC. Further research is needed to identify an optimal dosing strategy for TSCU patients at high risk for severe AWS.
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Affiliation(s)
- Christine Pham
- Department of Pharmacy, Adventist HealthCare White Oak Medical Center, Silver Spring, Maryland.
| | - Anna Goldenberg-Sandau
- Department of Trauma Surgery, Cooper University Healthcare, Camden, New Jersey; Department of Surgery, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Rachel Sensenig
- Department of Trauma Surgery, Cooper University Healthcare, Camden, New Jersey; Department of Surgery, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Terence Chau
- Department of Pharmacy, Cooper University Healthcare, Camden, New Jersey
| | - Lauren Igneri
- Department of Pharmacy, Cooper University Healthcare, Camden, New Jersey
| | - Diana Solomon
- Department of Pharmacy, Cooper University Healthcare, Camden, New Jersey
| | - Linda Chuang
- Department of Pharmacy, Baylor Scott and White Medical Center - Centennial, Frisco, Texas
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Seshadri A, Appelbaum R, Carmichael SP, Farrell MS, Filiberto DM, Jawa R, Kodadek L, Mandell S, Miles MVP, Paul J, Robinson B, Michetti CP. Prevention of alcohol withdrawal syndrome in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. Trauma Surg Acute Care Open 2022; 7:e001010. [PMCID: PMC9680182 DOI: 10.1136/tsaco-2022-001010] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/02/2022] [Indexed: 11/23/2022] Open
Abstract
Alcohol withdrawal syndrome is a common and challenging clinical entity present in trauma and surgical intensive care unit (ICU) patients. The screening tools, assessment strategies, and pharmacological methods for preventing alcohol withdrawal have significantly changed during the past 20 years. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews the best practices for screening, monitoring, and prophylactic treatment of alcohol withdrawal in the surgical ICU.
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Affiliation(s)
- Anupamaa Seshadri
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Rachel Appelbaum
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Samuel P Carmichael
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | | | - Dina M Filiberto
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Randeep Jawa
- Department of Surgery, Stony Brook University, Stony Brook, New York, USA
| | - Lisa Kodadek
- Surgery, Yale University School of Medicine, New Haven, Connecticut, USA,Department of Surgery, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Samuel Mandell
- Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - M Victoria P Miles
- College of Medicine Chattanooga, The University of Tennessee Health Science Center, Chattanooga, Tennessee, USA
| | - Jasmeet Paul
- Department of Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Bryce Robinson
- Department of Surgery, Harborview Medical Center, Seattle, Washington, USA
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Day E, Daly C. Clinical management of the alcohol withdrawal syndrome. Addiction 2022; 117:804-814. [PMID: 34288186 DOI: 10.1111/add.15647] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 07/06/2021] [Indexed: 02/06/2023]
Abstract
Up to half of individuals with a history of long-term, heavy alcohol consumption will experience the alcohol withdrawal syndrome (AWS) when consumption is significantly decreased or stopped. In its most severe form, AWS can be life-threatening. Medically assisted withdrawal (MAW) often forms the first part of a treatment pathway. This clinical review discusses key elements of the clinical management of MAW, necessary adjustments for pregnancy and older adults, likely outcome of an episode of MAW, factors that might prevent completion of the MAW process and ways of overcoming barriers to ongoing treatment of alcohol use disorder. The review also discusses the use of benzodiazepines in MAW. Although there is clear evidence for their use, benzodiazepines have been associated with abuse liability, blunting of cognition, interactions with depressant drugs, craving, delirium, dementia and disrupted sleep patterns. Because glutamatergic activation and glutamate receptor upregulation contribute to alcohol withdrawal, anti-glutamatergic strategies for MAW and other potential treatment innovations are also considered.
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Affiliation(s)
- Ed Day
- Addiction Psychiatry, Institute for Mental Health, School of Psychology, University of Birmingham, Edgbaston, Birmingham, UK
| | - Chris Daly
- Addiction Psychiatry, Greater Manchester Mental Health FT, Chapman Barker Unit, Prestwich Hospital, Manchester, UK
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Geriatric Trauma Patients with Alcohol Withdrawal: Current Overview. J Am Med Dir Assoc 2022; 23:701-702. [PMID: 35219604 DOI: 10.1016/j.jamda.2022.01.073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 01/19/2022] [Accepted: 01/24/2022] [Indexed: 12/27/2022]
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Kaggwa MM, Nkola R, Najjuka SM, Bongomin F, Ashaba S, Mamun MA. Extrapyramidal Side Effects in a Patient with Alcohol Withdrawal Symptoms: A Reflection of Quality of the Mental Health Care System. Risk Manag Healthc Policy 2021; 14:2789-2795. [PMID: 34234593 PMCID: PMC8257062 DOI: 10.2147/rmhp.s314451] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/15/2021] [Indexed: 12/27/2022] Open
Abstract
Background The burden of substance use disorders is increasing in most countries in sub-Saharan Africa. Individuals with substance use disorders (eg, alcohol use disorder) are at high risk of manifesting extrapyramidal side effects or extrapyramidal symptoms (EPS) during treatment of alcohol-induced mental illness symptoms especially psychosis. EPS management poses a challenge since some of the drugs used for treating EPS have addictive properties. The knowledge about EPS diagnosis and treatment is not well distributed across the health system, with health workers at lower health facilities having least awareness. The present case gives details of a patient who developed EPS during the management of alcohol withdrawal symptoms. Case Details Following cessation of alcohol use, a 54-year-old man with alcohol use disorder presented with a one-week history of visual, auditory and tactile hallucinations, illusions, insomnia, extreme fear and irritability. He was managed with several daily doses of intramuscular chlorpromazine 100 mg, whenever he woke up aggressive from sedation from a peripheral health facility. Four days after his admission, he became mute, stiff, immobile, triple-flexed, tremulous and was drooling saliva. He was referred to a secondary facility for further management while on antipsychotic medication. Finally, he was referred to a tertiary facility, managed with tablets of benzhexol 5 mg twice daily and intravenous diazepam 20 mg per day. Daily follow-up was done using the extrapyramidal symptom rating scale (ESRS) for EPS. EPS symptoms resolved ten days after initiation of treatment. Conclusion EPS among individuals with addictive disorders poses a challenge in its management, especially in countries where the mental health care system is not well developed at lower-level health facilities. The mental health system has to prepare sustainable interventions to properly manage EPS among the growing population of individuals with addictive disorders through strengthening the mental health policy by training and equipping all health providers with knowledge and skills in managing EPS, increasing finances allocated for mental health and controlling the production and use of addictive substances.
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Affiliation(s)
- Mark Mohan Kaggwa
- Department of Psychiatry, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Rahel Nkola
- Department of Psychiatry, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Scholastic Ashaba
- Department of Psychiatry, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Mohammed A Mamun
- CHINTA Research Bangladesh (Centre for Health Innovation, Networking, Training, Action and Research - Bangladesh), Dhaka, Bangladesh.,Department of Public Health and Informatics, Jahangirnagar University, Dhaka, Bangladesh
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Abstract
INTRODUCTION Delirium is a frequent complication in hospitalised patients, often leading to difficulties in patient management and is associated with increased morbidity and mortality. Most patients in intensive care units develop delirium, however, it is also frequently observed in non-intensive care unit settings. Risk factors are, among others, older age, brain pathology, severe trauma, orthopaedic or heart surgery, metabolic or electrolyte dysregulations, infections and polypharmacy. The most important measures to prevent and treat delirium are recognition and removal of risk factors and causes. Although delirium is a very common and serious complication, evidence for pharmacological treatment is poor, and guidelines remain controversial. Accordingly, non-pharmacological treatments have gained increasing attention and should be applied. Based on current literature, guidelines and personal recommendations, we developed a standard operating procedure (SOP) encompassing non-pharmacological and pharmacological treatment of delirium. COMMENTS In order to prevent delirium, risk factors should be identified and taken into account when planning the hospital stay and treatment. Prevention should include multimodal non-pharmacological interventions. The treatment of delirium should encompass the elimination of potential causes and non-pharmacological interventions. Pharmacological treatment should be used in a time-limited manner and in the lowest possible dose for the management of highly stressful symptoms or high-risk behaviour. CONCLUSION The SOP provides a pragmatic algorithm for the non-pharmacological and pharmacological treatment of delirium.
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Affiliation(s)
- Juraj Kukolja
- Department of Neurology and Clinical Neurophysiology, Helios University Hospital Wuppertal, Heusnerstr. 40, 42283 Wuppertal, Germany
- Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany
- Medical Faculty, University of Cologne, 50937 Cologne, Germany
| | - Jens Kuhn
- Department of Psychiatry and Psychotherapy, Medical Faculty, University of Cologne, Cologne, Germany
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, Johanniter Hospital Oberhausen, EVKLN, Steinbrinkstraße 96a, 46145 Oberhausen, Germany
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Braillon A. Alcohol Withdrawal Syndrome in Neurocritical Care Unit: Nicotine Replacement Therapy and Thiamine Deficiency. Neurocrit Care 2021; 34:706. [PMID: 33403577 DOI: 10.1007/s12028-020-01167-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 11/23/2020] [Indexed: 11/27/2022]
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