The impact of alcohol use and withdrawal on trauma outcomes: A case control study

A National Analysis of Alcohol Withdrawal Syndrome in Patients with Operative Trauma

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.

"Should We Phenobarb-it-All?" A Phenobarbital-Based Protocol for Non-Intensive Care Unit Trauma Patients at High Risk of or Experiencing Alcohol Withdrawal

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.

No Association of Blood Alcohol Concentration on Burn Patient Outcomes

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.

Eliminating the benzos: A benzodiazepine-sparing approach to preventing and treating alcohol withdrawal syndrome

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.

Alcohol Dependence and Rib Fracture Outcomes: A Systematic Review and Meta-Analysis

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.

Prevention of alcohol withdrawal syndrome in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document

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.