Does hypokalaemia precede delirium tremens?

Neutrophil-lymphocyte ratio as a predictor of delirium tremens in hospitalized patients with alcohol withdrawal

Delirium Tremens (DT) is a severe form of alcohol withdrawal that can be fatal if not recognized early and treated appropriately. In our study, we aimed to determine the role of Neutrophil-Lymphocyte ratio (NLR), a marker of systemic inflammation, in predicting the development of DT. This retrospective study was conducted in an alcohol and drug treatment center between March 2017 and March 2020. A total of 212 patients with a diagnosis of alcohol use disorder who were admitted to a special care unit after alcohol withdrawal were included. Blood tests were collected within 24 hours of the patients' admission. Comparisons were made according to whether the patients developed DT during the hospitalization. DT was diagnosed in 24.1% of the patients. It was determined that higher NLR level (odds ratio [OR]: 4.38, 95%CI: 2.58-7.43) and history of DT (OR: 1.33, 95%CI: 1.23-11.73) are independent risk factors for the development of DT in the logistic regression analysis. The optimal cut-off value of NLR in predicting DT was 2.67 (sensitivity: 82.4%, specificity: 88.8%). The ROC curve of NLR showed a larger area under the curve (AUC) than the curves of other systemic inflammation markers. NLR is a simple, practical and inexpensive marker that can predict the development of DT in patients with alcohol withdrawal syndrome.

A challenging case of lumbar vertebral burst fracture with alcohol withdrawal delirium: A case report

BACKGROUND

Delirium tremens is a symptom of alcohol withdrawal syndrome that occurs 48 to 96 hours after the last drink in 5% of withdrawing patients.

METHODS

This report describes the clinical progression of a case of lumbar vertebral burst fracture with alcohol withdrawal delirium that was difficult to manage.

RESULTS

A 47-year-old man was rushed to our hospital complaining of lumbar back pain and numbness in both lower extremities resulting from a 6-m fall during civil engineering work. Computed tomography (CT) revealed a L1 burst fracture with a highly protruding bone fragment in the spinal canal. Magnetic resonance imaging disclosed significant compression of the conus and intramedullary signal changes. We immediately performed posterior spinal fusion and vertebroplasty using instrumentation. On the 4th postoperative day, he became severely agitated, as diagnosed as having delirium tremens related to alcohol withdrawal syndrome, and soon began appropriate medication with diazepam. Although his symptoms persisted until 6 days postoperatively, follow-up CT detected no evidence of screw loosening or breakage.

CONCLUSION

We encountered a patient with severe delirium tremens developing several days after thoraco-lumbar fusion surgery. Prompt internal fixation successfully treated the spinal injury and prevented neurological damage. It may also be necessary to consider treatment strategies for patients with a background of heavy alcohol consumption in consideration of delirium tremens and other symptoms of alcohol withdrawal.

[Clinical and metabolic predictors for delirium tremens]

OBJECTIVE

To search for objective diagnostic criteria for the development of delirium tremens (DT) based on physiological and metabolic parameters.

MATERIAL AND METHODS

The total number of patients was 506, including 393 patients with DT and 113 patients with uncomplicated alcohol withdrawal syndrome (UAWS). Twenty clinical and metabolic indicators were analyzed statistically using comparison of means, logistic regression and ROC-analysis.

RESULTS AND CONCLUSION

Hyponatremia, thrombocytopenia and tachycardia are most prognostically significant indicators, changes in which are observed in the development of DT. These indicators can serve as the basis for objective diagnosis of alcohol withdrawal syndrome complicated by delirium.

Thrombocytopenia in Patients Hospitalized for Alcohol Withdrawal Syndrome and Its Associations to Clinical Complications

BACKGROUND

The aim of this study was to assess the predictive value of thrombocytopenia (TP) in alcohol withdrawal syndrome (AWS) as a marker of evolution of non-complicated AWS (nAWS) to severe, complicated AWS (cAWS): delirium tremens (DTs) and withdrawal seizures (wS), and to broaden knowledge about differences between nAWS and cAWS groups in relation to severity of TP.

METHODS

This study involved 300 people (236 males and 64 females), aged 19-65 years (M = 44.64, SD = 11.32), hospitalized in the detoxification ward with ICD-10 diagnosis of F10.3 (AWS) or F10.4 (DTs), divided into nAWS and cAWS groups, 150 cases each. AWS severity was measured by CIWA-Ar. Available clinical and laboratory data were analyzed.

RESULTS

TP was found in 139 (46%) of all subjects (nAWS = 32, cAWS = 107). nAWS and cAWS did not differ according to age, gender, length and severity of the last binge. A relationship between the occurrence of TP and cAWS was found (P < 0.001). The lower was the number of PLT, the more AWS incidence was observed. In CIWA-Ar, TP subjects had at least moderate AWS (P < 0.001). nAWS had higher PLT values than cAWS cases (Mrang = 195.96 vs. 105.04, P < 0.001). The predictive value of TP in cAWS was confirmed.

CONCLUSIONS

The study demonstrates that patients with AWS and TP (in particular <119k/mL) are at higher risk of developing cAWS.

The "Prediction of Alcohol Withdrawal Severity Scale" (PAWSS): systematic literature review and pilot study of a new scale for the prediction of complicated alcohol withdrawal syndrome

BACKGROUND

To date, no screening tools for alcohol withdrawal syndromes (AWS) have been validated in the medically ill. Although several tools quantify the severity of AWS (e.g., Clinical Institute Withdrawal Assessment for Alcohol [CIWA]), none identify subjects at risk of AWS, thus missing the opportunity for timely prophylaxis. Moreover, there are no validated tools for the prediction of complicated (i.e., moderate to severe) AWS in the medically ill.

OBJECTIVES

Our goals were (1) to conduct a systematic review of the published literature on AWS to identify clinical factors associated with the development of AWS, (2) to use the identified factors to develop a tool for the prediction of alcohol withdrawal among patients at risk, and (3) to conduct a pilot study to assess the validity of the tool.

METHODS

For the creation of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS), we conducted a systematic literature search using PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines for clinical factors associated with the development of AWS, using PubMed, PsychInfo, MEDLINE, and Cochrane Databases. Eligibility criteria included: (i) manuscripts dealing with human subjects, age 18 years or older, (ii) manuscripts directly addressing descriptions of AWS or its predisposing factors, including case reports, naturalistic case descriptions, and all types of clinical trials (e.g., randomized, single-blind, or open label studies), (iii) manuscripts describing characteristics of alcohol use disorder (AUD), and (iv) manuscripts dealing with animal data (which were considered only if they directly dealt with variables described in humans). Obtained data were used to develop the Prediction of Alcohol Withdrawal Severity Scale, in order to assist in the identification of patients at risk for complicated AWS. A pilot study was conducted to assess the new tool's psychometric qualities on patients admitted to a general inpatient medicine unit over a 2-week period, who agreed to participate in the study. Blind to PAWSS results, a separate group of researchers retrospectively examined the medical records for evidence of AWS.

RESULTS

The search produced 2802 articles describing factors potentially associated with increased risk for AWS, increased severity of withdrawal symptoms, and potential characteristics differentiating subjects with various forms of AWS. Of these, 446 articles met inclusion criteria and underwent further scrutiny, yielding a total of 233 unique articles describing factors predictive of AWS. A total of 10 items were identified as correlated with complicated AWS (i.e., withdrawal hallucinosis, withdrawal-related seizures, and delirium tremens) and used to construct the PAWSS. During the pilot study, a total of 68 subjects underwent evaluation with PAWSS. In this pilot sample the sensitivity, specificity, and positive and negative predictive values of PAWSS were 100%, using the threshold score of 4.

DISCUSSION

The results of the literature search identified 10 items which may be correlated with risk for complicated AWS. These items were assembled into a tool to assist in the identification of patients at risk: PAWSS. The results of this pilot study suggest that PAWSS may be useful in identifying risk of complicated AWS in medically ill, hospitalized individuals. PAWSS is the first validated tool for the prediction of severe AWS in the medically ill and its use may aid in the early identification of patients at risk for complicated AWS, allowing for prophylaxis against AWS before severe alcohol withdrawal syndromes develop.

Alcohol withdrawal delirium - diagnosis, course and treatment

OBJECTIVE

Delirium tremens represents the most severe complication of alcohol withdrawal syndrome and, in its complications, significantly increases the morbidity and mortality of patients. Alcohol withdrawal delirium is characterized by features of alcohol withdrawal itself (tremor, sweating, hypertension, tachycardia etc.) together with general delirious symptoms such as clouded consciousness, disorientation, disturbed circadian rhythms, thought processe and sensory disturbances, all of them fluctuating in time. The treatment combines a supportive and symptomatic approach. Benzodiazepines in supramaximal doses are usually used as drugs of choice but in some countries such as the Czech Republic or Germany, clomethiazole is frequently used as well.

METHOD

A computer search of the all the literature published between 1966 and December 2012 was accomplished on MEDLINE and Web of Science with the key words "delirium tremens", "alcohol withdrawal", "treatment" and "pharmacotherapy". There were no language or time limits applied.

CONCLUSIONS

When not early recognized and treated adequately, delirium tremens may result in death due to malignant arrhythmia, respiratory arrest, sepsis, severe electrolyte disturbance or prolonged seizures and subsequent trauma. Owing to these possible fatalities and other severe unexpected complications, delirium tremens should be managed at an ICU or wards ensuring vital signs monitoring. In symptomatic treatment, high doses of benzodiazepines, especially lorazepam, diazepam and oxazepam are considered the gold standard drugs. Supportive therapy is also of great importance.

Risk factors for delirium tremens in patients with alcohol withdrawal syndrome in a hospital setting

BACKGROUND

The clinical expressions of alcohol withdrawal syndrome (AWS) may vary and the factors determining these variations are not well-known. It would be useful to have a set of clinical tools capable of predicting which patients are likely to develop the more severe forms of the syndrome.

AIM

To analyse the clinical variables associated with the development of delirium tremens (DTs) in patients who were admitted to a general hospital with AWS.

METHODS

Cohort study of AWS patients admitted to the Xeral Hospital in Lugo, Spain, between 1987 and 2003. The characteristics of patients with the syndrome who did not develop delirium tremens were contrasted with those who did. Cases presenting with DTs at diagnosis were excluded. The different clinical, epidemiological and biochemical variables reflective of alcohol consumption habits, basal health status and presentation features of syndrome were all recorded.

RESULTS

Data from 156 episodes of AWS that coursed without DTs were compared with 147 cases that coursed with it. Three independent variables for development of DTs were identified in a multivariate logistic regression model: number of seizures [1 or 2: OR 2.2 (CI 95% 1.2-3.8), p=0.005; 3 or more: OR 2.6 (CI 95% 1.04-6.8), p=0.04]; systolic blood pressure >150 mm Hg [OR 1.9 (CI 95% 1.1-3.8), p=0.03] and axillary temperature >38 degrees C [OR 1.9 (CI 95% 1.05-3.5), p=0.01]. ROC analysis revealed an area under the curve of 0.679.

CONCLUSION

Three clinical findings (seizures, blood pressure and temperature) can aid in identifying patients with AWS who are likely to develop DTs. The model's predictive capacity is not high.

Development of a rating scale to predict the severity of alcohol withdrawal syndrome

AIM

Various factors that may influence the severity of the alcohol withdrawal syndrome (AWS) have been identified. We tested the predictive value of these factors compiled in a newly developed scale, LARS (Luebeck alcohol withdrawal risk scale).

METHOD

A total of 100 individuals (81 males, 19 females, mean age: 47.6 +/- 9.9 years) consecutively transferred to inpatient detoxification were included in this prospective study. All fulfilled the ICD-10 criteria for alcohol dependence. The LARS was applied at the time of admission. The course of the AWS was assessed by AWS-scale at least every 4 h. The maximum AWS-score was taken as indicator of the severity of AWS.

RESULTS

The mean AWS-score(max) was 6.5 +/- 3.3. In all 20% of the patients developed a severe AWS (AWS-score(max) > or =10). The maximum score usually occurred within 36 h after the last drink. A short version, the LARS11, was developed by statistically grounded item reduction. The optimal cut-off of the LARS11 was calculated as 10. The positive predictive value for severe AWS was 76%, while the negative predictive value was 98.7%. The sensitivity and specificity were high (95 or 92.5%, respectively).

CONCLUSION

LARS11 assessed immediately before detoxification appears to provide a useful estimate of mild/moderate versus severe AWS, and is now ready to be validated in an independent sample.

Persistent alterations of vasopressin and N-terminal proatrial natriuretic peptide plasma levels in long-term abstinent alcoholics

BACKGROUND

During alcohol withdrawal and early abstinence, severe alterations of electrolyte and water homeostasis and their regulating hormones are well recognized. Almost nothing is known about regeneration of these functions with long-term abstinence. This cohort study was designed to monitor determinants of electrolyte and water balance over 280 days of abstinence in alcohol-dependent men compared with healthy controls.

METHODS

Vasopressin (AVP), N-terminal proatrial natriuretic peptide, aldosterone, angiotensin II, and electrolytes, together with major parameters of kidney and liver function, were monitored in 35 male alcoholics aged 44 +/- 8 years. Of these, 21 could be followed up to 280 days of strictly controlled abstinence due to their participation in the Outpatient Long-Term Intensive Therapy for Alcoholics. The control group comprised 20 healthy male volunteers aged 39 +/- 7 years.

RESULTS

Basal AVP levels were found to be suppressed over the whole study period. In contrast, N-terminal proatrial natriuretic peptide remained increased over all 280 days. No persistent alterations were found for aldosterone or angiotensin II. Sodium and potassium in plasma and urine returned to normal within a few weeks. Creatinine clearance, urea nitrogen in plasma and urine, urinary osmolality, hematocrit, and hemoglobin remained low as compared with controls over the entire study.

CONCLUSIONS

Chronic alcohol abuse causes severe and persistent alterations in the hormonal regulatory systems of electrolyte and water balance. The suppressed basal secretion of AVP may reflect a dysregulation in the brain that influences the hypothalamic-pituitary-adrenal axis function, mood, memory, addiction behavior, and craving during alcohol abstinence. These findings may provide a ground for future therapeutic approaches to stable abstinence.

Effects of dihydropyridines on the components of the ethanol withdrawal syndrome: possible evidence for involvement of potassium, as well as calcium?

Comparison was made of the ability of two dihydropyridine calcium channel antagonists, nitrendipine and felodipine, to prevent a range of signs of ethanol withdrawal. The increases in handling-induced behavior seen in mice during withdrawal from chronic ethanol treatment were prevented by administration of nitrendipine, 50 mg/kg, but not by, felodipine, 10 mg/kg, a dose that caused a similar displacement of dihydropyridine binding in central nervous system tissue, in vivo and in vitro. A higher dose of felodipine, 20 mg/kg, also had no effects. Nitrendipine, but not felodipine, prevented audiogenic seizures during the withdrawal phase. Similarly, nitrendipine prevented both the decrease in thresholds for N-methyl-DL-aspartate seizures and the increase in thresholds for convulsions due to 4-aminopyridine, which were seen during the withdrawal period, while felodipine did not alter either of these changes. Withdrawal from the ethanol chronic treatment increased the thresholds to seizures produced by intravenous aminophylline; this change was also prevented by nitrendipine. The significance of this increase in thresholds was lost after felodipine administration. In naive mice (not treated with ethanol) the doses of nitrendipine and felodipine used in the withdrawal studies were tested against the effects of convulsant drugs. Both dihydropyridines increased, to similar extents, the thresholds for seizures produced by bicuculline, pentylenetetrazol, and by N-methyl-DL-aspartate. The thresholds for aminophylline were unaltered by either dihydropyridine. In contrast, the thresholds for seizures due to 4-aminopyridine in the naive animals were not changed by felodipine, but were increased by nitrendipine. The results suggest that changes in potassium, as well as calcium, may possibly be involved in some of the stages of the ethanol withdrawal syndrome.

Clinical predictors of alcohol withdrawal delirium

Up to now, clinical predictors for the course of the alcohol withdrawal syndrome, especially for the occurrence of a delirium, are lacking. Thus, this study was undertaken to examine whether clinical routine investigations at admission before the withdrawal syndrome can reveal factors indicating a higher risk for the development of a delirium. Our results showed that decreased serum electrolyte concentrations (i.e., chloride and potassium), elevated ALT, and gamma-glutamyltransferase serum levels, as well as ataxia and polyneuropathy at the neurological examination, indicate a higher risk for the development of an alcohol withdrawal delirium.

Inter-relationship between serum potassium and plasma catecholamines and 3':5' cyclic monophosphate in alcohol withdrawal

Serial analyses of serum potassium and plasma epinephrine, norepinephrine and adenosine 3':5'-cyclic monophosphate (cyclic AMP) concentrations were measured in 13 patients with alcohol withdrawal, six of whom presented delirium tremens. Patients with delirium showed at admission levels of potassium (3.45 +/- 0.45 mmol/l) lower (P less than 0.02) than patients without delirium (3.81 +/- 0.14 mmol/l). Three patients were hypokalemic, all of them with delirium. Serum potassium increased significantly in all the patients during evolution. A close negative correlation (r = -0.751) between the intensity of withdrawal and serum potassium was observed. Plasma epinephrine concentrations were increased at admission (623 +/- 192 pmol/l), patients with delirium showing greater values (705 +/- 137 pmol/l). As the alcohol withdrawal improved, plasma epinephrine concentration decreased. Plasma norepinephrine concentrations were also increased at admission (3422 +/- 1451 pmol/l), but did not change significantly during evolution, being similar in patients with and without delirium. Plasma cyclic AMP levels were high at admission (40.4 +/- 24.3 nmol/l) and increased significantly (P less than 0.05) during evolution. The data obtained suggest that in patients with alcohol withdrawal, as symptomatology improves, plasma epinephrine decreases, while plasma norepinephrine remains increased. The combined actions of the two facts--less beta-stimulus, maintaining of alpha-stimulus--would comprise a significant increase of kalemia, that in cases of initial hypokalemia would lead to normal values of serum potassium.

Ifosfamide encephalopathy: a reappraisal

Eighteen consecutive cases of encephalopathy occurring after ifosfamide/mesna chemotherapy were prospectively assessed. No relationship was found with tumour type or chemotherapy response. Onset was from 12 to 146 (mean 46) h after the start of the infusion and median duration was 3 days (range 1-12). In two patients recovery was incomplete. A confusional state and agitation were the major clinical features. Plasma potassium fell from a mean of 4.12 mmol/l before chemotherapy to 2.94 mmol/l at the onset of encephalopathy (P less than 0.001) with plasma potassium less than 3.0 mmol/l in 10 patients. Duration of hypokalaemia was not related to duration of encephalopathy. Median survival following encephalopathy was 25 days. The incidence of encephalopathy in 82 patients treated on two protocols was 11% and the sensitivity of a published nomogram was 18%. It is concluded that ifosfamide/mesna encephalopathy is a serious complication which may be irreversible and remains difficult to predict.

Hypokalaemia in alcoholics

Hyponatraemia has been described in beer drinkers and hypokalaemia resulting from increased levels of aldosterone is well recognised in patients with cirrhosis and ascites. We have encountered episodes of hypokalaemia in alcoholics accompanied by normal or increased serum concentrations of sodium. Despite a resemblance to syndromes of mineralocorticoid excess, increased levels of aldosterone and other mineralocorticoids were not found.

Duration of delirium shortened by the correction of electrolyte imbalance

Among 53 delirious patients with an electrolyte imbalance in the serum, the duration of delirium in 18 cases was significantly shortened by the correction of electrolyte imbalance, compared with that of 35 cases of delirium without an electrolyte correction. The mean duration of delirium (mean value +/- SE) corrected by electrolyte was 9.4 +/- 1.9 days, whereas the mean duration of delirium without the electrolyte correction was 25.7 +/- 4.6 days. The mean duration of delirium in 13 cases without the electrolyte imbalance was 25.0 +/- 6.6 days. From these results, the electrolyte correction should be done systematically for the delirious patients as a treatment for the disorder.

A retrospective and explorative study of hypokalemia in psychiatric disorders: a beta 2-receptor related phenomenon

Since the serum potassium level is under beta 2-adrenergic influence, we studied serum potassium values on admission in psychiatric patients. Data are reported on 683 patients from nine major diagnostic groups. Among these nine groups significant differences were found concerning the mean serum potassium level and incidence of hypokalemia. Significant differences existed between the alcohol withdrawal and attempted suicide groups compared to the dysthymic, bipolar manic, schizophrenic and nonschizophrenic psychosis groups. Like alcohol withdrawal, attempted suicide is assumed to be a hyper-adrenergic state. Although the relative contribution of factors like nutritional state, aldosterone, insulin, and beta 2-receptor density or sensitivity is unclear, the catecholamine-potassium relationship deserves further study.

A search for degeneration in the circumventricular area of ethanol-treated mice

Mice were treated with ethanol vapour for 6 weeks and the circumventricular area of the brains prepared for light and electron microscopy. No abnormalities were found in the subfornical organ, but degeneration was found in the medial preoptic area in 2 of the 6 ethanol-treated animals. There was no indication of functional impairment of brain or body water regulation mechanisms.

Magnesium deficiency in alcoholism

Significant magnesium deficiency occurs in chronic alcoholism. The evidence depends on a number of related lines of evidence: hypomagnesemia, a number of clinical symptoms in common with patients with nonalcoholic causes of magnesium deficiency, induction of magnesium excretion by alcohol ingestion (167-260% of control values), positive magnesium balance on alcohol withdrawal (average 1.15 meq/kg), decreased exchangeable magnesium (28Mg, mean deficit 1.12 meq/kg), a mean deficit of 11.4 meq/kg of fat-free dry weight of muscle of alcoholic patients, and hypocalcemia responsive only to magnesium therapy. When alcohol is withdrawn, free fatty acids rise sharply and plasma magnesium falls. Respiratory alkalosis occurs abruptly also on alcohol withdrawal. The alkalosis and rise of free fatty acids with concomitant fall of magnesium produces an acute instability of the internal milieu and could result in acute symptoms. There also are a number of nutritional deficiencies which need to be cared for, but magnesium, thiamine, and other B vitamins need to be administered immediately. Potassium and phosphorus should be supplied when they are low.

Special aspects of human alcohol withdrawal

There are still surprising gaps in our knowledge of alcohol withdrawal. While quantitative alcohol consumption accounts for about one third of the variability in severity of acute withdrawal, there is little systematic knowledge about the other factors involved. Thus, we cannot precisely predict the severity of withdrawal in individual patients. Controversy exists as to the role of medical vs. social detoxification approaches to acute withdrawal, the influence of acute withdrawal and its treatment on the long-term outcome of alcoholism, and the importance (or even existence) of chronic withdrawal. There is little systematic data to guide withdrawal treatment in special clinical settings, e.g., with concurrent medical or psychiatric illness or with mixed substance dependence. This chapter reviews the published literature, tries to point out methodological and conceptual problems, and suggests areas for future research.

Disorders of the serum electrolytes, acid-base balance, and renal function in alcoholism

This chapter reviews the disturbances of the serum sodium and potassium concentrations, acid-base imbalances, and acute renal dysfunction that are seen frequently in alcoholic patients. The hyponatremia common in decompensated cirrhotics is caused by an impairment of renal free water clearance and concomitant water ingestion. Excessive proximal renal tubular sodium reabsorption and nonosmotic vasopressin release underlie the defect in renal water excretion in cirrhosis. Restriction of water intake is the principal therapeutic measure for hyponatremia. Hypokalemia is common in alcoholics but when observed does not always represent true potassium depletion. Although most cirrhotics have a diminished total body potassium content, intracellular potassium concentration is usually normal. In some patients gastrointestinal and renal potassium losses and nutritional potassium deficiency may cause true potassium depletion. Respiratory and metabolic alkalosis are the acid-base disturbances seen most frequently in alcoholics. Acidosis is relatively uncommon and is usually due to renal insufficiency, lactic acid or keto-acid accumulation. Toxin ingestion (methanol, ethylene glycol, or isopropanol) may also cause severe acidosis. Rhabdomyolysis, common in severe alcoholism, may produce various electrolyte disturbances and acute renal failure. The prognosis for recovery is good although temporary dialysis may be necessary.

Alcohol withdrawal: effects of clonidine treatment on sympathetic activity, the renin-aldosterone system, and clinical symptoms

Twenty male alcoholics with alcohol withdrawal syndrome were randomized to receive either oral clonidine (3-600 micrograms, six hourly) or oral chlormethiazole (500-1000 mg, six hourly) for 4 days. All subjects were also given oral carbamazepine (200 mg, 12 hourly) throughout the study. Nine subjects given clonidine and eight given chlormethiazole completed the study. Clonidine was as effective as chlormethiazole in suppressing the symptoms and signs of alcohol withdrawal. However, plasma catecholamines, blood pressure, and pulse rate fell more rapidly and to a greater extent during clonidine than following chlormethiazole, findings which could have therapeutic implications. It is suggested that activation of brain noradrenergic neurons constitutes a common denominator in the pathophysiology of several withdrawal syndromes.

The effect of acute alcohol withdrawal on the serum potassium and total body potassium in heavy drinkers

In a group of 20 patients with heavy alcohol intake a relation was found between withdrawal symptoms and fall in serum potassium. Total body potassium (TBK) was measured in all subjects and was lower in the group of subjects who displayed symptoms than in the group who did not. The subgroup of the four most severe reactors had a mean TBK value significantly less than the 'non-reactor' group. The minimum serum potassium levels observed for all subjects in the four day period following alcohol withdrawal correlated with their TBK values. We suggest that the mechanism for the serum potassium fall might be overactivity of the Na-K pump caused by ethanol consumption. There was also an association between withdrawal reaction and abnormal liver function and a transient rise in serum phosphate in the more severely reacting subjects.

Impairment of extrarenal potassium disposal by alpha-adrenergic stimulation

Since beta-adrenergic stimulation enhances extrarenal potassium uptake, we postulated an opposite effect of the alpha-adrenergic nervous system. Seven healthy subjects were given intravenous potassium chloride (0.5 mmol per kilogram of body weight), in the presence and absence of the alpha-agonist phenylephrine. After potassium chloride alone, the potassium level rose to 0.64 +/- 0.03 mmol (mean +/- S.E.M.); phenylephrine augmented the rise (0.93 +/- 0.09 mmol, P less than 0.025) and prolonged it, without changing urinary potassium excretion. Subsequent administration of potassium and phenylephrine together with the alpha-antagonist phentolamine blocked the rise in the potassium level due to phenylephrine and shortened the duration of elevation, again without affecting urinary potassium excretion. No changes in plasma renin and aldosterone levels or in serum insulin concentrations occurred, to account for these findings. Stimulation of alpha-adrenergic receptors impairs extrarenal disposal of an acute potassium load--the opposite effect of beta-adrenergic stimulation. The alpha-adrenergic effect may act to preserve a normal serum potassium level or may contribute to hyperkalemia under certain circumstances, such as vigorous exercise.

The effects of alcohol on blood pressure and electrolytes

The interaction between alcohol abuse, changes in blood pressure, and electrolyte abnormalities is complex. Some effects of alcohol are seen only with acute ingestion, some during withdrawal, and some only in chronic drinkers. Careful attention to the interactions between the metabolism of various electrolytes can prevent unnecessary morbidity and mortality in alcoholic patients.

Pathophysiology of the alcohol withdrawal syndrome

A characteristic withdrawal syndrome appears following the interruption of chronic heavy consumption of alcoholic beverages. The pathophysiological elaborations of the various withdrawal signs and symptoms are considered. Among the unlikely, although plausible, pathophysiologic mechanisms of the tremulousness and skeletal muscle hyperreactivity of withdrawal is the accumulation or the sustained production of one or more circulating "toxic substances." Evidence consistent with such a mechanism includes the reported alleviation by dialysis of an impending withdrawal syndrome in alcoholic patients, the appearance of reflex hyperreactivity in withdrawing animals below the level of a chronic section of the spinal cord, and the time course of the appearance and disappearance of withdrawal syndromes. The various potential pathophysiological and neurochemical manifestations of the withdrawal illness are discussed--alterations in neural inhibition, in alpha-aminobutyric acid, catecholamines, acetylcholine, dopamine, prostaglandin, and in peptides. Experimental tests whereby a "toxic substance hypothesis" of withdrawal can be ruled in or out are proposed.

Occurrence of cerebral seizures provoked by alcohol abuse

Alcohol intoxication was detected in the immediate history of 277 (49%) of the 560 consecutive seizure patients brought to the emergency room of Meilahti hospital in Helsinki during the course of a year, most of these patients being young men of working age. The alcohol-provoked seizures occurred mainly on Sunday and Monday, following the weekly pattern of alcohol consumption in Finland, and preceded delirium tremens in 21 patients (4%). Even short periods of intoxication (1-2 days) provoked seizures. The data indicate that among patients with a previous history of recurrent alcohol-withdrawal seizures, new treatable diseases of the CNS, especially acute brain injuries, are frequently encountered. Therefore, all seizure problems, not neglecting those of alcoholics, should be carefully examined.

Stepwise regression analysis of an intensive 1-year study of delirium tremens

An intensive 1-year study was carried out on 41 male patients, mean age 49, mean hospitalization time 49 days, admitted to a special ward of the Beckomberga Hospital with the diagnosis of delirium tremens and 50 concomitant somatic and psychiatric diagnoses (1--9 per capita), and given a standardized treatment. The mean duration of delirium tremens after admission was 2 days; 76% recovered within 48 h. The duration after admission was positively correlated to age, number of previous delirium tremens, negatively correlated to B-haemoglobin and B-haematocrit for laboratory data obtained within the first 24 h and was positively correlated to blood sugar and S-creatinine on data taken within 40 h (Pearson correlation matrix). Stepwise multiple regression (SWR) based on 46 quantitative and dummy variables (the latter used to represent the presence of various concomitant diseases) was employed to identify the factors predicting the duration of delirium tremens. On final SWR analysis, which limited the number of observations to cases with complete observation vectors, the following regression equation was obtained: Duration after admission = 3.57--0.93 (S-magnesium)--0.29 (B-eosinophils) + 0.62 (liver disease), P greater than 0.05, n = 14. Although the regression coefficients were not statistically significant, S-magnesium, negatively associated with the duration after admission, offered 20% out of the total 38% of explanation given, whereas B-eosinophils, negatively associated, offered 12%, and liver disease, positively associated, 6%. The choice by the SWR program of S-magnesium as the most important factor in predicting the duration of delirium tremens is consistent with clinical evidence that alcohol ingestion causes magnesium diuresis and that magnesium deficiency is present in chronic alcoholism. In view of this knowledge, it is reasonable to assume that the lack of statistical significance is due to the small sample size rather than to the alternative that no explanation is offered by S-magnesium. Furthermore, B-haemoglobin, S-potassium, S-ASAT, and S-ALAT, known to be characteristically altered in delirium tremens, were found on forcing (a variant of SWR) to be of secondary importance to S-magnesium as explaining factors, whereas blood sugar and S-creatinine derived part of their explaining power from S-magnesium. In conclusion, extensive use of SWR analysis based on 46 potential explaining variables points to serum magnesium concentration as the most important factor in predicting the duration of delirium tremens.

Cardiac arrest following chlormethiazole infusion in chronic alcoholics

Two chronic alcoholics who had cardiac arrests (one fatal) while receiving chlormethiazole by infusion are reported. Although a causal relationship has not been indisputably established, caution is advised when administering this drug to chronic alcoholics during withdrawal.

A possible role of catecholamines and (Na+ + K+)ATPase in the ethanol withdrawl syndrome

Chronic ethanol intoxication leads to an increase in the intracellular Na+/K+ ratio. It is suggested that this derangement is counteracted by catecholamines via an activation of (Na+ + K+)ATPase. This hypothesis is discussed in relation to the symptomatology of ethanol withdrawal.

Magnesium concentrations in blood and cerebrospinal fluid during delirium tremens

Magnesium in plasma, erythrocytes, and cerebrospinal fluid (CSF) was measured immediately after hospital admission in 9 patients with delirium tremens (DT) and 11 patients with impending DT. Blood samples were taken daily during the acute state; a second lumbar puncture was performed when the patient's condition had improved. Plasma magnesium was low in patients with DT during the first days of the acute state and then spontaneously normalized. Normal plasma magnesium was consistently seen among patients with impending DT. Magnesium in erythrocytes and CSF was normal in both diagnostic categories. Patients with a high blood-alcohol concentration (BAC) at admission had a decreasing plasma magnesium, patients with a low BAC had a moderately increasing plasma magnesium, and patients with a BAC at nil had a more marked increase in plasma toms or with their duration. This finding, combined with the normal CSF magnesium and the lack of correlation between plasma and CSF magnesium, indicates that disturbances in magnesium metabolism do not play a role in the etiology or pathogenesis of DT; but it may be that disturbances in magnesium metabolism contribute to the development of alcoholic encephalopathy.