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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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Ratner JA, Blaney H, Rastegar DA. Management of alcohol withdrawal syndrome in patients with alcohol-associated liver disease. Hepatol Commun 2024; 8:e0372. [PMID: 38251886 PMCID: PMC10805424 DOI: 10.1097/hc9.0000000000000372] [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] [Received: 12/13/2023] [Accepted: 12/13/2023] [Indexed: 01/23/2024] Open
Abstract
Alcohol-associated liver disease is a common and severe sequela of excessive alcohol use; effective treatment requires attention to both liver disease and underlying alcohol use disorder (AUD). Alcohol withdrawal syndrome (AWS) can be dangerous, is a common barrier to AUD recovery, and may complicate inpatient admissions for liver-related complications. Hepatologists can address these comorbid conditions by learning to accurately stage alcohol-associated liver disease, identify AUD using standardized screening tools (eg, Alcohol Use Disorder Identification Test), and assess risk for and symptoms of AWS. Depending on the severity, alcohol withdrawal often merits admission to a monitored setting, where symptom-triggered administration of benzodiazepines based on standardized scoring protocols is often the most effective approach to management. For patients with severe liver disease, selection of benzodiazepines with less dependence on hepatic metabolism (eg, lorazepam) is advisable. Severe alcohol withdrawal often requires a "front-loaded" approach with higher dosing, as well as intensive monitoring. Distinguishing between alcohol withdrawal delirium and HE is important, though it can be difficult, and can be guided by differentiating clinical characteristics, including time to onset and activity level. There is little data on the use of adjuvant medications, including anticonvulsants, dexmedetomidine, or propofol, in this patient population. Beyond the treatment of AWS, inpatient admission and outpatient hepatology visits offer opportunities to engage in planning for ongoing management of AUD, including initiation of medications for AUD and referral to additional recovery supports. Hepatologists trained to identify AUD, alcohol-associated liver disease, and risk for AWS can proactively address these issues, ensuring that patients' AWS is managed safely and effectively and supporting planning for long-term recovery.
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Affiliation(s)
- Jessica A. Ratner
- Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Hanna Blaney
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Darius A. Rastegar
- Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Ahmed N, Kuo YH. Outcomes of elevated blood alcohol concentrations in elderly patients following a ground level fall: A matched analysis from the national trauma quality program. Alcohol 2023; 119:83-88. [PMID: 37967774 DOI: 10.1016/j.alcohol.2023.11.004] [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: 10/08/2020] [Revised: 09/22/2023] [Accepted: 11/10/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND The rising elderly population and the concomitant increase in alcohol consumption can result in a ground level fall (GLF). The purpose of this study is to evaluate the in-hospital mortality, hospital length of stay, and discharge disposition of elderly patients who sustained a ground level fall (GLF) and tested positive for an elevated blood alcohol concentration (BAC). METHODS The data of patients who were 65 years and older, had an injury after a GLF, and tested for BAC were accessed from the American College of Surgeon - Trauma Quality Improvement Program (ACS-TQIP) from the calendar years of 2011-2016. Patients' demography, injury, comorbidities, and outcomes were compared between the groups who tested positive (>0.08 g/dL) and negative (0 mg/dL) for BAC. Univariate, followed by matched analyses were performed. All p values are two-sided, and a p value < 0.05 is considered statistically significant. RESULTS Out of 20,163 patients who satisfied the inclusion criteria, 2398 patients (∼12%) tested positive for an elevated BAC. There were significant differences found between the two groups, BAC-positive vs. BAC-negative, in univariate analysis for age and sex with p values < 0.001. Propensity score matching balanced demographic characteristics; however, differences remained in certain comorbidities. Exact matching balanced patient demography, injury, and comorbidities. The paired-matched analysis showed no significant differences between the two groups for in-hospital mortality (2.1% vs. 2.1%, p = 1) and median hospital length of stay (5[4-5] vs. 5[5-5], p = 0.307). A higher proportion of patients in the BAC group suffered from alcohol withdrawal syndrome (AWS) and deep vein thrombosis (DVT) complications (9.5% vs. 1.4%, p < 0.001 and 1.5% vs. 0.5%, p = 0.018) compared to BAC-negative patients. A slightly higher percentage of patients in the BAC-positive group were discharged home without any additional services (39.6% vs. 36.9%, p = 0.009). CONCLUSION Of the elderly patients who sustained a GLF and tested for BAC, approximately 12% tested positive for BAC. The overall in-hospital mortality was 2.1%. The BAC-positive group suffered from higher complications of AWS and DVT, and more than 60% of patients required additional services at the time of discharge.
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Affiliation(s)
- Nasim Ahmed
- Division of Trauma & Surgical Critical Care, Jersey Shore University Medical Center, Neptune, NJ, United States; Hackensack Meridian School of Medicine, Nutley, NJ, United States.
| | - Yen-Hong Kuo
- Office of Research Administration, Hackensack Meridian Health Research Institute, Nutley, NJ, United States; Hackensack Meridian School of Medicine, Nutley, NJ, United States
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Marti-Aguado D, Gougol A, Gomez-Medina C, Jamali A, Abo-Zed A, Morales-Arraez D, Jimenez-Sosa A, Burns K, Bawa A, Hernández A, Pujol C, Alvarado-Tapias E, Szafranska J, Chiu WK, Villagrasa A, Ventura-Cots M, Gandicheruvu H, Lluch P, Chen HW, Rachakonda V, Duarte-Rojo A, Bataller R. Prevalence and clinical impact of alcohol withdrawal syndrome in alcohol-associated hepatitis and the potential role of prophylaxis: a multinational, retrospective cohort study. EClinicalMedicine 2023; 61:102046. [PMID: 37415844 PMCID: PMC10319982 DOI: 10.1016/j.eclinm.2023.102046] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 05/29/2023] [Accepted: 05/31/2023] [Indexed: 07/08/2023] Open
Abstract
Background The prevalence and impact of alcohol withdrawal syndrome (AWS) in patients with alcohol-associated hepatitis (AH) are unknown. In this study, we aimed to investigate the prevalence, predictors, management, and clinical impact of AWS in patients hospitalized with AH. Methods A multinational, retrospective cohort study enrolling patients hospitalized with AH at 5 medical centres in Spain and in the USA was performed between January 1st, 2016 to January 31st, 2021. Data were retrospectively retrieved from electronic health records. Diagnosis of AWS was based on clinical criteria and use of sedatives to control AWS symptoms. The primary outcome was mortality. Multivariable models controlling for demographic variables and disease severity were performed to determine predictors of AWS (adjusted odds ratio [OR]) and the impact of AWS condition and management on clinical outcomes (adjusted hazard ratio [HR]). Findings In total, 432 patients were included. The median MELD score at admission was 21.9 (18.3-27.3). The overall prevalence of AWS was 32%. Lower platelet levels (OR = 1.61, 95% CI 1.05-2.48) and previous history of AWS (OR = 2.09, 95% CI 1.31-3.33) were associated with a higher rate of incident AWS, whereas the use of prophylaxis decreased the risk (OR = 0.58, 95% CI 0.36-0.93). The use of intravenous benzodiazepines (HR = 2.18, 95% CI 1.02-4.64) and phenobarbital (HR = 2.99, 95% CI 1.07-8.37) for AWS treatment were independently associated with a higher mortality. The development of AWS increased the rate of infections (OR = 2.24, 95% CI 1.44-3.49), the need for mechanical ventilation (OR = 2.49, 95% CI 1.38-4.49), and ICU admission (OR = 1.96, 95% CI 1.19-3.23). Finally, AWS was associated with higher 28-day (HR = 2.31, 95% CI 1.40-3.82), 90-day (HR = 1.78, 95% CI 1.18-2.69), and 180-day mortality (HR = 1.54, 95% CI 1.06-2.24). Interpretation AWS commonly occurs in patients hospitalized with AH and complicates the hospitalization course. Routine prophylaxis is associated with a lower prevalence of AWS. Prospective studies should determine diagnostic criteria and prophylaxis regimens for AWS management in patients with AH. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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Affiliation(s)
- David Marti-Aguado
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Digestive Disease Department, Clinic University Hospital, Biomedical Research Institute (INCLIVA), Valencia, Spain
| | - Amir Gougol
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Concepcion Gomez-Medina
- Digestive Disease Department, Clinic University Hospital, Biomedical Research Institute (INCLIVA), Valencia, Spain
| | - Arsia Jamali
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Abdelrhman Abo-Zed
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Dalia Morales-Arraez
- Department of Gastroenterology, Hospital Universitario de Canarias, Tenerife, Spain
| | - Alejandro Jimenez-Sosa
- Statistical Consultant Research Unit, Hospital Universitario de Canarias, Tenerife, Spain
| | - Keith Burns
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Aditi Bawa
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Anjara Hernández
- Department of Gastroenterology, Hospital Universitario de Canarias, Tenerife, Spain
| | - Claudia Pujol
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Institut de Recerca Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Edilmar Alvarado-Tapias
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Institut de Recerca Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Justyna Szafranska
- Department of Pathology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Wai Kan Chiu
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ares Villagrasa
- Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Meritxell Ventura-Cots
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
- Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Haritha Gandicheruvu
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Paloma Lluch
- Digestive Disease Department, Clinic University Hospital, Biomedical Research Institute (INCLIVA), Valencia, Spain
| | | | | | - Andres Duarte-Rojo
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ramon Bataller
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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Marchand TD, Dunham CM, Chance EA, Hileman BM. Trauma center admission risk conditions and the probability for developing alcohol withdrawal syndrome: A retrospective study. Injury 2023; 54:198-206. [PMID: 36096958 DOI: 10.1016/j.injury.2022.08.072] [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: 03/22/2022] [Revised: 08/23/2022] [Accepted: 08/31/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Because the proportion of trauma patients developing alcohol withdrawal syndrome (AWS) is low, AWS risk conditions have not been precisely delineated. We aimed to create multifactor screening strategies to assess probabilities for the likelihood of developing AWS. METHODS We performed a retrospective chart review of 1,011 trauma patients admitted to a Level I trauma center to investigate the associations between AWS and probable AWS risk conditions. Included patients were adults who met trauma registry inclusion criteria and had blood alcohol concentration (BAC) testing performed. Patients were excluded if they had a traumatic brain injury with a Glasgow Coma Score (GCS) ≤ 8, or no BAC testing performed. We defined heavy drinking as daily drinking or >7 per week. RESULTS AWS had univariate associations with heavy drinking history, Injury Severity Score (ISS) ≥15, psychiatric disorders, liver disease, smoking history, in-hospital bronchodilator administration, age ≥45, male sex, Intensive Care Unit (ICU) admission, serum aspartate aminotransferase (AST) ≥40 U/L, and cognitive preservation (GCS ≥13 with BAC ≥100 mg/dL) (all, p < 0.05). ICU admission, AST ≥40 U/L, cognitive preservation, male sex, and age ≥45 had associations with ISS ≥15 or alcohol misuse (all, p < 0.0001). For patients with age ≥45 and heavy drinking history or age <45 and heavy drinking history with ISS ≥15 and ICU admission, the AWS proportion (15.3%) was greater in comparison to other patients (0.3%). The AWS risk score was the sum of the following nine conditions, assigned a zero when the condition was absent and one when present (range 0-9): ISS ≥15, psychiatric disorders, liver disease, smoking history, in-hospital bronchodilator administration, age ≥45, male sex, AST ≥40 U/L, and cognitive preservation. The AWS proportion was greater with a risk score of 5-9 (16.8%) than of 0-4 (1.2%; p < 0.0001). CONCLUSIONS AWS in the setting of traumatic injury is associated with multiple risk conditions. The presence of multiple risk conditions might have additive effects that could contribute toward a clinical manifestation of AWS. The identified risk conditions may be associated with a hyperadrenergic state.
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Affiliation(s)
- Tiffany D Marchand
- Trauma, Critical Care, and General Surgery Services, Mercy Health St. Elizabeth Youngstown Hospital, 1044 Belmont Ave., Youngstown, OH, 44501, United States.
| | - C Michael Dunham
- Trauma, Critical Care, and General Surgery Services, Mercy Health St. Elizabeth Youngstown Hospital, 1044 Belmont Ave., Youngstown, OH, 44501, United States
| | - Elisha A Chance
- Trauma and Neuroscience Research Department, Mercy Health St. Elizabeth Youngstown Hospital, 1044 Belmont Ave., Youngstown, OH, 44501, United States
| | - Barbara M Hileman
- Trauma and Neuroscience Research Department, Mercy Health St. Elizabeth Youngstown Hospital, 1044 Belmont Ave., Youngstown, OH, 44501, United States
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