Severe alcohol withdrawal syndrome: Evolution of care and impact of adjunctive therapy on course and complications of 171 intensive care unit patients

Sex difference in alcohol withdrawal syndrome: a scoping review of clinical studies

Background

We conducted a review of all studies comparing clinical aspects of alcohol withdrawal syndrome (AWS) between men and women.

Methods

Five databases (PubMed, Cochrane, EMBASE, Scopus and Clinical Trials) were searched for clinical studies using the keywords "alcohol withdrawal syndrome" or "delirium tremens" limited to "sex" or "gender" or "sex difference" or "gender difference." The search was conducted on May 19, 2023. Two reviewers selected studies including both male and female patients with AWS, and they compared males and females in type of AWS symptoms, clinical course, complications, and treatment outcome.

Results

Thirty-five observational studies were included with a total of 318,730 participants of which 75,346 had AWS. In twenty of the studies, the number of patients presenting with or developing AWS was separated by sex, resulting in a total of 8,159 (12.5%) female patients and a total of 56,928 (87.5%) male patients. Despite inconsistent results, males were more likely than females to develop complicated AWS [delirium tremens (DT) and AW seizures, collective DT in Males vs. females: 1,792 (85.4%) vs. 307 (14.6%), and collective seizures in males vs. females: 294 (78%) vs. 82 (22%)]. The rates of ICU admissions and hospital length of stay did not show sex differences. Although variable across studies, compared to females, males received benzodiazepine treatment at higher frequency and dose. One study reported that the time from first hospitalization for AWS to death was approximately 1.5 years shorter for males and males had higher mortality rate [19.5% (197/1,016)] compared to females [16% (26/163)].

Conclusion

Despite the significant heterogeneity of the studies selected and the lack of a focus on investigating potential sex differences, this review of clinical studies on AWS suggests that men and women exhibit different AWS manifestations. Large-scale studies focusing specifically on investigating sex difference in AWS are needed.

Alcohol Withdrawal Syndrome in Women vs Men: Analysis of 1496 Cases at a Single Site

BACKGROUND

Studies of alcohol withdrawal syndrome indicate a higher prevalence in men than in women. However, it is unknown how the condition differs between the sexes.

OBJECTIVE

To assess alcohol withdrawal syndrome in women versus men at a single site.

METHODS

All cases of alcohol withdrawal syndrome at a public hospital from 2010 to 2014 were reviewed retrospectively. For all 1496 episodes, age, sex, and admission to a general care unit (ward) versus the medical intensive care unit were ascertained, along with patient survival. A detailed analysis was performed of 437 cases: all 239 patients admitted to the medical intensive care unit, all 99 female patients admitted to the ward, and 99 randomly selected male patients admitted to the ward. Also analyzed were administration of benzodiazepines, disease course, length of stay, and complications.

RESULTS

Men accounted for 92% of all cases (1378 of 1496; P < .001) and medical intensive care unit admissions (220 of 239; P < .05). Sixteen percent of both men and women were admitted to the medical intensive care unit. Men were older (mean age, 45.6 vs 43.9 years; P < .01), and women required more benzodiazepines. Similar rates of complications occurred in both sexes, although women had a higher rate of pancreatitis and men had higher rates of pneumonia, higher rates of sepsis, and longer stays.

CONCLUSIONS

Men and women with alcohol withdrawal syndrome have similar complications, courses, and intensive care unit admission rates, although men are more prone to pneumonia and have longer stays.

Effect of Adjunctive Dexmedetomidine in the Treatment of Alcohol Withdrawal Compared to Benzodiazepine Symptom-Triggered Therapy in Critically Ill Patients: The EvADE Study

OBJECTIVE

This study evaluated the safety and efficacy of adjunctive dexmedetomidine for alcohol withdrawal syndrome (AWS) treatment compared to symptom-triggered benzodiazepine therapy.

METHODS

This single-center, retrospective, cohort study evaluated patients admitted to an intensive care unit (ICU) with AWS. Patients were divided into 2 groups: adjunctive dexmedetomidine or symptom-triggered therapy (control). Primary outcome was change in Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) score. Secondary outcomes assessed cumulative ICU benzodiazepine requirement and ICU/hospital length of stay (LOS). Safety outcomes evaluated incidence of adverse events, new onset seizures, and intubation. Propensity matching was performed to minimize differences between study groups.

RESULTS

Overall, 147 patients were included, 56 in the dexmedetomidine group and 91 in the control group. Patient demographics were similar, however baseline CIWA-Ar score was statistically higher in the dexmedetomidine group. Following propensity matching, 55 patients were included in each group. No significant difference was noted for change in CIWA-Ar score (median, IQR) [3.8 (-0.4-12.3) dexmedetomidine vs. 5.4 (1.4-12.9) control, p = 0.223]. Secondary endpoints revealed increased benzodiazepine requirements (p = 0.001), prolonged ICU LOS (p = 0.050), and more frequent use of physical restraints (p = 0.001) in the dexmedetomidine group. While not statistically significant, the development of new onset seizures (p = 0.775) and intubation (p = 0.294) occurred more frequently in the dexmedetomidine group.

CONCLUSION

The addition of dexmedetomidine to symptom-triggered benzodiazepines for AWS did not produce a significant change in CIWA-Ar scores from baseline compared to symptom-triggered therapy alone. The increased rate of new onset seizures and intubation warrant further investigation into the safety of dexmedetomidine in AWS.

Use of Propofol Plus Dexmedetomidine in Patients Experiencing Severe Alcohol Withdrawal in the Intensive Care Unit

Alcohol abuse and alcohol withdrawal syndrome are major problems in the United States. This retrospective chart review assessed efficacy and safety of propofol plus dexmedetomidine used in combination as adjunctive therapy to benzodiazepines compared with either agent used alone in the treatment of severe alcohol withdrawal. Patients admitted to the intensive care unit and experiencing severe alcohol withdrawal between September 1, 2015 and September 30, 2018 were assessed for eligibility. Primary end points were change in the revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar) score and incidence of bradycardia and hypotension. The combination of propofol and dexmedetomidine was associated with a change in CIWA-Ar score of -10.4 (95%CI -13.5 to -7.3) points compared with -4.7 (95%CI -6.6 to -2.8) points with propofol and -4.4 (95%CI -7.4 to -1.4) with dexmedetomidine (P = .21). Bradycardia was experienced by 11.1% of patients receiving the combination, 15.4% of patients receiving propofol, and 28.6% of patients receiving dexmedetomidine (P = .40). Patients receiving dexmedetomidine experienced hypotension at a rate of 21.4% compared with 22.2% of patients receiving the combination and 38.5% of patients receiving propofol (P = .08). Patients in the combination group also had a shorter length of hospital and intensive care unit stay and shorter time to extubation when compared with the propofol and dexmedetomidine groups. Although no statistical significance was found, the combination was associated with better efficacy and safety outcomes than produced by either agent used alone.

Seizures After Intracerebral Hemorrhage: Incidence, Risk Factors, and Impact on Mortality and Morbidity

OBJECTIVE

Spontaneous intracerebral hemorrhage (ICH) is one of the most frequent causes of epilepsy in the United States. However, reported risk factors for seizure after are inconsistent, and their impact on inpatient morbidity and mortality is unclear. We aimed to study the incidence, risk factors, and impact of seizures after ICH in a nationwide patient sample.

METHODS

We queried the Nationwide Inpatient Sample for patients admitted to the hospital with a primary diagnosis of ICH between the years 1999 and 2011. Patients were subsequently dichotomized into groups of those with a diagnosis consistent with seizure and those without. Multivariate logistic regression was used to assess risk factors for seizure in this patient sample, and the association between seizures and mortality and morbidity. Logistic regression was then used for trend analysis of incidence of seizure diagnoses over time.

RESULTS

We identified 220,075 patients admitted with a primary diagnosis of ICH. Of these, 11.87% had a diagnosis consistent with seizure. Factors associated with increased risk of seizure after ICH included higher categorical van Walraven score, encephalopathy, alcohol abuse, solid tumor, and prior stroke. Seizure was independently associated with decreased odds of morbidity (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.86-0.92) and mortality (OR, 0.75; 95% CI, 0.72-0.77) in multivariate models controlling for existing comorbidities.

CONCLUSIONS

Seizures after were associated with decreased mortality and morbidity despite attempts to correct for existing comorbidities. Continuous monitoring of these patients for seizures may not be necessary in all circumstances, despite their frequency.