Substance-Use Disorders in Critically Ill Patients: A Narrative Review

Substance-use disorders (SUDs) represent a major public health concern. The increased prevalence of SUDs within the general population has led to more patients with SUD being admitted to intensive care units (ICUs) for an SUD-related condition or with SUD as a relevant comorbidity. Multiprofessional providers of critical care should be familiar with these disorders and their impact on critical illness. Management of critically ill patients with SUDs is complicated by both acute exposures leading to intoxication, the associated withdrawal syndrome(s), and the physiologic changes associated with chronic use that can cause, predispose patients to, and worsen the severity of other medical conditions. This article reviews the epidemiology of substance use in critically ill patients, discusses the identification and treatment of common intoxication and withdrawal syndromes, and provides evidence-based recommendations for the management of patients exposed to chronic use.

Propofol-Related Infusion Syndrome: A Bibliometric Analysis of the 100 Most-Cited Articles

Propofol-related infusion syndrome (PRIS) is a rare, yet life-threatening sequelae to prolonged administration of the anesthetic propofol in mechanically intubated patients. The condition is characterized by progressive multi-system organ failure and eventual mortality; of note, the predominant characteristics of PRIS involve but are not limited to cardiovascular impairment and collapse, metabolic and lactic acidosis, rhabdomyolysis, hyperkalemia, and acute renal failure. While potent or extended doses of propofol have been found to be the primary precipitating factor of this condition, others such as age, critical illness, steroid therapy, and hyperlipidemia have been discovered to play a role as well. This bibliometric analysis was done to reflect the current relevance and understanding of PRIS in recent literature. The SCOPUS database was utilized to conduct a search for articles with keywords "propofol infusion syndrome" and "propofol syndrome" from February 24, 2001, until April 16, 2023, with parameters for article title, citation number, citation per year, author, institution, publishing journal, and country of origin. PRIS was first defined in 1990, just a year after its approval by the Food and Drug Administration for use as a sedative-hypnotic. Since then, interest in PRIS slowly rose up to 13 publications per year in 2013. Seven papers on the topic were published in Critical Care Medicine, six in Neurocritical Care, and four in Anesthesia. The most common institutions were Mayo Clinic, Northeastern University, and Tufts Medical Center. To our knowledge, this is the first bibliometric analysis to evaluate the most influential publications about PRIS. A majority of the research is case-based, possibly owing to the rarity of the condition. Our research suggests that confounding factors outside the precipitating dosage of propofol may be implicated in the onset and progression of PRIS. This study could therefore bring renewed interest to the topic and lead to additional research focused on fully understanding the pathophysiology of PRIS in order to promote the development of novel diagnostics and treatment.

Prevention of alcohol withdrawal syndrome in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document

Alcohol withdrawal syndrome is a common and challenging clinical entity present in trauma and surgical intensive care unit (ICU) patients. The screening tools, assessment strategies, and pharmacological methods for preventing alcohol withdrawal have significantly changed during the past 20 years. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews the best practices for screening, monitoring, and prophylactic treatment of alcohol withdrawal in the surgical ICU.

Alcohol withdrawal syndrome in ICU patients: Clinical features, management, and outcome predictors

Background

Alcohol withdrawal syndrome (AWS) is a common condition in hospitalized patients, yet its epidemiology in the ICU remains poorly characterized.

Methods

Retrospective cohort of patients admitted to the Nantes University Hospital ICU between January 1, 2017, and December 31, 2019, and coded for AWS using ICD-10 criteria. The objective of the study was to identify factors associated with complicated hospital stay defined as ICU length of stay ≥7 days or hospital mortality.

Results

Among 5,641 patients admitted to the ICU during the study period, 246 (4.4%) were coded as having AWS. Among them, 42 had exclusion criteria and 204 were included in the study. The three main reasons for ICU admission were sepsis (29.9%), altered consciousness (29.4%), and seizures (24%). At ICU admission, median Cushman’s score was 6 [4–9] and median SOFA score was 3 [2–6]. Delirium tremens occurred in half the patients, seizures in one fifth and pneumonia in one third. Overall, 48% of patients developed complicated hospital stay, of whom 92.8% stayed in the ICU for ≥7 days, 36.7% received MV for ≥7 days, and 16.3% died during hospital stay. By multivariable analysis, two factors were associated with complicated hospital stay: a higher number of organ dysfunctions at ICU admission was associated with a higher risk of complicated hospital stay (OR, 1.18; 95CI, 1.05–1.32, P = 0.005), whereas ICU admission for seizures was associated with a lower risk of complicated hospital stay (OR, 0.14; 95%CI, 0.026–0.80; P = 0.026).

Conclusions

AWS in ICU patients chiefly affects young adults and is often associated with additional factors such as sepsis, trauma, or surgery. Half the patients experienced an extended ICU stay or death during the hospital stay. The likelihood of developing complicated hospital stay relied on the reason for ICU admission and the number of organ dysfunctions at ICU admission.

Research Needs for Inpatient Management of Severe Alcohol Withdrawal Syndrome: An Official American Thoracic Society Research Statement

Background: Severe alcohol withdrawal syndrome (SAWS) is highly morbid, costly, and common among hospitalized patients, yet minimal evidence exists to guide inpatient management. Research needs in this field are broad, spanning the translational science spectrum. Goals: This research statement aims to describe what is known about SAWS, identify knowledge gaps, and offer recommendations for research in each domain of the Institute of Medicine T0-T4 continuum to advance the care of hospitalized patients who experience SAWS. Methods: Clinicians and researchers with unique and complementary expertise in basic, clinical, and implementation research related to unhealthy alcohol consumption and alcohol withdrawal were invited to participate in a workshop at the American Thoracic Society 2019 International Conference. The committee was subdivided into four groups on the basis of interest and expertise: T0-T1 (basic science research with translation to humans), T2 (research translating to patients), T3 (research translating to clinical practice), and T4 (research translating to communities). A medical librarian conducted a pragmatic literature search to facilitate this work, and committee members reviewed and supplemented the resulting evidence, identifying key knowledge gaps. Results: The committee identified several investigative opportunities to advance the care of patients with SAWS in each domain of the translational science spectrum. Major themes included 1) the need to investigate non-γ-aminobutyric acid pathways for alcohol withdrawal syndrome treatment; 2) harnessing retrospective and electronic health record data to identify risk factors and create objective severity scoring systems, particularly for acutely ill patients with SAWS; 3) the need for more robust comparative-effectiveness data to identify optimal SAWS treatment strategies; and 4) recommendations to accelerate implementation of effective treatments into practice. Conclusions: The dearth of evidence supporting management decisions for hospitalized patients with SAWS, many of whom require critical care, represents both a call to action and an opportunity for the American Thoracic Society and larger scientific communities to improve care for a vulnerable patient population. This report highlights basic, clinical, and implementation research that diverse experts agree will have the greatest impact on improving care for hospitalized patients with SAWS.

[Alcohol withdrawal delirium: What's new for an old disease?]

The management of alcohol withdrawal syndrome is a frequent work in both community medicine and hospital wards. One of the most severe complications of alcohol withdrawal is Delirium Tremens (DT). The purpose of this development is to update knowledge on this complication in terms of diagnosis, evaluation and therapeutic approaches. It also proposes a reflection on the trajectory of care during and after DT.

Alcohol Withdrawal Syndrome in Neurocritical Care Unit: Assessment and Treatment Challenges

Alcohol withdrawal syndrome (AWS) can range from mild jittery movements, nausea, sweating to more severe symptoms such as seizure and death. Severe AWS can worsen cognitive function, increase hospital length of stay, and in-hospital mortality and morbidity. Due to a lack of reliable history of present illness in many patients with neurological injury as well as similarities in clinical presentation of AWS and some commonly encountered neurological syndromes, the true incidence of AWS in neurocritical care patients remains unknown. This review discusses challenges in the assessment and treatment of AWS in patients with neurological injury, including the utility of different scoring systems such as the Clinical Institute Withdrawal Assessment and the Minnesota Detoxification Scale as well as the reliability of admission alcohol levels in predicting AWS. Treatment strategies such as symptom-based versus fixed dose benzodiazepine therapy and alternative agents such as baclofen, carbamazepine, dexmedetomidine, gabapentin, phenobarbital, ketamine, propofol, and valproic acid are also discussed. Finally, a treatment algorithm considering the neurocritical care patient is proposed to help guide therapy in this setting.

Management of Alcohol Withdrawal in the Emergency Department: Current Perspectives

Alcohol withdrawal syndrome (AWS) is a common, heterogenous, and life-threatening complication of alcohol use disorder (AUD). AUD is a leading cause of worldwide mortality, and many patients with AUD will develop AWS during their ED course. This review summarizes the epidemiology, pathology, and management of AWS and AUD in the emergency setting. The time course of AWS and its impact on ED treatment is emphasized. Once AWS is diagnosed, symptom-triggered benzodiazepine administration remains the most commonly provided treatment but may not be appropriate for patients with significant medical or psychiatric comorbidity or pending discharge. In these cases, ED clinicians may consider short courses of barbiturates or alternative regimens based on novel anticonvulsants. Specific treatment protocols are enumerated for clinical practice. Finally, emergency providers must not only manage acute patients' AWS but also lay the foundation for successful treatment of AUD. An approach to the disposition of the patient with AUD is presented. The authors examine shortcomings in the extant literature and suggest opportunities for further study.

Evaluation of a Symptom-triggered Protocol for Alcohol Withdrawal for Use in the Emergency Department, General Medical Wards, and Intensive Care Unit

BACKGROUND

Alcohol withdrawal is common in hospitalized patients and symptom-triggered guidelines have been shown to reduce treatment duration, length of stay, and need for mechanical ventilation.

OBJECTIVES

To assess the feasibility of incorporating symptom-triggered alcohol withdrawal guidelines early in the hospital course and to evaluate outcomes of patients before and after implementation of the guidelines.

METHODS

This was a retrospective pre-post study of adult patients admitted from the emergency department to an urban, academic, tertiary care center. Subjects in the preguideline (PRE) group were given benzodiazepines in a nonprotocolized manner at the discretion of the treating physician, whereas subjects in the postguideline (POST) group were treated according to the alcohol withdrawal guidelines with treatment beginning in the emergency department.

RESULTS

The PRE group involved 113 admissions for severe alcohol withdrawal and the POST group involved 103 admissions for severe alcohol withdrawal. The median benzodiazepine dose per day, in milligrams of chlordiazepoxide, was higher in the POST group (100 mg in the PRE group vs. 141 mg in the POST group; P<0.02). A higher percentage of patients in the POST group were admitted to the intensive care unit (4.4% in the PRE group vs. 12.6% in the POST group; P=0.05); however, more patients in the PRE group than in the POST group received continuous intravenous sedation and mechanical ventilation, although the difference was not statistically significant (P=0.37 for both variables). There was no difference between the 2 groups in length of stay in the intensive care unit or hospital or discharge disposition.

CONCLUSIONS

Incorporating symptom-triggered guidelines for alcohol withdrawal early in the hospital course at a large medical center is feasible. This approach may result in increased benzodiazepine use, but it seems that it is safe and does not result in adverse outcomes.

Treatment of Severe Alcohol Withdrawal: A Focus on Adjunctive Agents

Objective:To review adjunctive treatment options for severe alcohol withdrawal. Data Sources: The search strategy included a search of Ovid MEDLINE using keywords alcohol withdrawal, severe alcohol withdrawal, AWS, delirium tremens, delirium, dexmedetomidine, propofol, anticonvulsants, clonidine, and phenobarbital and included articles dated from January 1990 to March 2017. Study Selection and Data Extraction: All English-language clinical trials and case reports assessing the efficacy of adjunctive agents in severe alcohol withdrawal were evaluated. Data Synthesis: Although first-line pharmacotherapy for alcohol withdrawal continues to be benzodiazepines, literature does not clearly define adjunctive treatment options for severe alcohol withdrawal. During severe alcohol withdrawal patients may become unable to tolerate or may become unresponsive to high-dose benzodiazepines. Large doses of benzodiazepines may also result in oversedation, respiratory insufficiency, and worsening delirium. Conclusions: Phenobarbital and dexmedetomidine are both viable adjunctive treatment options for severe alcohol withdrawal. Current evidence has shown these agents decrease the dose requirements of benzodiazepines with limited incidence of adverse reactions. Propofol may also be a viable option in mechanically ventilated patients, but its lack of clear safety and efficacy advantages over current treatment options may limit its use in practice. Clonidine, oral anticonvulsants, and ketamine require further controlled clinical trials to clearly define their role in the treatment of severe alcohol withdrawal.

Alcohol Withdrawal Syndrome in Critically Ill Patients: Identification, Assessment, and Management

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).

The emergency medicine management of severe alcohol withdrawal

INTRODUCTION

Alcohol use is widespread, and withdrawal symptoms are common after decreased alcohol intake. Severe alcohol withdrawal may manifest with delirium tremens, and new therapies may assist in management of this life-threatening condition.

OBJECTIVE

To provide an evidence-based review of the emergency medicine management of alcohol withdrawal and delirium tremens.

DISCUSSION

The underlying pathophysiology of alcohol withdrawal syndrome (AWS) is central nervous system hyperexcitation. Stages of withdrawal include initial withdrawal symptoms, hallucinations, seizures, and delirium tremens. Management focuses on early diagnosis, resuscitation, and providing medications with gamma-aminobutyric acid (GABA) receptor activity. Benzodiazepines with symptom-triggered therapy have been the predominant medication class utilized and should remain the first treatment option with rapid escalation of dosing. Treatment resistant withdrawal warrants the use of phenobarbital or propofol, both demonstrating efficacy in management. Propofol can be used as an induction agent to decrease the effects of withdrawal. Dexmedetomidine does not address the underlying pathophysiology but may reduce the need for intubation. Ketamine requires further study. Overall, benzodiazepines remain the cornerstone of treatment. Outpatient management of patients with minimal symptoms is possible.

CONCLUSIONS

Alcohol withdrawal syndrome can result in significant morbidity and mortality. Physicians must rapidly diagnose these conditions while evaluating for other diseases. Benzodiazepines are the predominant medication class utilized, with adjunctive treatments including propofol or phenobarbital in patients with withdrawal resistant to benzodiazepines. Dexmedetomidine and ketamine require further study.

Treatment of Severe Alcohol Withdrawal

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.

Approach to the Complicated Alcohol Withdrawal Patient

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.

Management of benzodiazepine-resistant alcohol withdrawal across a healthcare system: Benzodiazepine dose-escalation with or without propofol

BACKGROUND

Severe cases of alcohol withdrawal syndrome (AWS) may not resolve despite escalating doses of benzodiazepines (BZDs). Benzodiazepine-resistant alcohol withdrawal (RAW) is a subset of severe alcohol withdrawal defined by the requirement of ≥40mg of diazepam administered within one hour. Use of adjunct agents, such as propofol, may be beneficial to minimize BZD adverse effects and improve symptom control. While limited evidence suggests propofol as an effective adjunct in AWS through improved sedation, evidence is currently lacking for the addition of only propofol to BZDs for management of RAW.

METHODS

Retrospective review of adult patients from January, 2009 to March, 2012 with RAW. Patients were categorized into BZD dose-escalation only or BZD plus propofol. The primary endpoint was time to resolution of AWS. Secondary endpoints included safety outcomes associated with medication use.

RESULTS

Of 1083 patients with severe AWS, 66 RAW patients (n=33 BZD only, n=33 BZD plus propofol) met inclusion. Median time to AWS resolution was 5.0 and 7.0 days for BZD only vs. BZD plus propofol (p=0.025). Duration of mechanical ventilation, ICU and hospital length of stay were significantly higher with propofol (p=0.017, <0.001 and <0.001, respectively). Ten patients required intervention for management of propofol-induced adverse reactions.

CONCLUSIONS

The addition of propofol for RAW treatment is associated with significant increases in clinical care. While randomized, prospective evaluations are necessary to determine the cause of this association, our data suggests use of adjunctive propofol therapy in RAW is associated with longer and more complicated hospital admissions.

Evaluating the effects of dexmedetomidine compared to propofol as adjunctive therapy in patients with alcohol withdrawal

BACKGROUND

In severe alcohol withdrawal (AW), benzodiazepines may be inadequate to control symptoms. In many situations, benzodiazepine dosing escalates despite no additional efficacy and introduces potential toxicities. Severe cases of AW may require additional agents to control symptoms. Case reports and studies have shown benefits with dexmedetomidine and propofol in severe AW, but these agents have not been compared with one another. This study compares the effects of dexmedetomidine and propofol on benzodiazepine and haloperidol utilization in patients with AW.

METHODS

A retrospective chart review was completed on 41 patients with AW who received adjunctive dexmedetomidine or propofol. The primary objective was to compare benzodiazepine and haloperidol utilization before and after initiation of dexmedetomidine or propofol. Secondary measures included AW and sedation scoring, analgesic use, intensive care unit length of stay, rates of intubation, and adverse events.

RESULTS

Among the dexmedetomidine and propofol groups, significant reductions in benzodiazepine (P≤0.0001 and P=0.043, respectively) and haloperidol (P≤0.0001 and P=0.026, respectively) requirements were observed. These reductions were comparable between groups (P=0.933 and P=0.465, respectively). A trend toward decreased intensive care unit length of stay in the dexmedetomidine group (123.6 hours vs 156.5 hours; P=0.125) was seen. Rates of intubation (14.7% vs 100%) and time of intubation (19.9 hours vs 97.6 hours; P=0.002) were less in the dexmedetomidine group. Incidence of hypotension was 17.6% in the dexmedetomidine group vs 28.5% in the propofol group. Incidence of bradycardia was 17.6% in the dexmedetomidine group vs 0% in the propofol group. No differences were observed in other secondary outcomes.

CONCLUSION

In patients with severe AW who require sedation, both dexmedetomidine and propofol have unique and advantageous properties. Both agents appear to have equivalent efficacy in reducing AW-related symptoms and benzodiazepine and haloperidol requirements. These results should be validated in a larger, prospective trial.