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Ronan MV, Gordon KS, Skanderson M, Krug M, Godwin P, Heppe D, Hoegh M, Boggan JC, Gutierrez J, Kaboli P, Pescetto M, Guidry M, Caldwell P, Mitchell C, Ehlers E, Allaudeen N, Cyr J, Smeraglio A, Yarbrough P, Rose R, Jagannath A, Vargas J, Cornia PB, Shah M, Tuck M, Arundel C, Laudate J, Elzweig J, Rodwin B, Akwe J, Trubitt M, Gunderson CG. Contemporary Management and Outcomes of Veterans Hospitalized With Alcohol Withdrawal: A Multicenter Retrospective Cohort Study. J Addict Med 2024; 18:389-396. [PMID: 38452185 DOI: 10.1097/adm.0000000000001297] [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: 03/09/2024]
Abstract
OBJECTIVES Few studies describe contemporary alcohol withdrawal management in hospitalized settings or review current practices considering the guidelines by the American Society of Addiction Medicine (ASAM). METHODS We conducted a retrospective cohort study of patients hospitalized with alcohol withdrawal on medical or surgical wards in 19 Veteran Health Administration (VHA) hospitals between October 1, 2018, and September 30, 2019. Demographic and comorbidity data were obtained from the Veteran Health Administration Corporate Data Warehouse. Inpatient management and hospital outcomes were obtained by chart review. Factors associated with treatment duration and complicated withdrawal were examined. RESULTS Of the 594 patients included in this study, 51% were managed with symptom-triggered therapy alone, 26% with fixed dose plus symptom-triggered therapy, 10% with front loading regimens plus symptom-triggered therapy, and 3% with fixed dose alone. The most common medication given was lorazepam (87%) followed by chlordiazepoxide (33%), diazepam (14%), and phenobarbital (6%). Symptom-triggered therapy alone (relative risk [RR], 0.68; 95% confidence interval [CI], 0.57-0.80) and front loading with symptom-triggered therapy (RR, 0.75; 95% CI, 0.62-0.92) were associated with reduced treatment duration. Lorazepam (RR, 1.20; 95% CI, 1.02-1.41) and phenobarbital (RR, 1.28; 95% CI, 1.06-1.54) were associated with increased treatment duration. Lorazepam (adjusted odds ratio, 4.30; 95% CI, 1.05-17.63) and phenobarbital (adjusted odds ratio, 6.51; 95% CI, 2.08-20.40) were also associated with complicated withdrawal. CONCLUSIONS Overall, our results support guidelines by the ASAM to manage patients with long-acting benzodiazepines using symptom-triggered therapy. Health care systems that are using shorter acting benzodiazepines and fixed-dose regimens should consider updating alcohol withdrawal management pathways to follow ASAM recommendations.
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Affiliation(s)
- Matthew V Ronan
- From the Medical Service, GIM Section, VA Boston Healthcare System, West Roxbury, MA (MR); Harvard Medical School, Boston, MA (MR); VA Connecticut Healthcare System, West Haven, CT (KSG, M Skanderson, BR, CGG); Yale University School of Medicine, New Haven, CT (KSG, BR, CGG); Medical Service, Boise VA Medical Center, Boise, ID (MK); University of Washington School of Medicine, Seattle, WA (MK, PBC, M Shah); Medical Service, Jesse Brown VA Medical Center, Chicago, IL (PG); University of Illinois, College of Medicine, Chicago, IL (PG); VA Eastern Colorado Health Care System, Aurora, CO (DH, MH); Department of Medicine, University of Colorado School of Medicine, Aurora, CO (DH, MH); Medical Service, Durham VA Medical Center, Durham, NC (JCB); Department of Medicine, Duke University School of Medicine, Durham, NC (JCB); Section of Hospital Medicine, Iowa City VA Healthcare System, Iowa City, IA (JG, PK); Department of Medicine, University of Iowa Health Care, Carver College of Medicine, Iowa City, IA (JG, PK); Medical Service, VA Kansas City Health Care, Kansas City, MO (MP); Medical Service, New Orleans VA Medical Center, New Orleans, LA (MG, PC); Tulane University School of Medicine, New Orleans, LA (MG, PC); Medical Service, Veteran Affairs Nebraska-Western Iowa Health Care System, Omaha, NE (CM, EE); University of Nebraska Medical Center, College of Medicine, Omaha, NE (EE); Medical Service, VA Palo Alto Healthcare System, Palo Alto, CA (NA); Stanford University School of Medicine, Palo Alto, CA (NA); Medical Service, Pittsburgh VA Medical Center, Pittsburgh, PA (JC); Pittsburgh University School of Medicine, Pittsburgh, PA (JC); Medical Service, VA Portland Healthcare System, Portland, OR (AS, AJ); Oregon Health and Science University, School of Medicine, Portland, OR (AS, AJ); Medical Service, Salt Lake City VA Medical Center, Salt Lake City, UT (PY, RR); University of Utah School of Medicine, Salt Lake City, UT (PY, RR); Medical Service, San Diego VA Medical Center, San Diego, CA (JV); Medical Service, VA Puget Sound Healthcare System, Seattle, WA (PBC, M Shah); Medical Service, VA Washington DC Health Care System, Washington, DC (MT, CA); George Washington University School of Medicine and Health Sciences, Washington, DC (MT); Georgetown University School of Medicine, Washington, DC (CA); Medical Service, White River Junction VA Medical Center, White River Junction, VT (JL, JE); Geisel School of Medicine at Dartmouth, Hanover, NH (JL, JE); Medical Service, Atlanta VA Medical Center, Atlanta, GA (JA, MT); Emory University School of Medicine, Atlanta, GA (JA, MT)
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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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Krcmarik KM, Hulley BJ, Huang J, Juang D, Cadman P, Urbiztondo C, Vo C, Vargas J, Motarjemi R, Moinizandi T, Kwan B. Assessment of a modified MINDS-based protocol for management of alcohol withdrawal syndrome on an inpatient medical service. Pharmacotherapy 2023; 43:1297-1306. [PMID: 37475509 DOI: 10.1002/phar.2855] [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: 03/31/2023] [Revised: 06/14/2023] [Accepted: 06/19/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVE To determine if a novel symptom-based alcohol withdrawal syndrome (AWS) protocol in a US Veterans cohort leads to significant clinical improvements in patient outcomes and safety. BACKGROUND Prior studies of AWS management, oftentimes using the revised version of the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) index, have demonstrated the effectiveness of symptom-triggered therapy for AWS. The Minnesota Detoxification Scale (MINDS) is an alternative to the CIWA-Ar index but remains unevaluated outside of the intensive care unit (ICU) setting. This study assesses outcomes in AWS management prior to and after the implementation of a novel MINDS-based AWS protocol (SDAWP) utilizing a revised MINDS index (MINDS-rev) in an inpatient medical ward setting. METHODS Retrospective cohort study including encounters prior to (n = 342) and after (n = 338) the implementation of the protocol. Pre- and post-protocol encounters were selected by combinations of diagnostic codes and charting elements. Outcome measures of AWS management were obtained in both groups. The primary endpoint was median total benzodiazepine exposure. Secondary outcomes included median length of hospitalization, median duration of benzodiazepine administration, and the incidence of complications. RESULTS The median total benzodiazepine exposure in the post-SDAWP group was significantly lower than the pre-SDAWP group (21.2 vs. 12.0 mg, p < 0.0001) and for a significantly shorter median duration of time (4.0 vs. 3.0 days, p < 0.0001). There was no significant difference in the median length of stay (4.0 vs. 4.0 days, p = 0.50). The incidence of delirium tremens (21 vs. 7, p = 0.01) and need for transfer to a higher level of care (33 vs. 12, p = 0.002) was significantly lower in the post-SDAWP group. CONCLUSION The SDAWP has provided significant improvements in AWS management in our institution and may potentially serve as a template for wider use in other inpatient settings.
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Affiliation(s)
- Kevin M Krcmarik
- Department of Internal Medicine, Section of Hospitalist Medicine, Jennifer Moreno Veterans Affairs Medical Center, San Diego, California, USA
| | - Benjamin J Hulley
- Department of Internal Medicine, Section of Hospitalist Medicine, Jennifer Moreno Veterans Affairs Medical Center, San Diego, California, USA
| | - Jiayi Huang
- Department of Pharmacy, Jennifer Moreno Veterans Affairs Medical Center, San Diego, California, USA
| | - Derek Juang
- Department of Internal Medicine, Section of Hospitalist Medicine, Jennifer Moreno Veterans Affairs Medical Center, San Diego, California, USA
| | - Peter Cadman
- Department of Internal Medicine, Section of Hospitalist Medicine, Jennifer Moreno Veterans Affairs Medical Center, San Diego, California, USA
| | - Charisma Urbiztondo
- Department of Pharmacy, Jennifer Moreno Veterans Affairs Medical Center, San Diego, California, USA
| | - Christine Vo
- Department of Pharmacy, Jennifer Moreno Veterans Affairs Medical Center, San Diego, California, USA
| | - Jaclyn Vargas
- Department of Internal Medicine, Section of Hospitalist Medicine, Jennifer Moreno Veterans Affairs Medical Center, San Diego, California, USA
| | - Ramin Motarjemi
- Department of Internal Medicine, Section of Hospitalist Medicine, Jennifer Moreno Veterans Affairs Medical Center, San Diego, California, USA
| | - Tarlan Moinizandi
- Department of Internal Medicine, Section of Hospitalist Medicine, Jennifer Moreno Veterans Affairs Medical Center, San Diego, California, USA
| | - Brian Kwan
- Department of Internal Medicine, Section of Hospitalist Medicine, Jennifer Moreno Veterans Affairs Medical Center, San Diego, California, USA
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George A, Baxter M. Decreasing Length of Stay in Opioid Withdrawal. J Am Psychiatr Nurses Assoc 2023; 29:483-486. [PMID: 34796751 DOI: 10.1177/10783903211059565] [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] [Indexed: 11/16/2022]
Abstract
INTRODUCTION In 2017, more than 1,200 opioid-related deaths were reported in Virginia, with slightly fewer in 2018, at 1,193 deaths. The current opioid crisis has placed a strain on an already limited number of mental health (MH) inpatient beds. The industry standard for assessment and treatment of opioid withdrawal symptoms, in the inpatient setting, is the Clinical Opiate Withdrawal Scale (COWS), and yet some units continue to utilize the Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) for this population. AIM The purpose of this nurse-led performance improvement project was to implement COWS in the inpatient MH setting and improve length of stay (LOS) by 1 day. METHOD In 2018, in a large federal teaching facility in the mid-Atlantic region, the COWS was implemented to replace the CIWA-Ar for opioid withdrawal, with the focus on decreasing LOS. Prior to implementation of COWS, LOS on the inpatient MH unit for opioid withdrawal was 8.6 days, which was higher than the ~6- to 7-day LOS for surrounding private sector hospitals. Individual electronic medical records were reviewed for LOS and completion of COWS and pertinent details were discussed daily with nursing staff and monthly with the interdisciplinary team. Baseline data were collected from April 2017 to March 2018, with data collection continuing through the project implementation, April to September 2018. RESULTS Completion of COWS on 100% of patients admitted with opioid withdrawal and a decrease in LOS from 8.6 to 4.7 days was found, a 45% reduction. CONCLUSION The nurse-driven performance improvement project affected business acumen, through decreased LOS, as well as quality of care, through better symptom management.
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Affiliation(s)
- Ansa George
- Ansa George, BSc, BSN, MSN, PMH-RN-BC, Richmond VA Medical Center, Richmond, VA, USA
| | - Marian Baxter
- Marian L Baxter, PhD, RN, GCNS-BC, CRRN, Richmond VA Medical Center, Richmond, VA, USA
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Al-Maqbali JS, Al Alawi AM, Al-Mamari Q, Al-Huraizi A, Al-Maqrashi N. Symptoms-triggered approach versus fixed-scheduled approach of benzodiazepines for management of alcohol withdrawal syndrome: Non-randomized controlled trial. Alcohol 2023; 106:10-14. [PMID: 36240945 DOI: 10.1016/j.alcohol.2022.09.004] [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: 02/08/2022] [Revised: 09/29/2022] [Accepted: 09/29/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Alcohol withdrawal syndrome, if untreated, can lead to potentially life-threatening complications. Benzodiazepines are the drugs of choice for the treatment of alcohol withdrawal syndrome. We aimed to compare the symptoms-triggered approach and fixed-dose approach of benzodiazepine administration for treatment of alcohol withdrawal syndrome in regard to the health care utilization measured by the total dose of benzodiazepines, length of hospital stays, and 90-day readmissions rate. METHODS A single-center prospective non-randomized controlled trial included all patients diagnosed with alcohol withdrawal syndrome. The group of patients admitted between October 1, 2019, and September 30, 2020, were treated with the fixed-scheduled approach (n = 150), while all patients admitted between November 1, 2020, to October 31, 2021, were treated with the symptoms-trigger approach (n = 50). RESULTS The fixed-dose approach group showed a significant higher 90-day readmissions rate (HR: 2.61; 95% CI = 1.18, 6.84; p = 0.01). Kaplan-Meier survival analysis showed a significantly shorter duration to the first readmission in the fixed-scheduled approach group (HR: 2.3; 95% CI = 5.6, 1.16; p = 0.02). The symptoms-triggered approach group required a significantly lower dose of diazepam (40 mg vs. 10 mg; p < 0.01) and a higher dose of thiamine (800 mg vs. 600 mg; p < 0.01). Length of hospital stay was significantly increased in the symptoms-triggered approach group (3.9 vs. 2.2 days; p < 0.01). DISCUSSION The use of a symptoms-triggered approach to treat alcohol withdrawal syndrome was associated with a lower 90-day readmission rate, prolonged period to the first readmission, and reduced total dose of benzodiazepines, but longer length of hospital stays. CONCLUSION The symptoms-triggered approach is safe, cost-effective, and associated with reduced alcohol dependence relapse.
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Affiliation(s)
| | - Abdullah M Al Alawi
- Department of Medicine, Sultan Qaboos University Hospital, Muscat, Oman; Internal Medicine Training Program, Oman Medical Specialty Board, Muscat, Oman.
| | - Qasim Al-Mamari
- Department of Nursing, Sultan Qaboos University Hospital, Muscat, Oman
| | - Aisha Al-Huraizi
- Department of Medicine, Sultan Qaboos University Hospital, Muscat, Oman
| | - Nasiba Al-Maqrashi
- Internal Medicine Training Program, Oman Medical Specialty Board, Muscat, Oman
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Smith JT, Sage M, Szeto H, Myers LC, Lu Y, Martinez A, Kipnis P, Liu VX. Outcomes After Implementation of a Benzodiazepine-Sparing Alcohol Withdrawal Order Set in an Integrated Health Care System. JAMA Netw Open 2022; 5:e220158. [PMID: 35191968 PMCID: PMC8864512 DOI: 10.1001/jamanetworkopen.2022.0158] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 01/01/2022] [Indexed: 11/14/2022] Open
Abstract
Importance Alcohol withdrawal syndrome (AWS) is a common inpatient diagnosis managed primarily with benzodiazepines. Concerns about the adverse effects associated with benzodiazepines have spurred interest in using benzodiazepine-sparing treatments. Objective To evaluate changes in outcomes after implementation of a benzodiazepine-sparing AWS inpatient order set that included adjunctive therapies (eg, gabapentin, valproic acid, clonidine, and dexmedetomidine). Design, Setting, and Participants This difference-in-differences quality improvement study was conducted among 22 899 AWS adult hospitalizations from October 1, 2014, to September 30, 2019, in the Kaiser Permanente Northern California integrated health care delivery system. Data were analyzed from September 2020 through November 2021. Exposures Implementation of the benzodiazepine-sparing AWS order set on October 1, 2018. Main Outcomes and Measures Adjusted rate ratios for medication use, inpatient mortality, length of stay, intensive care unit admission, and nonelective readmission within 30 days were calculated comparing postimplementation and preimplementation periods among hospitals with and without order set use. Results Among 904 540 hospitalizations in the integrated health care delivery system during the study period, AWS was present in 22 899 hospitalizations (2.5%), occurring among 16 323 unique patients (mean [SD] age, 57.1 [14.8] years; 15 764 [68.8%] men). Of these hospitalizations, 12 889 (56.3%) used an order set for alcohol withdrawal. Among hospitalizations with order set use, any benzodiazepine use decreased after implementation from 6431 hospitalizations (78.1%) to 2823 hospitalizations (60.7%) (P < .001), with concomitant decreases in the mean (SD) total dosage of lorazepam before vs after implementation (19.7 [38.3] mg vs 6.0 [9.1] mg; P < .001). There were also significant changes from before to after implementation in the use of adjunctive medications, including gabapentin (2413 hospitalizations [29.3%] vs 2814 hospitalizations [60.5%]; P < .001), clonidine (1476 hospitalizations [17.9%] vs 2208 hospitalizations [47.5%]; P < .001), thiamine (6298 hospitalizations [76.5%] vs 4047 hospitalizations [87.0%]; P < .001), valproic acid (109 hospitalizations [1.3%] vs 256 hospitalizations [5.5%]; P < .001), and phenobarbital (412 hospitalizations [5.0%] vs 292 hospitalizations [6.3%]; P = .003). Compared with AWS hospitalizations without order set use, use of the benzodiazepine-sparing order set was associated with decreases in intensive care unit use (adjusted rate ratio [ARR], 0.71; 95% CI, 0.56-0.89; P = .003) and hospital length of stay (ARR, 0.71; 95% CI, 0.58-0.86; P < .001). Conclusions and Relevance This study found that implementation of a benzodiazepine-sparing AWS order set was associated with decreased use of benzodiazepines and favorable trends in outcomes. These findings suggest that further prospective research is needed to identify the most effective treatments regimens for patients hospitalized with alcohol withdrawal.
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Affiliation(s)
- Joshua T. Smith
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Mary Sage
- Consultation-Liaison Psychiatry Service, Walnut Creek Medical Center, Kaiser Permanente Northern California, Walnut Creek
| | - Herb Szeto
- Hospital Based Specialist Service, Redwood City Medical Center, Kaiser Permanente Northern California, Redwood City
| | - Laura C. Myers
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Yun Lu
- Division of Research, Kaiser Permanente Northern California, Oakland
| | | | - Patricia Kipnis
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente Northern California, Oakland
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Cohen SM, Alexander RS, Holt SR. The Spectrum of Alcohol Use: Epidemiology, Diagnosis, and Treatment. Med Clin North Am 2022; 106:43-60. [PMID: 34823734 DOI: 10.1016/j.mcna.2021.08.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In the United States, alcohol is the most common substance used and the spectrum of unhealthy alcohol use is highly prevalent. Complications of unhealthy alcohol use affect nearly every organ system. One of the most frequent and potentially life-threatening of these complications is alcohol withdrawal syndrome for which benzodiazepines remain first-line therapy. Pharmacologic treatment of alcohol use disorder, the most severe form of unhealthy alcohol use, is underutilized despite the availability of multiple effective medications. Although behavioral therapies are an important component of treatment, they are overemphasized at the expense of pharmacotherapy.
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Affiliation(s)
- Shawn M Cohen
- Program in Addiction Medicine, Section of General Internal Medicine, Yale School of Medicine, 367 Cedar Street, Harkness Hal A, Suite 417A, New Haven, CT 06510, USA.
| | - Ryan S Alexander
- Program in Addiction Medicine, Section of General Internal Medicine, Yale School of Medicine, 367 Cedar Street, Harkness Hal A, Suite 417A, New Haven, CT 06510, USA; Department of Preventive Medicine, Griffin Hospital, Derby, CT 06418, USA; Department of Internal Medicine, Griffin Hospital, Derby, CT 06418, USA
| | - Stephen R Holt
- Program in Addiction Medicine, Section of General Internal Medicine, Yale School of Medicine, 367 Cedar Street, Harkness Hal A, Suite 417A, New Haven, CT 06510, USA
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Vigouroux A, Garret C, Lascarrou JB, Martin M, Miailhe AF, Lemarié J, Dupeyrat J, Zambon O, Seguin A, Reignier J, Canet E. Alcohol withdrawal syndrome in ICU patients: Clinical features, management, and outcome predictors. PLoS One 2021; 16:e0261443. [PMID: 34928984 PMCID: PMC8687554 DOI: 10.1371/journal.pone.0261443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/01/2021] [Indexed: 12/01/2022] Open
Abstract
Background Alcohol withdrawal syndrome (AWS) is a common condition in hospitalized patients, yet its epidemiology in the ICU remains poorly characterized. Methods Retrospective cohort of patients admitted to the Nantes University Hospital ICU between January 1, 2017, and December 31, 2019, and coded for AWS using ICD-10 criteria. The objective of the study was to identify factors associated with complicated hospital stay defined as ICU length of stay ≥7 days or hospital mortality. Results Among 5,641 patients admitted to the ICU during the study period, 246 (4.4%) were coded as having AWS. Among them, 42 had exclusion criteria and 204 were included in the study. The three main reasons for ICU admission were sepsis (29.9%), altered consciousness (29.4%), and seizures (24%). At ICU admission, median Cushman’s score was 6 [4–9] and median SOFA score was 3 [2–6]. Delirium tremens occurred in half the patients, seizures in one fifth and pneumonia in one third. Overall, 48% of patients developed complicated hospital stay, of whom 92.8% stayed in the ICU for ≥7 days, 36.7% received MV for ≥7 days, and 16.3% died during hospital stay. By multivariable analysis, two factors were associated with complicated hospital stay: a higher number of organ dysfunctions at ICU admission was associated with a higher risk of complicated hospital stay (OR, 1.18; 95CI, 1.05–1.32, P = 0.005), whereas ICU admission for seizures was associated with a lower risk of complicated hospital stay (OR, 0.14; 95%CI, 0.026–0.80; P = 0.026). Conclusions AWS in ICU patients chiefly affects young adults and is often associated with additional factors such as sepsis, trauma, or surgery. Half the patients experienced an extended ICU stay or death during the hospital stay. The likelihood of developing complicated hospital stay relied on the reason for ICU admission and the number of organ dysfunctions at ICU admission.
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Affiliation(s)
- Aliénor Vigouroux
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Charlotte Garret
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Jean-Baptiste Lascarrou
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Maëlle Martin
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Arnaud-Félix Miailhe
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Jérémie Lemarié
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Julien Dupeyrat
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Olivier Zambon
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Amélie Seguin
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Jean Reignier
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Emmanuel Canet
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
- * E-mail:
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Chebolu E, Schwandt ML, Ramchandani VA, Stangl BL, George DT, Horneffer Y, Vinson T, Vogt EL, Manor BA, Diazgranados N, Goldman D. Common Factors Underlying Diverse Responses in Alcohol Use Disorder. PSYCHIATRIC RESEARCH AND CLINICAL PRACTICE 2021; 3:76-87. [PMID: 34746678 PMCID: PMC8552111 DOI: 10.1176/appi.prcp.20200028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/19/2020] [Accepted: 10/24/2020] [Indexed: 01/23/2023] Open
Abstract
Objective Interindividual variation in responses to alcohol is substantial, posing challenges for medical management and for understanding the biological underpinnings of alcohol use disorders (AUD). It is important to understand whether diverse alcohol responses such as sedation, which is predictive of risk and partly heritable, occur concurrently or independently from responses such as blackouts and withdrawal. We hypothesized that latent factors accounting for sources of variance in diverse alcohol response phenotypes could be identified in a large, deeply phenotyped sample of patients with AUD. Methods We factor analyzed 17 alcohol response related items from the Alcohol Dependence Scale (ADS) in 938 individuals diagnosed with AUD via structured clinical interviews. Demographic, genetic, and clinical characteristics were tested as predictors of the latent factors by multiple indicators, multiple causes analysis. Results The final factor solution included three alcohol response factors: Physical Symptoms, Perceptual Disturbances, and Neurobiological Effects. Both gender and genetic ancestry were identified as variables influencing alcohol response. Major depressive disorder positively predicted physical symptoms and aggression negatively predicted physical symptoms. Barratt's Impulsivity Scale total score predicted the Physical and Perceptual domains. Family history, average drinks per drinking day, and negative urgency (an impulsivity measure) predicted all three domains. Conclusions Diverse items from the ADS concurrently load onto three correlated alcohol response factors rather than loading independently. Genetic ancestry and clinical characteristics predicted the severity of items that define the alcohol response factors even after accounting for degree of alcohol consumption. Co‐occurring phenotypes point towards an underlying shared physiology of diverse alcohol responses. Three common factors relevant for diverse alcohol responses are identified: Physical Symptoms, Perceptual Disturbances, and Neurobiological Effects Alcohol response items from the Alcohol Dependence Scale concurrently load onto these three factors rather than loading independently The three factors are correlated; patients presenting to clinical settings with a problem such as blackout are likely to experience several other problems either acutely or in the future
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Affiliation(s)
- Esha Chebolu
- Office of the Clinical Director Laboratory of Neurogenetics NIAAA Bethesda MD
| | | | | | | | | | | | | | - Emily L Vogt
- University of Michigan Medical School Ann Arbor MI
| | | | | | - David Goldman
- Office of the Clinical Director Laboratory of Neurogenetics NIAAA Bethesda MD
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Adaptation and Validation of a scale to Assess Knowledge, Attitudes, and Perceptions of Healthcare Workers Towards Alcohol Withdrawal and Its Detection. Int J Ment Health Addict 2021. [DOI: 10.1007/s11469-021-00562-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Kumar PR, Yee A, Francis B. Impact of alcohol withdrawal training program on knowledge, attitude, and perception among healthcare providers in a hospital setting. JOURNAL OF SUBSTANCE USE 2021. [DOI: 10.1080/14659891.2021.1897696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Padma Rani Kumar
- Department of Psychological Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Anne Yee
- Department of Psychological Medicine, University of Malaya Centre for Addiction Science (UMCAS), University Malaya, Kuala Lumpur, Malaysia
| | - Benedict Francis
- Department of Psychological Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
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Glahn A, Proskynitopoulos PJ, Bleich S, Hillemacher T. Pharmacotherapeutic management of acute alcohol withdrawal syndrome in critically Ill patients. Expert Opin Pharmacother 2020; 21:1083-1092. [PMID: 32281894 DOI: 10.1080/14656566.2020.1746271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Alcohol withdrawal syndrome is a common and life-threatening condition in patients suffering from alcohol use disorder. Treatment of this syndrome is challenging, especially in patients that are critically ill, either because of withdrawal symptoms or underlying conditions. For the treatment, several pharmacological agents exist, such as benzodiazepines, barbiturates, or dexmedetomidine. Nonetheless, as alcohol withdrawal syndromes can occur in every clinical setting, it is necessary to provide a guideline for clinicians confronted with this syndrome in varying clinical contexts. AREAS COVERED The authors provide a systematic review of the literature found in PubMed and Embase following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. EXPERT OPINION For the treatment of alcohol withdrawal syndrome, medications targeting the GABA system are preferred. Benzodiazepines are regarded as the gold standard. However, as many adjunct therapeutic options exist, it is essential to find symptom-triggered approaches and treatment protocols for the variety of clinical contexts. Apart from that, it is necessary to compare protocols toward clinical variables rather than investigating medications that are in use for the treatment of alcohol withdrawal syndrome.
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Affiliation(s)
- A Glahn
- Department of Psychiatry, Psychotherapy and Social Psychiatry, Hannover Medical School , Hannover, Germany
| | - P J Proskynitopoulos
- Department of Psychiatry, Psychotherapy and Social Psychiatry, Hannover Medical School , Hannover, Germany
| | - S Bleich
- Department of Psychiatry, Psychotherapy and Social Psychiatry, Hannover Medical School , Hannover, Germany
| | - T Hillemacher
- Department of Psychiatry, Psychotherapy and Social Psychiatry, Hannover Medical School , Hannover, Germany.,Department of Psychiatry and Psychotherapy, Paracelcus Medical University , Nuremberg, Germany
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