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Balian J, Cho NY, Vadlakonda A, Curry J, Chervu N, Ali K, Benharash P. A National Analysis of Alcohol Withdrawal Syndrome in Patients with Operative Trauma. Surg Open Sci 2024; 19:199-204. [PMID: 38800119 PMCID: PMC11127230 DOI: 10.1016/j.sopen.2024.05.001] [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] [Received: 03/28/2024] [Accepted: 05/04/2024] [Indexed: 05/29/2024] Open
Abstract
Background Alcohol withdrawal syndrome (AWS) presents with a complex spectrum of clinical manifestations that complicate postoperative management. In trauma setting, subjective screening for AWS remains challenging due to the criticality of injury in these patients. We thus identified several patient characteristics and perioperative outcomes associated AWS development. Methods The 2016-2020 National Inpatient Sample was queried to identify all non-elective adult (≥18 years) hospitalizations for blunt or penetrating trauma undergoing operative management with a diagnosis of AWS. Patients with traumatic brain injury or with a hospital duration of stay <2 days were excluded. Outcomes of interest included in-hospital mortality, perioperative complications, hospitalization costs, length of stay (LOS) and non-home discharge. Results Of an estimated 2,965,079 operative trauma hospitalizations included for analysis, 36,415 (1.23 %) developed AWS following admission. The AWS cohort demonstrated increased odds of mortality (Adjusted Odds Ratio [AOR] 1.46, 95 % Confidence Interval [95 % CI] 1.23-1.73), along with infectious (AOR 1.73, 95 % CI 1.58-1.88), cardiac (AOR 1.24, 95 % CI 1.06-1.46), and respiratory (AOR 1.96, 95 % CI 1.81-2.11) complications. AWS was associated with prolonged LOS, (β: 3.3 days, 95 % CI: 3.0 to 3.5), greater cost (β: +$8900, 95 % CI $7900-9800) and incremental odds of nonhome discharge (AOR 1.43, 95 % CI 1.34-1.53). Furthermore, male sex, Medicaid insurance status, head injury and thoracic operation were linked with greater odds of development of AWS. Conclusion In the present study, AWS development was associated with increased odds of in-hospital mortality, perioperative complications, and resource burden. The identification of patient and operative characteristics linked with AWS may improve screening protocols in trauma care.
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Affiliation(s)
- Jeffrey Balian
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Nam Yong Cho
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Amulya Vadlakonda
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Joanna Curry
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Nikhil Chervu
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Konmal Ali
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Peyman Benharash
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
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Wang M, Falank C, Simboli V, Ontengco JB, Spurling B, Rappold J, Chung B, Smith KE. "Should We Phenobarb-it-All?" A Phenobarbital-Based Protocol for Non-Intensive Care Unit Trauma Patients at High Risk of or Experiencing Alcohol Withdrawal. Am Surg 2024:31348241244639. [PMID: 38574377 DOI: 10.1177/00031348241244639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
BACKGROUND Alcohol use is frequent in trauma patients and alcohol withdrawal syndrome (AWS) is associated with significant morbidity. Benzodiazepines are commonly used for AWS, but may cause neurologic and respiratory adverse events (AEs). The objective was to evaluate the effectiveness and safety of a phenobarbital-based protocol for the treatment of AWS in non-intensive care unit (ICU) trauma patients. METHODS Adult non-ICU trauma patients at high risk of or experiencing AWS PRE and POST implementation of a phenobarbital-based protocol were included. Outcomes were AWS-related complications (AWS-RC), benzodiazepine use, adjunctive medication use, hospital length of stay (HLOS), and medication-related AEs. Subgroup analyses were performed on patients with traumatic brain injury (TBI), rib fractures, and at high risk of severe AWS. RESULTS Overall, 110 patients were included (51 PRE, 59 POST). AWS-RC developed in 17 PRE patients compared to 10 POST patients (33% vs 17%; P = .05). PRE patients were more likely to receive benzodiazepines (88% vs 42%, P < .0001) and higher total dose (11 vs 4 mg lorazepam equivalent; P = .001). No difference noted in HLOS (8 vs 8 days, P = .27), adjunctive medication use (49% vs 54%, P = .60), or AEs (57% vs 39%, P = .06). There was no difference in AWS-RC in the TBI subgroup (P = .19), less AEs in the rib fracture POST subgroup (P = .04), and less AWS-RC in the high risk of severe AWS POST subgroup (P = .03). DISCUSSION A phenobarbital-based protocol in trauma patients is effective in preventing AWS-RC and decreasing benzodiazepine use without increasing AEs.
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Affiliation(s)
- Michelle Wang
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Carolyne Falank
- Department of Surgery, Maine Medical Center, Portland, ME, USA
| | - Vincent Simboli
- Department of Pharmacy, Maine Medical Center, Portland, ME, USA
| | | | - Brandi Spurling
- Department of Surgery, Maine Medical Center, Portland, ME, USA
| | - Joseph Rappold
- Department of Surgery, Maine Medical Center, Portland, ME, USA
| | - Bruce Chung
- Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Kathryn E Smith
- Department of Pharmacy, Maine Medical Center, Portland, ME, USA
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Bria J, Shahait A, Nagle L, White M, Tarras S. No Association of Blood Alcohol Concentration on Burn Patient Outcomes. J Surg Res 2024; 296:766-771. [PMID: 38377703 DOI: 10.1016/j.jss.2024.01.038] [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] [Received: 02/28/2023] [Revised: 01/09/2024] [Accepted: 01/18/2024] [Indexed: 02/22/2024]
Abstract
INTRODUCTION Alcohol abuse is common among burn patients. Burn patients under the influence of alcohol are at risk for developing organ failure, prolonged hospital duration, and increased intensive care unit (ICU) resources. Our study aims to analyze the association between presenting alcohol levels and the outcomes of burn patients. METHODS A retrospective analysis of admitted burn patients was performed from 2016 to 2021. Patients were divided into two groups based on blood alcohol content (BAC), low (<80), and high (≥80) mg/dL. Data included demographics, comorbidities, and outcomes. Univariate analyses were performed, and a P value <0.05 was significant. RESULTS A total of 197 patients were included (32.5% females, mean age 47.2 ± 15.2, 26.9% smokers, 28.4% illegal drug abuse, and 56.3% no comorbidities). Mortality was 7.6%, morbidity 20.8%, 39.1% required burn ICU admission, and 25.9% were intubated. When comparing BAC groups, we found no differences in demographics, comorbidities, inhalational injury incidence, carbon monoxide level, intubation, or burn ICU admission rates. The high-BAC group had longer ventilator days (high BAC 16.7 ± 19.3 versus low BAC 7.5 ± 9.1, P = 0.026) and longer stays in the ICU (18.6 ± 21.8 versus 10.7 ± 15.4, P = 0.075). The low-BAC group had more 3rd-degree burn percentage (5.0 ± 15.3 versus 15.4 ± 27.5, P = 0.024). Both morbidity and in-house mortality rates were similar for both groups (23.8% versus 16.0%, P = 0.192, and 6.6% versus 9.3%, P = 0.476, respectively). CONCLUSIONS Burn patients with higher BAC had significantly longer mechanical ventilator days. However, higher alcohol concentrations had no association with regard to mortality, overall length of stay, or complication rates.
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Affiliation(s)
- Justin Bria
- The Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit, Michigan
| | - Awni Shahait
- Department of Surgery, Southern Illinois University School of Medicine, Carbondale, Illinois
| | - Luz Nagle
- The Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit, Michigan
| | - Michael White
- The Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit, Michigan
| | - Samantha Tarras
- The Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit, Michigan.
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McCullough MA, Miller PR, Martin T, Rebo KA, Stettler GR, Martin RS, Cantley M, Shilling EH, Hoth JJ, Nunn AM. Eliminating the benzos: A benzodiazepine-sparing approach to preventing and treating alcohol withdrawal syndrome. J Trauma Acute Care Surg 2024; 96:394-399. [PMID: 37934662 DOI: 10.1097/ta.0000000000004188] [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: 11/09/2023]
Abstract
BACKGROUND Alcohol withdrawal syndrome (AWS) represents significant cost to the hospitalized trauma population from a clinical and financial perspective. Historically, AWS has been managed with benzodiazepines. Despite their efficacy, benzodiazepines carry a heavy adverse effect profile. Recently, benzodiazepine-sparing protocols for the prophylaxis and treatment of AWS have been used in medical patient populations. Most existing benzodiazepine-sparing protocols use phenobarbital, while ours primarily uses gabapentin and clonidine, and no such protocol has been developed and examined for safety and efficacy specifically within a trauma population. METHODS In December of 2019, we implemented our benzodiazepine-sparing protocol for trauma patients identified at risk for alcohol withdrawal on admission. Trauma patients at risk for AWS admitted to an academic Level 1 trauma center before (conventional) and after (benzodiazepine-sparing [BS]) protocol implementation were compared. Outcomes examined include morphine milligram equivalent dosing rates and lorazepam equivalent dosing rates as well as the Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) scores, hospital length of stay, intensive care unit length of stay, and ventilator days. RESULTS A total of 387 conventional and 134 benzodiazepine sparing patients were compared. Injury Severity Score (13 vs. 16, p = 0.10) and admission alcohol levels (99 vs. 149, p = 0.06) were similar. Patients in the BS pathway had a lower maximum daily CIWA-Ar (2.7 vs. 1.5, p = 0.04). While mean morphine milligram equivalent per day was not different between groups (31.5 vs. 33.6, p = 0.49), mean lorazepam equivalents per day was significantly lower in the BS group (1.1 vs. 0.2, p < 0.01). Length of stay and vent days were not different between the groups. CONCLUSION Implementation of a benzodiazepine-sparing pathway that uses primarily clonidine and gabapentin to prevent and treat alcohol withdrawal syndrome in trauma patients is safe, reduces the daily maximum CIWA-Ar, and significantly decreases the need for benzodiazepines. Future studies will focus on outcomes affected by avoiding AWS and benzodiazepines in the trauma population. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Mary Alyce McCullough
- From the Department of Surgery (M.A.M., P.R.M., T.M., G.R.S., R.S.M., E.H.S., J.J.H., A.M.N.), and Department of Acute Care Pharmacy (K.A.R.), Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, NC; and Department of Clinical Pharmacy (M.C.), Virginia Commonwealth University Health, Richmond, VA
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Field F, Olsson J, Hurley A. Alcohol Dependence and Rib Fracture Outcomes: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e42639. [PMID: 37644941 PMCID: PMC10461216 DOI: 10.7759/cureus.42639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2023] [Indexed: 08/31/2023] Open
Abstract
Chronic alcohol use has been associated with impaired pulmonary function, increased risk of pneumonia and poor outcomes after trauma. With a high incidence of rib fractures in this population, the clinical and physiological factors associated with alcohol dependence may influence how these patients recover from thoracic injuries. Therefore, the aim of the systematic review was to examine the effect of alcohol dependence on rib fracture outcomes. The Embase, PubMed and Web of Science databases were searched for studies examining adult patients with rib fractures, with and without a history of alcohol dependency. The outcomes of interest were mortality, pulmonary complications, intensive care length of stay, ventilator days and hospital length of stay. A meta-analysis was performed to combine the data and compare results. Three studies met the criteria for inclusion in the review and all studies were observational in design. Alcohol dependency was associated with increased mortality (OR 1.44 (95% CI: 1.33-1.56)), pneumonia (OR 2.14 (2.02-2.27)) and ARDS (OR 1.71(1.48-1.98)) as well as longer stays in hospital and intensive care (p<0.05). No difference was found in ventilator days between the two groups. Early intensive care review should be considered to reduce complications in this population alongside prompt management of withdrawal symptoms. However, limited primary research exists on this topic and the quality of current evidence is low. Additional primary research is needed to further understand this correlation and draw meaningful conclusions.
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Affiliation(s)
- Fiona Field
- Trauma Sciences, Queen Mary University of London, London, GBR
| | - Jenny Olsson
- Anaesthetics, King's College Hospital NHS Foundation Trust, London, GBR
| | - Anna Hurley
- Plastic Surgery, Hull University Teaching Hospitals, Hull, GBR
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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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