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Thaller M, Wong A, Yankama T, Eche IM, Elsamadisi P. Evaluation of Clinical Outcomes Associated With Phenobarbital With Taper Compared to No Taper for the Management of Alcohol Withdrawal Syndrome. Ann Pharmacother 2024:10600280241236412. [PMID: 38501811 DOI: 10.1177/10600280241236412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Phenobarbital (PHB) has been shown to be an effective treatment of alcohol withdrawal syndrome (AWS), with multiple dosing strategies used (e.g., single-dose and symptom-triggered). Studies have often used tapered doses, typically following a front-loaded dose, despite PHB's long half-life which should lead to an ability to auto-taper. OBJECTIVE The purpose of this study was to compare clinical outcomes associated with two PHB dosing strategies (taper [T], no taper [NT]) for AWS. METHODS This retrospective cohort study compared adult patients admitted to the ICU from October 2017 to May 2019 who received an initial loading dose of PHB for AWS. The use of PHB was at the discretion of the clinician per our institutional guidelines. Prior to November 2018, patients were prescribed a PHB taper, while after this period, the taper was no longer recommended. The primary outcome was the proportion of patients requiring rescue PHB or adjunctive medications for AWS. Secondary outcomes included number of adjunctive agents used, prevalence of severe manifestations of AWS, ICU and hospital lengths of stay, and incidence of potentially significant drug interactions. RESULTS A total of 172 patients were included (T: n = 81, NT: n = 91). Baseline characteristics were similar between groups, including history of severe AWS and cumulative benzodiazepine dose pre-PHB. There was no difference in the primary outcome between groups (T: 70.4% vs NT: 59.3%, P = 0.152). The median number of adjunctive agents per patient, severe manifestations, and ICU and hospital length of stay did not differ between groups. Twenty-five patients (14.5%) had potentially significant drug interactions. CONCLUSION AND RELEVANCE The use of a PHB loading dose without a taper may be comparable to a taper strategy on clinical outcomes. Prospective studies are needed to further delineate the optimal dose of PHB for AWS.
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Affiliation(s)
- Matthew Thaller
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Adrian Wong
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Tuyen Yankama
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ifeoma Mary Eche
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Pansy Elsamadisi
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA
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To DC, Steel TL, Carey KA, Joyce CJ, Salisbury-Afshar EM, Edelson DP, Mayampurath A, Churpek MM, Afshar M. Alcohol Withdrawal Severity Measures for Identifying Patients Requiring High-Intensity Care. Crit Care Explor 2024; 6:e1066. [PMID: 38505174 PMCID: PMC10950191 DOI: 10.1097/cce.0000000000001066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024] Open
Abstract
OBJECTIVES Alcohol withdrawal syndrome (AWS) may progress to require high-intensity care. Approaches to identify hospitalized patients with AWS who received higher level of care have not been previously examined. This study aimed to examine the utility of Clinical Institute Withdrawal Assessment Alcohol Revised (CIWA-Ar) for alcohol scale scores and medication doses for alcohol withdrawal management in identifying patients who received high-intensity care. DESIGN A multicenter observational cohort study of hospitalized adults with alcohol withdrawal. SETTING University of Chicago Medical Center and University of Wisconsin Hospital. PATIENTS Inpatient encounters between November 2008 and February 2022 with a CIWA-Ar score greater than 0 and benzodiazepine or barbiturate administered within the first 24 hours. The primary composite outcome was patients who progressed to high-intensity care (intermediate care or ICU). INTERVENTIONS None. MAIN RESULTS Among the 8742 patients included in the study, 37.5% (n = 3280) progressed to high-intensity care. The odds ratio for the composite outcome increased above 1.0 when the CIWA-Ar score was 24. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) at this threshold were 0.12 (95% CI, 0.11-0.13), 0.95 (95% CI, 0.94-0.95), 0.58 (95% CI, 0.54-0.61), and 0.64 (95% CI, 0.63-0.65), respectively. The OR increased above 1.0 at a 24-hour lorazepam milligram equivalent dose cutoff of 15 mg. The sensitivity, specificity, PPV, and NPV at this threshold were 0.16 (95% CI, 0.14-0.17), 0.96 (95% CI, 0.95-0.96), 0.68 (95% CI, 0.65-0.72), and 0.65 (95% CI, 0.64-0.66), respectively. CONCLUSIONS Neither CIWA-Ar scores nor medication dose cutoff points were effective measures for identifying patients with alcohol withdrawal who received high-intensity care. Research studies for examining outcomes in patients who deteriorate with AWS will require better methods for cohort identification.
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Affiliation(s)
- Daniel C To
- Department of Medicine, University of Wisconsin-Madison, Madison, WI
| | - Tessa L Steel
- Department of Medicine, University of Washington, Seattle, WA
| | - Kyle A Carey
- Department of Medicine, University of Chicago, Chicago, IL
| | - Cara J Joyce
- Department of Public Health Sciences, Loyola University Chicago, Maywood, IL
| | | | - Dana P Edelson
- Department of Medicine, University of Chicago, Chicago, IL
| | - Anoop Mayampurath
- Department of Medicine, University of Wisconsin-Madison, Madison, WI
- Department of Bioinformatics and Medical Informatics, University of Wisconsin-Madison, Madison, WI
| | - Matthew M Churpek
- Department of Medicine, University of Wisconsin-Madison, Madison, WI
- Department of Bioinformatics and Medical Informatics, University of Wisconsin-Madison, Madison, WI
| | - Majid Afshar
- Department of Medicine, University of Wisconsin-Madison, Madison, WI
- Department of Bioinformatics and Medical Informatics, University of Wisconsin-Madison, Madison, WI
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Kessel KM, Olson LM, Kruse DA, Lyden ER, Whiston KE, Blodgett MM, Balasanova AA. Phenobarbital Versus Benzodiazepines for the Treatment of Severe Alcohol Withdrawal. Ann Pharmacother 2024:10600280231221241. [PMID: 38247044 DOI: 10.1177/10600280231221241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND Phenobarbital may offer advantages over benzodiazepines for severe alcohol withdrawal syndrome (SAWS), but its impact on clinical outcomes has not been fully elucidated. OBJECTIVE The purpose of this study was to determine the clinical impact of phenobarbital versus benzodiazepines for SAWS. METHODS This retrospective cohort study compared phenobarbital to benzodiazepines for the management of SAWS for patients admitted to progressive or intensive care units (ICUs) between July 2018 and July 2022. Patients included had a history of delirium tremens (DT) or seizures, Clinical Institute Withdrawal Assessment of Alcohol-Revised (CIWA-Ar) >15, or Prediction of Alcohol Withdrawal Severity Scale (PAWSS) score ≥4. The primary outcome was hospital length of stay (LOS). Secondary outcomes included progressive or ICU LOS, incidence of adjunctive pharmacotherapy, and incidence/duration of mechanical ventilation. RESULTS The final analysis included 126 phenobarbital and 98 benzodiazepine encounters. Patients treated with phenobarbital had shorter median hospital LOS versus those treated with benzodiazepines (2.8 vs 4.7 days; P < 0.0001); a finding corroborated by multivariable analysis. The phenobarbital group also had shorter median progressive/ICU LOS (0.7 vs 1.3 days; P < 0.0001), and lower incidence of dexmedetomidine (P < 0.0001) and antipsychotic initiation (P < 0.0001). Fewer patients in the phenobarbital group compared to the benzodiazepine group received new mechanical ventilation (P = 0.045), but median duration was similar (1.2 vs 1.6 days; P = 1.00). CONCLUSION AND RELEVANCE Scheduled phenobarbital was associated with decreased hospital LOS compared to benzodiazepines for SAWS. This was the first study to compare outcomes of fixed-dose, nonoverlapping phenobarbital to benzodiazepines in patients with clearly defined SAWS and details a readily implementable protocol.
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Affiliation(s)
| | - Logan M Olson
- Department of Pharmacy, Nebraska Medicine, Omaha, NE, USA
| | - Derek A Kruse
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Elizabeth R Lyden
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Mindy M Blodgett
- Department of Critical Care Medicine, Nebraska Medicine, Omaha, NE, USA
| | - Alena A Balasanova
- Department of Psychiatry, University of Nebraska Medical Center, Omaha, NE, USA
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Schreiber N, Reisinger AC, Hatzl S, Schneider N, Scholz L, Herrmann M, Kolland M, Schuller M, Kirsch AH, Eller K, Kink C, Fandler-Höfler S, Rosenkranz AR, Hackl G, Eller P. Biomarkers of alcohol abuse potentially predict delirium, delirium duration and mortality in critically ill patients. iScience 2023; 26:108044. [PMID: 37854697 PMCID: PMC10579439 DOI: 10.1016/j.isci.2023.108044] [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: 07/20/2023] [Revised: 08/30/2023] [Accepted: 09/21/2023] [Indexed: 10/20/2023] Open
Abstract
Carbohydrate-deficient transferrin (CDT) and the γ-glutamyltransferase-CDT derived Anttila-Index are established biomarkers for sustained heavy alcohol consumption and their potential role to predict delirium and mortality in critically ill patients is not clear. In our prospective observational study, we included 343 consecutive patients admitted to our ICU, assessed the occurrence of delirium and investigated its association with biomarkers of alcohol abuse measured on the day of ICU admission. 35% of patients developed delirium during ICU stay. We found significantly higher CDT levels (p = 0.011) and Anttila-Index (p = 0.001) in patients with delirium. CDT above 1.7% (OR 2.06), CDT per percent increase (OR 1.26, AUROC 0.75), and Anttila-Index per unit increase (OR 1.28, AUROC 0.74) were associated with delirium development in adjusted regression models. Anttila-Index and CDT also correlated with delirium duration exceeding 5 days. Additionally, Anttila-Index above 4, Anttila-Index per unit increase, and CDT per percent increase were independently associated with hospital mortality.
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Affiliation(s)
- Nikolaus Schreiber
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Graz, Austria
- Department of Internal Medicine, Division of Nephrology, Medical University of Graz, Graz, Austria
| | - Alexander C. Reisinger
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Graz, Austria
| | - Stefan Hatzl
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Graz, Austria
| | - Nikolaus Schneider
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Graz, Austria
| | - Laura Scholz
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Graz, Austria
| | - Markus Herrmann
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Michael Kolland
- Department of Internal Medicine, Division of Nephrology, Medical University of Graz, Graz, Austria
| | - Max Schuller
- Department of Internal Medicine, Division of Nephrology, Medical University of Graz, Graz, Austria
| | - Alexander H. Kirsch
- Department of Internal Medicine, Division of Nephrology, Medical University of Graz, Graz, Austria
| | - Kathrin Eller
- Department of Internal Medicine, Division of Nephrology, Medical University of Graz, Graz, Austria
| | - Christiane Kink
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Graz, Austria
| | | | - Alexander R. Rosenkranz
- Department of Internal Medicine, Division of Nephrology, Medical University of Graz, Graz, Austria
| | - Gerald Hackl
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Graz, Austria
| | - Philipp Eller
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Graz, Austria
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5
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Goldfine CE, Tom JJ, Im DD, Yudkoff B, Anand A, Taylor JJ, Chai PR, Suzuki J. The therapeutic use and efficacy of ketamine in alcohol use disorder and alcohol withdrawal syndrome: a scoping review. Front Psychiatry 2023; 14:1141836. [PMID: 37181899 PMCID: PMC10172666 DOI: 10.3389/fpsyt.2023.1141836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/22/2023] [Indexed: 05/16/2023] Open
Abstract
Introduction Alcohol use disorder (AUD) is the most prevalent substance use disorder (SUD) globally. In 2019, AUD affected 14.5 million Americans and contributed to 95,000 deaths, with an annual cost exceeding 250 billion dollars. Current treatment options for AUD have moderate therapeutic effects and high relapse rates. Recent investigations have demonstrated the potential efficacy of intravenous ketamine infusions to increase alcohol abstinence and may be a safe adjunct to the existing alcohol withdrawal syndrome (AWS) management strategies. Methods We followed Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines to conduct a scoping review of two databases (PubMed and Google Scholar) for peer-reviewed manuscripts describing the use of ketamine in AUD and AWS. Studies that evaluated the use of ketamine in AUD and AWS in humans were included. We excluded studies that examined laboratory animals, described alternative uses of ketamine, or discussed other treatments of AUD and AWS. Results We identified 204 research studies in our database search. Of these, 10 articles demonstrated the use of ketamine in AUD or AWS in humans. Seven studies investigated the use of ketamine in AUD and three studies described its use in AWS. Ketamine used in AUD was beneficial in reducing cravings, alcohol consumption and longer abstinence rates when compared to treatment as usual. In AWS, ketamine was used as an adjunct to standard benzodiazepine therapy during severe refractory AWS and at signs of delirium tremens. Adjunctive use of ketamine demonstrated earlier resolution of delirium tremens and AWS, reduced ICU stay, and lowered likelihood of intubation. Oversedation, headache, hypertension, and euphoria were the documented adverse effects after ketamine administration for AUD and AWS. Conclusion The use of sub-dissociative doses of ketamine for the treatment of AUD and AWS is promising but more definitive evidence of its efficacy and safety is required before recommending it for broader clinical use.
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Affiliation(s)
- Charlotte E Goldfine
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Jeremiah J Tom
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Dana D Im
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Benjamin Yudkoff
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, United States
| | - Amit Anand
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, United States
| | - Joseph J Taylor
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, United States
- Center for Brain Circuit Therapeutics, Brigham and Women's Hospital, Boston, MA, United States
| | - Peter R Chai
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, United States
- The Fenway Institute, Fenway Health, Boston, MA, United States
- Koch Institute for Integrated Cancer Research, Massachusetts Institute of Technology, Boston, MA, United States
| | - Joji Suzuki
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, United States
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6
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Maschke M. S1-Leitlinie: Delir und Verwirrtheitszustände inklusive Alkoholentzugsdelir. ACTA ACUST UNITED AC 2021. [DOI: 10.1007/s42451-021-00302-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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7
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Implementation of the Modified Minnesota Detoxification Scale (mMINDS) for Alcohol Withdrawal Syndrome in Critically Ill Patients. Jt Comm J Qual Patient Saf 2020; 46:656-658. [PMID: 32917542 DOI: 10.1016/j.jcjq.2020.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/10/2020] [Accepted: 08/12/2020] [Indexed: 11/21/2022]
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8
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Therapeutic options for agitation in the intensive care unit. Anaesth Crit Care Pain Med 2020; 39:639-646. [PMID: 32777434 DOI: 10.1016/j.accpm.2020.01.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 01/23/2020] [Accepted: 01/24/2020] [Indexed: 11/20/2022]
Abstract
Agitation is common in the intensive care unit (ICU). There are numerous contributing factors, including pain, underlying disease, withdrawal syndrome, delirium and some medication. Agitation can compromise patient safety through accidental removal of tubes and catheters, prolong the duration of stay in the ICU, and may be related to various complications. This review aims to analyse evidence-based medical literature to improve management of agitation and to consider pharmacological strategies. The non-pharmacological approach is considered to reduce the risk of agitation. Pharmacological treatment of agitated patients is detailed and is based on a judicious choice of neuroleptics, benzodiazepines and α2 agonists, and on whether a withdrawal syndrome is identified. Specific management of agitation in elderly patients, brain-injured patients and patients with sleep deprivation are also discussed. This review proposes a practical approach for managing agitation in the ICU.
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9
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Lorazepam versus chlordiazepoxide for the treatment of alcohol withdrawal syndrome and prevention of delirium tremens in general medicine ward patients. Alcohol 2019; 81:56-60. [PMID: 31176787 DOI: 10.1016/j.alcohol.2019.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/24/2019] [Accepted: 05/29/2019] [Indexed: 11/20/2022]
Abstract
Alcohol withdrawal syndrome (AWS) is a serious complication of abrupt alcohol cessation. Severe AWS can develop into delirium tremens (DT), which is potentially life-threatening. Lorazepam (LOR) and chlordiazepoxide (CDE) are mainstays of therapy for AWS. Current literature lacks studies comparing outcomes between the two drugs for patients who are not in a de-addiction ward specifically for withdrawal treatment. The primary objective of the study was to determine the incidence rate of DT between the groups. Of 2112 patients screened, 142 met inclusion criteria (LOR = 74, CDE = 68). Baseline characteristics were similar between groups. No significant difference in the primary outcome of DT development was observed (7% LOR, 9% CDE; p = 0.76). No significant differences in cumulative doses of scheduled LOR or CDE were observed (LOR 14.6 ± 8 mg, CDE 15.4 ± 12; p = 0.64). However, significant differences were found in the amount of "as needed" (PRN) LOR required for the two groups (LOR 3.2 ± 4 mg, CDE 6.6 ± 13 mg; p = 0.03) and the amount of scheduled plus PRN LOR required (LOR 17.7 ± 10 mg, CDE 21.9 ± 14 mg; p = 0.04). Doses are reported in LOR equivalents. There were no observed differences in duration of treatment (LOR 3.6 ± 1.3 days, CDE 3.9 ± 2.1 days; p = 0.3) or length of stay (LOR 5.28 ± 3.8 days, CDE 4.73 ± 4.2 days p = 0.4). No adverse events related to BZD were noted in either group. Hospital outcomes did not differ between the groups, but patients treated with CDE may require more adjuvant therapy to control symptoms of AWS. Both agents appear equally effective at preventing the development of DT in those patients admitted to general medicine wards.
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10
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Correlation between the epigenetic modification of histone H3K9 acetylation of NR2B gene promoter in rat hippocampus and ethanol withdrawal syndrome. Mol Biol Rep 2019; 46:2867-2875. [PMID: 30903572 DOI: 10.1007/s11033-019-04733-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 02/28/2019] [Indexed: 12/31/2022]
Abstract
Patients with alcohol use disorder may develop acute ethanol withdrawal syndrome (EWS). Previous studies showed that an epigenetic modification of the N-methyl-D-aspartate (NMDA) receptor, especially NMDA receptor 2B subunit (NR2B), was involved in the pathological process of EWS. However, the relationship between the epigenetic regulation of the NR2B gene in the rat hippocampus region and EWS were inconsistent. The purpose of this study was to explore the role of the histone H3K9 acetylation of the NR2B gene in the rat hippocampus region in EWS. A rat model of chronic ethanol exposure was established. EWS score and the behavioral changes were recorded at different time points. The NR2B expression levels and the histone H3K9 acetylation level in the NR2B gene promoter region were measured using qRT-PCR, Western blot, immunofluorescence, and chromatin immunoprecipitation, respectively. Finally, the relationship between the epigenetic modification of histone H3K9 acetylation of NR2B gene promoter and EWS were examined. Our ultimate results showed that the EWS score was increased at 2 h, peaked at 6 h after withdrawal of ethanol, and reduced to the level parallel to the normal control group at day 3 after ethanol withdrawal. The NR2B mRNA expression and protein levels showed similar patterns. Further correlation analyses indicted that both histone H3K9 acetylation in NR2B gene promoter and the expression levels of NR2B were positively associated with EWS. Our results suggest that chronic ethanol exposure may result in epigenetic modification of histone H3K9 acetylation in NR2B gene promoter in rat hippocampus, and the expression levels of NR2B were found to be positively correlated with ethanol withdrawal syndrome.
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Shafiekhani M, Mirjalili M, Vazin A. Psychotropic drug therapy in patients in the intensive care unit - usage, adverse effects, and drug interactions: a review. Ther Clin Risk Manag 2018; 14:1799-1812. [PMID: 30319262 PMCID: PMC6168070 DOI: 10.2147/tcrm.s176079] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Managing psychological problems in patients admitted to intensive care unit (ICU) is a big challenge, requiring pharmacological interventions. On the other hand, these patients are more prone to side effects and drug interactions associated with psychotropic drugs use. Benzodiazepines (BZDs), antidepressants, and antipsychotics are commonly used in critically ill patients. Therefore, their therapeutic effects and adverse events are discussed in this study. Different studies have shown that non-BZD drugs are preferred to BZDs for agitation and pain management, but antipsychotic agents are not recommended. Also, it is better not to start antidepressants until the patient has fully recovered. However, further investigations are required for the use of psychotropic drugs in ICUs.
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Affiliation(s)
- Mojtaba Shafiekhani
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran,
| | - Mahtabalsadat Mirjalili
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran,
| | - Afsaneh Vazin
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran,
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12
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Stewart D, Kinsella J, McPeake J, Quasim T, Puxty A. The influence of alcohol abuse on agitation, delirium and sedative requirements of patients admitted to a general intensive care unit. J Intensive Care Soc 2018; 20:208-215. [PMID: 31447913 DOI: 10.1177/1751143718787748] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Purpose Patients with alcohol-related disease constitute an increasing proportion of those admitted to intensive care unit. There is currently limited evidence regarding the impact of alcohol use on levels of agitation, delirium and sedative requirements in intensive care unit. This study aimed to determine whether intensive care unit-admitted alcohol-abuse patients have different sedative requirements, agitation and delirium levels compared to patients with no alcohol issues. Methods This retrospective analysis of a prospectively acquired database (June 2012-May 2013) included 257 patients. Subjects were stratified into three risk categories: alcohol dependency (n = 69), at risk (n = 60) and low risk (n = 128) according to Fast Alcohol Screening Test scores and World Health Organisation criteria for alcohol-related disease. Data on agitation and delirium were collected using validated retrospective chart-screening methods and sedation data were extracted and then log-transformed to fit the regression model. Results Incidence of agitation (p = 0.034) and delirium (p = 0.041) was significantly higher amongst alcohol-dependent patients compared to low-risk patients as was likelihood of adverse events (p = 0.007). In contrast, at-risk patients were at no higher risk of these outcomes compared to the low-risk group. Alcohol-dependent patients experienced suboptimal sedation levels more frequently and received a wider range of sedatives (p = 0.019) but did not receive higher daily doses of any sedatives. Conclusions Our analysis demonstrates that when admitted to intensive care unit, it is those who abuse alcohol most severely, alcohol-dependent patients, rather than at-risk drinkers who have a significantly increased risk of agitation, delirium and suboptimal sedation. These patients may require closer assessment and monitoring for these outcomes whilst admitted.
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Affiliation(s)
- Donald Stewart
- School of Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - John Kinsella
- School of Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - Joanne McPeake
- School of Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - Tara Quasim
- School of Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
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13
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Author response to “management of alcohol withdrawal and nicotine replacement therapy” manuscript 16429. Am J Emerg Med 2017; 35:1956-1957. [DOI: 10.1016/j.ajem.2017.09.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 09/28/2017] [Indexed: 11/18/2022] Open
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14
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Hashmi AM, Han JY, Demla V. Intensive Care and its Discontents: Psychiatric Illness in the Critically Ill. Psychiatr Clin North Am 2017; 40:487-500. [PMID: 28800804 DOI: 10.1016/j.psc.2017.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Critically ill patients can develop a host of cognitive and psychiatric complaints during their intensive care unit (ICU) stay, many of which persist for weeks or months following discharge from the ICU and can seriously affect their quality of life, including their ability to return to work. This article describes some common psychiatric problems encountered by clinicians in the ICU, including their assessment and management. A comprehensive approach is needed to decrease patient suffering, improve morbidity and mortality, and ensure that critically ill patients can return to the highest quality of life after an ICU stay.
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Affiliation(s)
- Ali M Hashmi
- Department of Psychiatry and Behavioral Sciences, King Edward Medical University/Mayo Hospital, Neela Gumbad, Lahore-54700, Pakistan.
| | - Jin Y Han
- Menninger Department of Psychiatry and Behavioral Sciences, Department of Family and Community Medicine, Baylor College of Medicine, 1502 Taub Loop NPC 2nd Floor, Houston, TX 77030, USA
| | - Vishal Demla
- Division of Critical Care Medicine, Department of Internal Medicine, University of Texas Health Science Center, 6431 Fannin, MSB 1.150, Houston, TX 77030, USA
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15
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Tow A, Holtzer R, Wang C, Sharan A, Kim SJ, Gladstein A, Blum Y, Verghese J. Cognitive Reserve and Postoperative Delirium in Older Adults. J Am Geriatr Soc 2017; 64:1341-6. [PMID: 27321616 DOI: 10.1111/jgs.14130] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To examine the role of cognitive reserve in reducing delirium incidence and severity in older adults undergoing surgery. DESIGN Prospective cohort study. SETTING Hospital. PARTICIPANTS Older adults (mean age 71.2, 65% women) undergoing elective orthopedic surgery (N = 142). MEASUREMENTS Incidence (Confusion Assessment Method) and severity (Memorial Delirium Assessment Scale) of postoperative delirium were the primary outcomes. Predictors included early- (literacy) and late-life (cognitive activities) proxies for cognitive reserve. RESULTS Forty-five participants (32%) developed delirium. Greater participation in cognitive activity was associated with lower incidence (odds ratio = 0.92 corresponding to increase of 1 activity per week, 95% confidence interval (CI) = 0.86-0.98, P = .006) and severity (B = -0.06, 95% CI = -0.11 to -0.01, P = .02) of delirium after adjustment for age, sex, medical illnesses, and baseline cognition. Greater literacy was not associated with lower delirium incidence or severity. Of individual leisure activities, reading books, using electronic mail, singing, and computer games were associated with lower dementia incidence and severity. CONCLUSION Greater late-life cognitive reserve was associated with lower delirium incidence and severity in older adults undergoing surgery. Interventions to enhance cognitive reserve by initiating or increasing participation in cognitive activities may be explored as a delirium prophylaxis strategy.
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Affiliation(s)
- Amanda Tow
- Department of Epidemiology, Albert Einstein College of Medicine, Bronx, New York
| | - Roee Holtzer
- Department of Neurology, Albert Einstein College of Medicine, Bronx, New York
| | - Cuiling Wang
- Department of Epidemiology, Albert Einstein College of Medicine, Bronx, New York
| | - Alok Sharan
- Department of Orthopedics, Albert Einstein College of Medicine, Bronx, New York
| | - Sun Jin Kim
- Department of Orthopedics, Albert Einstein College of Medicine, Bronx, New York
| | - Aharon Gladstein
- Department of Orthopedics, Albert Einstein College of Medicine, Bronx, New York
| | - Yossef Blum
- Department of Orthopedics, Albert Einstein College of Medicine, Bronx, New York
| | - Joe Verghese
- Department of Neurology, Albert Einstein College of Medicine, Bronx, New York.,Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
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16
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Kerr A, McVey JT, Wood AM, Van Haren F. Safety of nicotine replacement therapy in critically ill smokers: a retrospective cohort study. Anaesth Intensive Care 2017; 44:758-761. [PMID: 27832565 DOI: 10.1177/0310057x1604400621] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Nicotine replacement therapy (NRT) is a common first-line treatment to prevent nicotine withdrawal in smokers. However, available literature reports conflicting results regarding its efficacy and safety in critically ill patients. The objective of this study was to evaluate the relationship between NRT in smokers in the intensive care unit (ICU) and outcomes. This case-control study was conducted in a university-affiliated tertiary hospital ICU. Over a period of five years, 126 active smokers who received transdermal NRT were matched to 126 active smokers who did not receive NRT. The groups were case-matched for sex, age and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. The primary outcome was administration of antipsychotic medication. Secondary outcomes included use of physical restraints, 30-day mortality, and ventilation requirements. Antipsychotic medication was prescribed in 43 (34.1%) patients who received NRT compared to 14 (11.1%) in controls (P <0.01). Physical restraints were used in 37 (29.4%) patients who received NRT, compared to 12 (9.5%) of controls (P <0.01). The 30-day mortality and number of patients intubated was not statistically different between groups. Average length of intubation time was greater in the NRT group (2.56 days; standard deviation 4.16) compared to the control group (1.44 days; standard deviation 2.68) (P=0.012). The use of NRT to prevent nicotine withdrawal in ICU patients is associated with increased use of antipsychotic medication and physical restraint, and with prolonged mechanical ventilation.
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Affiliation(s)
- A Kerr
- Junior Medical Officer, Intensive Care Unit, The Canberra Hospital, ACT
| | - J T McVey
- Junior Medical Officer, Intensive Care Unit, The Canberra Hospital, ACT
| | - A M Wood
- Junior Medical Officer, Intensive Care Unit, The Canberra Hospital, ACT
| | - Fmp Van Haren
- Intensive Care Physician, Intensive Care Unit, The Canberra Hospital, Associate Professor, Australian National University Medical School, Canberra, ACT
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17
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Sutton LJ, Jutel A. Alcohol Withdrawal Syndrome in Critically Ill Patients: Identification, Assessment, and Management. Crit Care Nurse 2017; 36:28-38. [PMID: 26830178 DOI: 10.4037/ccn2016420] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Management of alcohol withdrawal in critically ill patients is a challenge. The alcohol consumption histories of intensive care patients are often incomplete, limiting identification of patients with alcohol use disorders. Abrupt cessation of alcohol places these patients at risk for alcohol withdrawal syndrome. Typically benzodiazepines are used as first-line therapy to manage alcohol withdrawal. However, if patients progress to more severe withdrawal or delirium tremens, extra adjunctive medications in addition to benzodiazepines may be required. Sedation and mechanical ventilation may also be necessary. Withdrawal assessment scales such as the Clinical Institute of Withdrawal Assessment are of limited use in these patients. Instead, general sedation-agitation scales and delirium detection tools have been used. The important facets of care are the rapid identification of at-risk patients through histories of alcohol consumption, management with combination therapies, and ongoing diligent assessment and evaluation. (Critical Care Nurse. 2016;36[1]:28-39).
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Affiliation(s)
- Lynsey J Sutton
- Lynsey Sutton is an associate charge nurse manager of a level 3 intensive care unit, Capital and Coast District Health Board, Wellington Regional Hospital, Riddiford, Wellington, New Zealand. She is a guest teaching assistant in the postgraduate nursing program at Victoria University of Wellington, New Zealand.Annemarie Jutel works at Victoria University of Wellington. She is also a locum emergency nurse in Central Otago, New Zealand.
| | - Annemarie Jutel
- Lynsey Sutton is an associate charge nurse manager of a level 3 intensive care unit, Capital and Coast District Health Board, Wellington Regional Hospital, Riddiford, Wellington, New Zealand. She is a guest teaching assistant in the postgraduate nursing program at Victoria University of Wellington, New Zealand.Annemarie Jutel works at Victoria University of Wellington. She is also a locum emergency nurse in Central Otago, New Zealand
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18
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Kowalski M, Udy AA, McRobbie HJ, Dooley MJ. Nicotine replacement therapy for agitation and delirium management in the intensive care unit: a systematic review of the literature. J Intensive Care 2016; 4:69. [PMID: 27891229 PMCID: PMC5109763 DOI: 10.1186/s40560-016-0184-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 09/09/2016] [Indexed: 11/16/2022] Open
Abstract
Background Active smokers are prevalent within the intensive care setting and place a significant burden on healthcare systems. Nicotine withdrawal due to forced abstinence on admission may contribute to increased agitation and delirium in this patient group. The aim of this systematic review was to determine whether management of nicotine withdrawal, with nicotine replacement therapy (NRT), reduces agitation and delirium in critically ill patients admitted to the intensive care unit (ICU). Methods The following sources were used in this review: MEDLINE, EMBASE, and CINAHL Plus databases. Included studies reported delirium or agitation outcomes in current smokers, where NRT was used as management of nicotine withdrawal, in the intensive care setting. Studies were included regardless of design or number of participants. Data were extracted on ICU classification; study design; population baseline characteristics; allocation and dose of NRT; agitation and delirium assessment methods; and the frequency of agitation, delirium, and psychotropic medication use. Results Six studies were included. NRT was mostly prescribed for smokers with heavier smoking histories. Three studies reported an association between increased agitation or delirium and NRT use; one study could not find any significant benefit or harm from NRT use; and two described a reduction of symptomatic nicotine withdrawal. A lack of consistent and validated assessment measures, combined with limitations in the quality of reported data, contribute to conflicting results. Conclusions Current evidence for the use of NRT in agitation and delirium management in the ICU is inconclusive. An evaluation of risk versus benefit on an individual patient basis should be considered when prescribing NRT. Further studies that consider prognostic balance, adjust for confounders, and employ validated assessment tools are urgently needed.
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Affiliation(s)
- Melanie Kowalski
- Pharmacy Department, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004 Australia ; Intensive Care Unit, Alfred Health, Melbourne, Australia ; Monash University, Melbourne, Australia
| | - Andrew A Udy
- Intensive Care Unit, Alfred Health, Melbourne, Australia ; Monash University, Melbourne, Australia
| | - Hayden J McRobbie
- Wolfson Institute of Preventive Medicine, London, UK ; Queen Mary University of London, London, UK
| | - Michael J Dooley
- Pharmacy Department, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004 Australia ; Monash University, Melbourne, Australia
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19
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Dixit D, Endicott J, Burry L, Ramos L, Yeung SYA, Devabhakthuni S, Chan C, Tobia A, Bulloch MN. Management of Acute Alcohol Withdrawal Syndrome in Critically Ill Patients. Pharmacotherapy 2016; 36:797-822. [DOI: 10.1002/phar.1770] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Deepali Dixit
- Ernest Mario School of Pharmacy; Rutgers, The State University of New Jersey; Piscataway New Jersey
- Critical Care; Robert Wood Johnson University Hospital; New Brunswick New Jersey
| | | | - Lisa Burry
- Mt. Sinai Hospital; University of Toronto; Toronto Ontario Canada
| | - Liz Ramos
- New York-Presbyterian Weill Cornell Medical Center; New York New York
| | | | | | - Claire Chan
- Yale-New Haven Hospital; New Haven Connecticut
| | - Anthony Tobia
- Division of Psychiatry; Rutgers Robert Wood Johnson Medical School; New Brunswick New Jersey
| | - Marilyn N. Bulloch
- Harrison School of Pharmacy; Auburn University; Auburn Alabama
- Department of Internal Medicine; College of Community Health Sciences; University of Alabama; Tuscaloosa Alabama
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20
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Riggi G, Zapantis A, Leung S. Tolerance and Withdrawal Issues with Sedatives in the Intensive Care Unit. Crit Care Nurs Clin North Am 2016; 28:155-67. [PMID: 27215354 DOI: 10.1016/j.cnc.2016.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Prolonged use of sedative medications continues to be a concern for critical care practitioners, with potential adverse effects including tolerance and withdrawal. The amount of sedatives required in critically ill patients can be lessened and tolerance delayed with the use of pain and/or sedation scales to reach the desired effect. The current recommendation for prolonged sedation is to wean patients from the medications over several days to reduce the risk of drug withdrawal. It is important to identify patients at risk for iatrogenic withdrawal and create a treatment strategy.
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Affiliation(s)
- Gina Riggi
- Department of Pharmacy, Jackson Memorial Hospital, 1611 Northwest 12th Avenue, Miami, FL 33136, USA.
| | - Antonia Zapantis
- Department of Pharmacy, Delray Medical Center, 5352 Linton Boulevard, Delray Beach, FL 33484, USA
| | - Simon Leung
- Department of Pharmacy, Memorial Regional Hospital, 3501 Johnson Street, Hollywood, FL 33021, USA
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21
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Schmidt KJ, Doshi MR, Holzhausen JM, Natavio A, Cadiz M, Winegardner JE. Treatment of Severe Alcohol Withdrawal. Ann Pharmacother 2016; 50:389-401. [PMID: 26861990 DOI: 10.1177/1060028016629161] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Approximately 50% of patients with alcohol dependence experience alcohol withdrawal. Severe alcohol withdrawal is characterized by seizures and/or delirium tremens, often refractory to standard doses of benzodiazepines, and requires aggressive treatment. This review aims to summarize the literature pertaining to the pharmacotherapy of severe alcohol withdrawal. DATA SOURCES PubMed (January 1960 to October 2015) was searched using the search termsalcohol withdrawal, delirium tremens, intensive care, andrefractory Supplemental references were generated through review of identified literature citations. STUDY SELECTION AND DATA EXTRACTION Available English language articles assessing pharmacotherapy options for adult patients with severe alcohol withdrawal were included. DATA SYNTHESIS A PubMed search yielded 739 articles for evaluation, of which 27 were included. The number of randomized controlled trials was limited, so many of these are retrospective analyses and case reports. Benzodiazepines remain the treatment of choice, with diazepam having the most favorable pharmacokinetic profile. Protocolized escalation of benzodiazepines as an alternative to a symptom-triggered approach may decrease the need for mechanical ventilation and intensive care unit (ICU) length of stay. Propofol is appropriate for patients refractory to benzodiazepines; however, the roles of phenobarbital, dexmedetomidine, and ketamine remain unclear. CONCLUSIONS Severe alcohol withdrawal is not clearly defined, and limited data regarding management are available. Protocolized administration of benzodiazepines, in combination with phenobarbital, may reduce the need for mechanical ventilation and lead to shorter ICU stays. Propofol is a viable alternative for patients refractory to benzodiazepines; however, the role of other agents remains unclear. Randomized, prospective studies are needed to clearly define effective treatment strategies.
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Affiliation(s)
- Kyle J Schmidt
- Spectrum Health Butterworth Hospital, Grand Rapids, MI, USA
| | - Mitesh R Doshi
- St John Hospital and Medical Center, Grosse Pointe, MI, USA
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22
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Alkoholentzugsdelir und akute Komplikationen. Notf Rett Med 2016. [DOI: 10.1007/s10049-015-0108-7] [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]
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23
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Sandiumenge A, Torrado H, Muñoz T, Alonso MÁ, Jiménez MJ, Alonso J, Pardo C, Chamorro C. Impact of harmful use of alcohol on the sedation of critical patients on mechanical ventilation: A multicentre prospective, observational study in 8 Spanish intensive care units. Med Intensiva 2015; 40:230-7. [PMID: 26548615 DOI: 10.1016/j.medin.2015.06.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 06/14/2015] [Accepted: 06/29/2015] [Indexed: 12/17/2022]
Abstract
PURPOSE To evaluate the impact of a history of harmful use of alcohol (HUA) on sedoanalgesia practices and outcomes in patients on mechanical ventilation (MV). METHODS A prospective, observational multicentre study was made of all adults consecutively admitted during 30 days to 8 Spanish ICUs. Patients on MV >24h were followed-up on until discharge from the ICU or death. Data on HUA, smoking, the use of illegal (IP) and medically prescribed psychotropics (MPP), sedoanalgesia practices and their related complications (sedative failure [SF] and sedative withdrawal [SW]), as well as outcome, were prospectively recorded. RESULTS A total of 23.4% (119/509) of the admitted patients received MV >24h; 68.9% were males; age 57.0 (17.9) years; APACHE II score 18.8 (7.2); with a medical cause of admission in 53.9%. Half of them consumed at least one psychotropic agent (smoking 27.7%, HUA 25.2%; MPP 9.2%; and IP 7.6%). HUA patients more frequently required PS (86.7% vs. 64%; p<0.02) and the use of >2 sedatives (56.7% vs. 28.1%; p<0.02). HUA was associated to an eightfold (p<0.001) and fourfold (p<0.02) increase in SF and SW, respectively. In turn, the duration of MV and the stay in the ICU was increased by 151h (p<0.02) and 4.4 days (p<0.02), respectively, when compared with the non-HUA group. No differences were found in terms of mortality. CONCLUSIONS HUA may be associated to a higher risk of SF and WS, and can prolong MV and the duration of stay in the ICU in critical patients. Early identification could allow the implementation of specific sedation strategies aimed at preventing these complications.
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Affiliation(s)
- A Sandiumenge
- Vall d́Hebron University Hospital, Barcelona, Spain.
| | - H Torrado
- Intensive Care Department, Bellvitge University Hospital, Barcelona, Spain
| | - T Muñoz
- Intensive Care Department, Cruces University Hospital, San Vicente de Barakaldo, Spain
| | - M Á Alonso
- Intensive Care Department del Tajo University Hospital, Madrid, Spain
| | - M J Jiménez
- Intensive Care Department Clinico San Carlos University Hospital, Madrid, Spain
| | - J Alonso
- Intensive Care Department, Vall d́Hebron University Hospital, Barcelona, Spain
| | - C Pardo
- Intensive Care Department, Infanta Sofia University Hospital, Madrid, Spain
| | - C Chamorro
- Intensive Care Department, Puerta de Hierro-Majadahonda University Hospital, Madrid, Spain
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24
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Ferreira JA, Wieruszewski PM, Cunningham DW, Davidson KE, Weisberg SF. Approach to the Complicated Alcohol Withdrawal Patient. J Intensive Care Med 2015; 32:3-14. [PMID: 26518697 DOI: 10.1177/0885066615614273] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 09/30/2015] [Accepted: 10/07/2015] [Indexed: 11/17/2022]
Abstract
Alcohol withdrawal syndromes are common causes for admission to the intensive care unit. As many as one-fifth of the admitted patients have an alcohol-associated disorder. Identifying the benefit of the γ-aminobutyric acid (GABA) agonists has shifted toward methods to improve benzodiazepine (BZD) utilization. Literature validating this treatment approach in severe withdrawal, especially in the critical care setting, is limited, and extrapolation to this population may be dangerous. Multiple therapies have been suggested or utilized in the literature including continuous infusion of GABA agonists, ethanol, dexmedetomidine, antiepileptics, and antipsychotics, introducing a significant amount of variability into clinical practice. This variability in treatment approaches highlights the lack of uniformity and recommendations available for the treatment of severe refractory patients. In patients progressing to severe withdrawal, it may be warranted to escalate care with adjunctive or more aggressive therapies. Although multiple practices are commonly used, the evidence supporting their use after failing symptom-triggered or aggressive therapy with BZDs is virtually nonexistent. These patients commonly receive a multimodal approach, which varies substantially between providers and institutions. Further literature should be directed at the approach most likely to provide benefit when standard of care has failed.
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Affiliation(s)
- Jason A Ferreira
- University of Florida Health Jacksonville, Jacksonville, FL, USA
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25
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Mirijello A, D’Angelo C, Ferrulli A, Vassallo G, Antonelli M, Caputo F, Leggio L, Gasbarrini A, Addolorato G. Identification and management of alcohol withdrawal syndrome. Drugs 2015; 75:353-65. [PMID: 25666543 PMCID: PMC4978420 DOI: 10.1007/s40265-015-0358-1] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Symptoms of alcohol withdrawal syndrome (AWS) may develop within 6-24 h after the abrupt discontinuation or decrease of alcohol consumption. Symptoms can vary from autonomic hyperactivity and agitation to delirium tremens. The gold-standard treatment for AWS is with benzodiazepines (BZDs). Among the BZDs, different agents (i.e., long-acting or short-acting) and different regimens (front-loading, fixed-dose or symptom-triggered) may be chosen on the basis of patient characteristics. Severe withdrawal could require ICU admission and the use of barbiturates or propofol. Other drugs, such as α2-agonists (clonidine and dexmetedomidine) and β-blockers can be used as adjunctive treatments to control neuroautonomic hyperactivity. Furthermore, neuroleptic agents can help control hallucinations. Finally, other medications for the treatment for AWS have been investigated with promising results. These include carbamazepine, valproate, sodium oxybate, baclofen, gabapentin and topiramate. The usefulness of these agents are discussed.
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Affiliation(s)
- Antonio Mirijello
- Alcohol Use Disorders Unit, Department of Internal Medicine, Gemelli Hospital, Catholic University of Rome, Rome, Italy
| | - Cristina D’Angelo
- Alcohol Use Disorders Unit, Department of Internal Medicine, Gemelli Hospital, Catholic University of Rome, Rome, Italy
| | - Anna Ferrulli
- Alcohol Use Disorders Unit, Department of Internal Medicine, Gemelli Hospital, Catholic University of Rome, Rome, Italy
| | - Gabriele Vassallo
- Alcohol Use Disorders Unit, Department of Internal Medicine, Gemelli Hospital, Catholic University of Rome, Rome, Italy
| | - Mariangela Antonelli
- Alcohol Use Disorders Unit, Department of Internal Medicine, Gemelli Hospital, Catholic University of Rome, Rome, Italy
| | - Fabio Caputo
- Department of Internal Medicine, SS Annunziata Hospital, Cento, Ferrara, Italy
- Department of Clinical Medicine, “G. Fontana” Centre for the Study and Multidisciplinary Treatment of Alcohol Addiction, University of Bologna, Bologna, Italy
| | - Lorenzo Leggio
- Section on Clinical Psychoneuroendocrinology and Neuropsychopharmacology, Laboratory of Clinical and Translational Studies, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, USA
- Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, Baltimore, MD, USA
- Center for Alcohol and Addiction Studies, Department of Behavioral and Social Sciences, Brown University, Providence, RI, USA
| | - Antonio Gasbarrini
- Alcohol Use Disorders Unit, Department of Internal Medicine, Gemelli Hospital, Catholic University of Rome, Rome, Italy
| | - Giovanni Addolorato
- Alcohol Use Disorders Unit, Department of Internal Medicine, Gemelli Hospital, Catholic University of Rome, Rome, Italy
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Straube A, Klein M, Erbguth F, Maschke M, Klawe C, Sander D, Hilz MJ, Ziemssen T, Klucken J, Kohl Z, Winkler J, Bettendorf M, Staykov D, Berrouschot J, Dörfler A. Metabolische Störungen. NEUROINTENSIV 2015. [PMCID: PMC7175475 DOI: 10.1007/978-3-662-46500-4_36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Im folgenden Kapitel werden die verschiedenen metabolischen Störungen betrachtet. Zunächst wird auf die allgemeinen und spezifischen neurologischen Komplikationen bei Organtransplantation eingegangen. Dann geht es um die metabolischen Enzephalopathien: Störungen der Gehirntätigkeit bei angeborenen und erworbenen Stoffwechselerkrankungen im engeren Sinn, Elektrolytstörungen, Hypovitaminosen, zerebrale Folgen einzelner Organdysfunktionen, zerebrale Hypoxien, Endotheliopathien und Mitochondropathien. Anschließend werden das Alkoholdelir und die Wernicke-Enzephalopathie erörtert. Bei zahlreichen akuten Erkrankungen von Gehirn, Rückenmark und peripherem Nervensystem treten typische Störungen vegetativer Systeme auf, deren Erkennung und Therapie insbesondere bei Intensivpatienten eine vitale Bedeutung haben kann: die autonomen Störungen. Bei der zentralen pontinen Myelinolyse kommt es zu einer akuten, vorwiegend fokal-symmetrischen Demyelinisierung im Hirnparenchym. Auch Basalganglienerkrankungen können intensivmedizinisch relevant werden. Und schließlich wird die akute Stressreaktion betrachtet, die aufgrund der vielfältigen metabolischen und endokrinen Veränderungen bei kritischen Erkrankungen entsteht. Gerade das RCVS als neuere Krankheitsentität und wichtige Differenzialdiagnose zur Vaskulitis des ZNS verdient einen eigenen Platz, in diesem Unterkapitel werden ebenfalls verwandte Syndrome wie die hypertensive Enzephalopathie und das PRES abgehandelt.
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27
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Albertson TE, Chenoweth J, Ford J, Owen K, Sutter ME. Is it prime time for alpha2-adrenocepter agonists in the treatment of withdrawal syndromes? J Med Toxicol 2014; 10:369-81. [PMID: 25238670 PMCID: PMC4252292 DOI: 10.1007/s13181-014-0430-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The need to treat withdrawal syndromes is a common occurrence in outpatient, inpatient ward, and intensive care unit (ICU) settings. A PubMed and Google Scholar search using alpha2-adrenoreceptor agonist (A2AA), specific A2AA agents, withdrawal syndrome and nicotine, and alcohol and opioid withdrawal terms was performed. A2AA agents appear to be able to modulate many of the signs and symptoms of significant withdrawal syndromes but are also capable of significant side effects, which can limit clinical use. Non-opioid oral A2AA agent use for opioid withdrawal has been well established. Pharmacologic combination therapy that utilizes A2AA agents for withdrawal syndromes appears promising but requires further formal testing to better define which other agents, under what condition(s), and at what A2AA doses are needed. The A2AA dexmedetomidine may be useful as an adjunctive agent in treating severe alcohol withdrawal syndromes in the ICU. In general, the current data does not support the routine use of A2AA as the primary or sole agent to treat ethanol/alcohol or nicotine withdrawal syndromes. Specific A2AA agents such as lofexidine has been shown to have a primary role in non-opioid-based treatment of opioid withdrawal syndrome and dexmedetomidine in combination with benzodiazepines has been shown to have potential in the treatment of severe ICU-based alcohol withdrawal syndrome.
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Affiliation(s)
- Timothy E Albertson
- Department of Internal Medicine, UC Davis, 4150 V Street, Suite 3100, Sacramento, 95817, CA, USA,
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28
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Lawlor PG, Bush SH. Delirium in patients with cancer: assessment, impact, mechanisms and management. Nat Rev Clin Oncol 2014; 12:77-92. [DOI: 10.1038/nrclinonc.2014.147] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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29
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Repetitive myocardial infarctions secondary to delirium tremens. Case Rep Crit Care 2014; 2014:638493. [PMID: 25197580 PMCID: PMC4145389 DOI: 10.1155/2014/638493] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 07/28/2014] [Indexed: 11/18/2022] Open
Abstract
Delirium tremens develops in a minority of patients undergoing acute alcohol withdrawal; however, that minority is vulnerable to significant morbidity and mortality. Historically, benzodiazepines are given intravenously to control withdrawal symptoms, although occasionally a more substantial medication is needed to prevent the devastating effects of delirium tremens, that is, propofol. We report a trauma patient who required propofol sedation for delirium tremens that was refractory to benzodiazepine treatment. Extubed prematurely, he suffered a non-ST segment myocardial infarction followed by an ST segment myocardial infarction requiring multiple interventions by cardiology. We hypothesize that his myocardial ischemia was secondary to an increased myocardial oxygen demand that occurred during his stress-induced catecholamine surge during the time he was undertreated for delirium tremens. This advocates for the use of propofol for refractory benzodiazepine treatment of delirium tremens and adds to the literature on the instability patients experience during withdrawal.
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30
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Voils SA, Human T, Brophy GM. Adverse neurologic effects of medications commonly used in the intensive care unit. Crit Care Clin 2014; 30:795-811. [PMID: 25257742 DOI: 10.1016/j.ccc.2014.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Adverse drug effects often complicate the care of critically ill patients. Therefore, each patient's medical history, maintenance medication, and new therapies administered in the intensive care unit must be evaluated to prevent unwanted neurologic adverse effects. Optimization of pharmacotherapy in critically ill patients can be achieved by considering the need to reinitiate home medications, and avoiding drugs that can decrease the seizure threshold, increase sedation and cognitive deficits, induce delirium, increase intracranial pressure, or induce fever. Avoiding medication-induced neurologic adverse effects is essential in critically ill patients, especially those with neurologic injury.
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Affiliation(s)
- Stacy A Voils
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, 1225 Center Drive, HPNP Building, Room 3315, PO Box 100486, Gainesville, FL 32610-0486, USA
| | - Theresa Human
- Barnes-Jewish Hospital, Washington University in St. Louis, St. Louis, MO 63110, USA
| | - Gretchen M Brophy
- Departments of Pharmacotherapy & Outcomes Science and Neurosurgery, Medical College of Virginia Campus, Virginia Commonwealth University, 410 North, 12th Street, Richmond, VA 23298-0533, USA.
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Using dexmedetomidine as adjunctive therapy for patients with severe alcohol withdrawal syndrome: another piece of the puzzle. Crit Care Med 2014; 42:1298-9. [PMID: 24736345 DOI: 10.1097/ccm.0000000000000173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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