Protracted alcohol withdrawal delirium

Twenty-Eight-Day-Long Delirium Tremens

Refractory alcohol withdrawal delirium is uncommon in day-to-day clinical practice. This case report presents a rare case of delirium tremens of unusually long duration that was complicated by the difficulty in tapering down benzodiazepines despite adding midazolam drip as well as phenobarbitone to the management regimen and excluding other possible diagnoses.

Safety and tolerability of sauna detoxification for the protracted withdrawal symptoms of substance abuse

Objective

Protracted drug withdrawal symptoms can last months or years after drug cessation, often precipitating a return to substance misuse. We evaluated the safety and preliminary health benefits of a unique chemical exposure regimen based on exercise, sauna and therapeutic nutrients.

Methods

This was a prospective evaluation of 109 individuals sequentially enrolled into a sauna detoxification component of a multi-modal, long-term residential substance abuse treatment centre.

Results

Data from medical charts, client self-reports and Short Form Health Survey (SF-36) responses indicated that the Hubbard sauna detoxification method was well tolerated, with a 99% completion rate, including one human immunodeficiency virus and nine hepatitis C positive clients. There were no cases of dehydration, overhydration or heat illness. Statistically significant improvements were seen in both mental and physical SF-36 scores at regimen completion, as well as in Addiction Severity Index and Global Appraisal of Individual Needs Short Screener change scores at rehabilitation program discharge, compared with enrolment.

Conclusions

The regimen lacked serious adverse events, had a very low discontinuation rate and high client-reported satisfaction. The SF-36 data indicated improved physical and emotional symptoms. Therefore, broader investigation of this sauna-based treatment regimen is warranted.

The "Forgotten" Treatment of Alcohol Withdrawal Delirium With Electroconvulsive Therapy: Successful Use in a Very Prolonged and Severe Case

OBJECTIVE

Alcohol withdrawal delirium (AWD) is a notorious complication in alcohol withdrawal. Usually, the symptomatic treatment is efficacious; however, some patients show treatment resistance or a prolonged course of AWD.

METHOD

We report the case of a patient with a prolonged and severest form of AWD. Even 11 weeks after admission, he received approximately 100 mg diazepam per week to manage the symptoms of withdrawal delirium.

RESULTS

A treatment course of electroconvulsive therapy was initiated, which allowed a complete tapering off of benzodiazepines during electroconvulsive therapy without adverse effects.

CONCLUSIONS

The reported case might contribute to alternative approaches reserved for severest forms of prolonged AWD.

Alcohol withdrawal delirium manifested by manic symptoms in an elderly patient

Alcohol withdrawal syndrome is a commonly seen problem in psychiatric practice. Alcohol withdrawal delirium is associated with significant morbidity and mortality. Withdrawal symptoms usually include tremulousness, psychotic and perceptual symptoms, seizures, and consciousness disturbance. Herein, we report a case involving a 63-year-old man who had alcohol withdrawal delirium that was manifested mainly by manic symptoms.

A case of prolonged delirium tremens

We present a case of delirium tremens lasting for five weeks in an alcohol-dependent individual. The patient required high-dose benzodiazepines, which is atypical and rare. The clinical presentation and management of this patient is discussed.

Delayed-onset delirium tremens - a diagnostic and management challenge

BACKGROUND

Delirium tremens (DT) is one of the most serious complications of alcohol withdrawal, affecting 5-10% of in-patients with a mortality rate up to 15%. DT, characterised by delirium and tremors, appears within 48-72 h of abstinence and persists for about 5-10 days.

CASE PRESENTATION

We report a case of DT in a young man with delayed onset on the 15th day after the cessation of alcohol use, despite an uncomplicated detoxification with benzodiazepine treatment.

CONCLUSION

We hypothesise that the intake of country liquor in our patient, which contains higher percentages of alcohol, causes a prolonged imbalance of N-methyl-d-aspartic acid and glutamate receptor activity, leading to the picture of delayed-onset DT and that an atypical presentation at the time of admission and atypicality in early course are clinical pointers to the subsequent development of delayed-onset DT.

Symptom-driven lorazepam protocol for treatment of severe alcohol withdrawal delirium in the intensive care unit

STUDY OBJECTIVE

To compare outcomes of treating alcohol withdrawal delirium (AWD) with a symptom-driven benzodiazepine protocol versus nonprotocol benzodiazepine infusions in the intensive care unit (ICU).

DESIGN

Retrospective observational study of a quality improvement project.

SETTING

Medical intensive care unit at a Veterans Affairs medical center.

PATIENTS

Thirty-six patients who had 40 ICU admissions for AWD between January 1, 1994, and May 31, 2003. Sixteen episodes (15 patients [historical controls]) occurred before implementation of the symptom-driven protocol in 1998, and 24 episodes (21 patients) occurred after implementation.

MEASUREMENTS AND MAIN RESULTS

Outcomes evaluated were time to reach symptom control, total dose of benzodiazepine, amount of time receiving continuous benzodiazepine infusion, length of ICU and hospital stay, polypharmacy (use of multiple benzodiazepines), and complications of treatment. The historical control group was treated according to physician preference, which consisted of continuous-infusion midazolam without a protocol. The symptom-driven protocol used lorazepam administered initially as intermittent intravenous doses, progressing to a continuous intravenous infusion according to a locally developed symptom scale. The mean +/- SD values for the outcomes in the historical control group versus the protocol group were as follows: time to control symptoms 19.4 +/- 9.7 versus 7.7 +/- 4.9 hours (p=0.002), cumulative benzodiazepine dose in lorazepam equivalents 1677 +/- 937 versus 1044 +/- 534 mg (p=0.014), time receiving benzodiazepine continuous infusion 122.1 +/- 64.4 versus 52.0 +/- 35.1 hours (p=0.001), length of stay in the ICU 7.7 +/- 6.3 versus 5.6 +/- 1.7 days (p=0.21), and length of hospital stay 15.3 +/- 8.9 versus 11.2 +/- 3.4 days (p=0.43).

CONCLUSIONS

Use of a symptom-driven protocol was associated with significantly decreased time to symptom control, amount of sedative required, and time spent receiving benzodiazepine infusion compared with historical controls. The use of the protocol is effective but requires close monitoring to ensure protocol compliance and to avoid potential propylene glycol toxicity.

Substance abuse and withdrawal in the intensive care unit. Contemporary issues

Because 36% of intentional injury victims are drug dependent, the association between drug abuse and violence, especially in urban settings, is high. Withdrawal syndromes in ICU patients confuse their clinical management, may be extremely difficult to diagnose, are often lethal, need to be suspected, and should be prophylaxed against; therefore, all ICU patients should be considered to be at high risk for drug or alcohol dependence, should be tested for evidence of such drugs, and should be interviewed (together with their family members) for the presence of drug dependence traits. Appropriate patients should be referred for formal evaluation and treatment. Withdrawal syndromes must be promptly recognized, differentiated from traumatic or metabolic deterioration, and immediately treated. As patients are unique, so is their drug dependence. Individualized withdrawal therapy, not a "one method fits all" approach, works best. The mainstay of most withdrawal therapy is supportive care and benzodiazepine therapy. Also, considering the high rate of multiple intoxicants present in trauma patients, withdrawal can occur from multiple agents in a single patient, further compounding these difficulties. Withdrawal from unusual substances, such as GHB, or from therapeutic interventions (e.g., prolonged opioid or benzodiazepine administration) also must be considered.

Alcohol withdrawal syndrome: current management strategies for the surgery patient

PURPOSE

As advances in the therapeutic management of alcohol withdrawal syndrome occur, oral and maxillofacial surgeons should be aware of the current treatment philosophies and modalities. This article provides a comprehensive review of alcohol withdrawal syndrome and presents some of the current management strategies that can be used for these patients, whether it be in the office or in the hospital.

Effects of long-term abstinence on psychological functioning: a prospective longitudinal analysis comparing alcohol-dependent patients and healthy volunteers

Using a prospective longitudinal design, differences between abstinent alcohol-dependent patients (n = 15) and abstinent healthy volunteers (n = 11) were determined with respect to their psychological functioning and alcohol consumption patterns following abstinence. Results showed no differences in alcohol consumption. In 20% of the patients and 9% of the controls more than 10% of protocols indicated alcohol intake, and in 27% of the patients and 27% of the controls less than 10% of protocols indicated alcohol intake. Total abstinence was reported by 53% of the patients and by 64% of the controls. For patients, validation of self-reported alcohol consumption was carried out via biological markers. Patients and controls differed in terms of increased sleep, euphoria, concentration, initiative, anxiety, negative and positive craving, pessimistic thoughts, autonomic disturbances, and humour. A gradual normalization back to baseline levels was observed for some symptoms. These results suggest that affective/mood states may be unstable for alcoholics, and further, that these symptoms may be related to the protracted withdrawal syndrome or may represent residual symptomatology.