Alcohol Withdrawal in the Surgical Patient

Physical Activity, Alcohol, and Cigarette Use in Urological Cancer Patients over Time since Diagnosis

Urological cancers represent a substantial global public health concern, exerting far-reaching effects on both individuals and their families. There is an urgent need to comprehensively understand the transformations in patients' lifestyles and behaviors, given their critical role in the treatment process and overall well-being. This study, involving 128 urological cancer patients, aims to investigate changes in physical activity levels, problematic drinking behaviors assessed through the Alcohol Use Disorders Identification Test (AUDIT), and smoking habits assessed using the Fagerström Test for Nicotine Dependence (FTND) over four distinct time intervals over the subsequent three years from the time of diagnosis and among individuals diagnosed more than three years ago. The results reveal a significant decrease in physical activity levels between study intervals (p < 0.0001), declining from 69% to 45% between the first and second post-diagnosis assessments. Furthermore, the highest levels of problematic substance use, indicated by mean scores, were noted in the first year following diagnosis (AUDIT: 4.20, p = 0.01; FTND: 4.83, p = 0.08). Given the significant impact of physical activity on the prospects of recovery, it is imperative to delve more deeply into the factors contributing to this decline and devise targeted interventions for its improvement. In the context of substance use, it is essential to ascertain whether the initially high levels are a result of coping with the cancer diagnosis or represent a turning point at which patients modify their behaviors and cease their addiction. A more thorough understanding of this phenomenon would enhance the effectiveness of precisely focused interventions.

Evaluation of a Phenobarbital-Based Protocol for Severe Alcohol Withdrawal in Critically Ill Patients

Background: Phenobarbital offers several possible advantages to benzodiazepines including a longer half-life and anti-glutamate activity, and is an alternative for the treatment of alcohol withdrawal. The objective of this analysis was to evaluate the safety and efficacy of a phenobarbital protocol for alcohol withdrawal newly implemented at our institution. Methods: This was a single-center, retrospective analysis of adult patients admitted to the medical/surgical/burn/trauma intensive care unit (ICU) with or at risk of severe alcohol withdrawal. Patients who were admitted prior to guideline implementation and received scheduled benzodiazepines (PRE) were compared to those who received phenobarbital post guideline update (POST). The primary outcome was ICU length of stay (LOS). Results: Upon analysis, 68 patients in the PRE and 64 patients in the POST were identified for inclusion. The median APACHE II score was significantly higher in the POST (4.5 [3:9] vs 10 [5:13], P < 0.001). ICU (2 [1:2] vs 2 [2:5], P = 0.002) and hospital (4.5 [3:6] vs 8 [6:12], P < 0.001) LOS were significantly longer in the POST. There was no difference in mortality or duration of mechanical ventilation. More patients required propofol or dexmedetomidine on day one in the POST (P < 0.001). Conclusion: Patients in the POST had significantly longer ICU and hospital LOS, and had a higher baseline severity of illness. Future research is needed to evaluate the efficacy and safety of phenobarbital compared to benzodiazepines for severe alcohol withdrawal.

Spinal astrocyte aldehyde dehydrogenase-2 mediates ethanol metabolism and analgesia in mice

BACKGROUND

Little is known about the targets in the CNS that mediate ethanol analgesia. This study explores the role of spinal astrocyte aldehyde dehydrogenase-2 (ALDH2), a key ethanol-metabolising enzyme, in the analgesic effects of ethanol in mice.

METHODS

Astrocyte and hepatocyte ALHD2-deficient mice were generated and tested in acute and chronic pain models. Cell-type-specific distribution of ALDH2 was analysed by RNA in situ hybridisation in spinal slices from astrocytic ALDH2-deficient mice and their wild-type littermates. Spinal ethanol metabolites and γ-aminobutyric acid (GABA) content were measured using gas chromatography/mass spectrometry and liquid chromatography/mass spectrometry.

RESULTS

ALDH2 mRNA was expressed in both astrocytes and neurones in spinal cord slices. Astrocyte ALDH2-deficient mice had decreased expression of ALDH2 mRNA in astrocytes, but not in neurones. Astrocyte ALDH2 deficiency inhibited ethanol-derived acetate, but not acetaldehyde content in spinal cord tissues. Depletion of spinal astrocyte ALDH2 selectively inhibited ethanol-induced anti-nociceptive effect, but not the effect of ethanol, on motor function. Astrocyte ALDH2 deficiency abolished ethanol-induced GABA elevation. The ethanol metabolite acetate produced anti-nociception and increased GABA synthesis in a manner similar to ethanol. I.T. delivery of either GABA_A or GABA_B receptor antagonists prevented ethanol and acetate-induced analgesia.

CONCLUSIONS

These findings provide evidence that ALDH2 in spinal astrocytes mediates spinal ethanol metabolism and ethanol-induced analgesic effects by promoting GABA synthesis and GABAergic transmission in spinal cord.

The concept of "food addiction" helps inform the understanding of overeating and obesity: YES

Addictive substances such as opiates and other drugs are highly reinforcing and some (but not all) individuals consume them compulsively. Highly processed (HP) foods have unnaturally high concentrations of refined carbohydrates and fat. These foods are highly reinforcing and some (but not all) individuals consume them compulsively. HP foods, like addictive substances, are more effective in activating reward-related neural systems than minimally processed foods. More importantly, HP foods are associated with the behavioral indicators of addiction: diminished control over consumption, strong craving, continued use despite negative consequences, and repeated failed attempts to reduce or eliminate intake. Thus, HP foods are key in addictive patterns of food intake. Like addictive drugs, HP foods are complex, human-made substances designed to effectively deliver reinforcing ingredients (e.g., refined carbohydrates, fat). Withdrawal and tolerance are not necessary for an addiction classification; however, HP foods can trigger both these processes. On a public health level, the negative consequences of HP foods are high, even for those without clinically relevant levels of addictive eating. The recognition that some foods can be addictive will inform clinical obesity treatment and underscore the importance of environmentally focused policy interventions.

Prevention of withdrawal symptoms in alcoholic patients with head and neck cancer

BACKGROUND

The role of alcohol abuse is common in the onset of cancer of the upper aerodigestive tract, especially that affecting the tongue, floor of the mouth, palatine tonsil and piriform sinus. The consequences of the abuse of alcohol immediately after surgery in these patients are less known. But they are very important to achieve good final results.

METHODS

To try to understand the best treatment for withdrawal symptoms in a group of Italian patient with head and neck cancers, we administered a 10-item questionnaire. Subsequently, we decided to send the questionnaire to the main Italian centers of head and neck oncology using the platform of online surveys SurveyMonkey.

RESULTS

The results show clearly that it is not easy, within the Italian "latin" culture and lifestyle to correctly identify the alcoholic patient (patients in the last stage of the of the disease with a "behavioral dependency") and that the centers which address these problems mostly use a drug treatment, employing in particular two classes of drugs, associated or not with thiamine, with a varying quantity of other vitamins.

CONCLUSIONS

It is important to know the early withdrawal syndrome to assess the ideal treatment. We propose a personal protocol to present this complication.

Evaluation of the Brief Alcohol Withdrawal Scale Protocol at an Academic Medical Center

OBJECTIVES

The standard of care for treatment of alcohol withdrawal is symptom-triggered dosing of benzodiazepines using a withdrawal scale. Abbreviated scales are desired for clinician efficiency. The objective of this study was to evaluate the use of the 5-item Brief Alcohol Withdrawal Scale (BAWS) protocol.

METHODS

This single-center, retrospective, observational, cohort study assessed patients ordered the BAWS protocol between August 1, 2016 and July 31, 2017. Data were collected on benzodiazepine exposure, duration of treatment, withdrawal severity, agitation, over-sedation, and delirium while being treated for alcohol withdrawal. Comparisons were made to analyze predetermined patient subgroups.

RESULTS

Seven hundred ninety-nine patients were initiated on the BAWS protocol. Patients received a median (IQR) of 0 (0-4) lorazepam equivalents (LEs) and were on the BAWS protocol for a median (IQR) of 44.9 (22.4-77.2) hours. Of the patients that received benzodiazepines while on the BAWS protocol, a median (IQR) of 4 (2-11) LEs were given. Seventeen (2.1%) patients had severe withdrawal. Days of agitation, over-sedation, and delirium were minimal, with the median (IQR) of 0 (0-0). Few patients received adjunctive medications for symptom management. Intensive care unit (ICU) patients had more severe withdrawal than non-ICU patients, but received the same cumulative benzodiazepine dose.

CONCLUSIONS

Most patients on the BAWS protocol received little-to-no benzodiazepines; severe withdrawal, agitation, delirium, or over-sedation were uncommon. This is the first evaluation of the BAWS protocol on a diverse population of hospitalized patients.

Perioperative Management of Alcohol Withdrawal Syndrome

Background

In the perioperative course, alcohol withdrawal syndrome (AWS) can occur in any setting, especially in aero-digestive and acute trauma surgery. Challenging issues are the overlap of other forms of delirium in perioperative and intensive care settings as well as general anesthesia masking the onset of withdrawal symptoms. In contrast to other etiologies of delirium, the pathophysiology and thus treatment strategy of AWS is different: the key point is the tolerance to GABAergic molecules of alcohol-dependent subjects resulting in central nervous hyperactivity once the effect of alcohol or other GABA-stimulating agents is decreased.

Summary

Despite limitations due to insufficient accuracy of self-reporting questionnaires and limited feasibility in emergency settings, the AUDIT and the shortened AUDIT-C are the standard tools for detection of alcohol use disorders (AUD), as well as predicting AWS risk and severity in approximately half of these AUD patients. The most important risk factors for AWS are a high blood alcohol concentration at hospital admission, AWS episodes in medical history, and lack of control of alcohol use. Patients considered at risk for severe AWS must be treated with prophylactic medication before the onset of symptoms. Thiamine supplementation is required for all malnourished alcohol-dependent patients. Writing down alcohol-related diagnoses in the medical records requires the patient's presumed consent after shared decision-making. These reports should remain strictly confidential if the patient desires. Psychological support for the perioperative period as well as the following course should be offered to all AUD patients including support in short- and long-term detoxification. Alternative diagnoses must be ruled out with no timely delay, especially if fever and coma are the leading symptoms. The backbone of AWS therapy is the symptom-triggered administration of intravenous benzodiazepines (BZO) in escalating doses until the aimed revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar) or Richmond Agitation-Sedation Scale (RASS) score is achieved. Clonidine, dexmedetomidine, baclofen, ketamine, and neuroleptics may be used as symptom-orientated adjuncts. The therapeutic administration of ethanol or clomethiazole is considered to be harmful in critically ill patients after the onset of AWS. General supportive and intensive care including high-dose thiamine supplementation are mandatory in severe AWS cases. The timely differential diagnosis of delirium is important - and AWS is a diagnosis of exclusion - because BZO are strongly recommended for AWS patients but may not be the treatment of choice in other etiologies of delirium.

Key Messages

Screening for AWS risk factors should be integrated in the preoperative and emergency assessment. Other severe diagnoses must be ruled out before the diagnosis of AWS can be established. Preventive treatment should be given to high-risk patients scoring positive for AUD and for patients with a lack of alcohol use control. The principles of AWS therapy are symptom-orientated doses of BZO and as adjuncts α₂-agonists, neuroleptics, and others guided by repeated reassessment with validated tools and thiamine administration. Length of stay and morbidity are reduced if AWS therapy is symptom-orientated and protocol-based.

Phenobarbital for Acute Alcohol Withdrawal Management in Surgical Trauma Patients-A Retrospective Comparison Study

BACKGROUND

Alcohol withdrawal syndrome (AWS) in surgical trauma patients is associated with significant morbidity and mortality. Benzodiazepines, commonly used for withdrawal management, pose unique challenges in this population given the high prevalence of head trauma and delirium. Phenobarbital is an antiepileptic drug that offers a viable alternative to benzodiazepines for AWS treatment.

METHODS

This is a retrospective chart review of patients with active alcohol use disorder who presented to a level 1 trauma center over a 4-year period and required medication-assisted management for AWS. The primary outcome variable examined was the development of AWS and associated complications. Additional outcomes measured included hospital length of stay, mortality, and medication-related adverse events.

RESULTS

Of the 85 patients in the study sample, 52 received a fixed-dose benzodiazepine-based protocol and 33 received phenobarbital-based protocol. In the benzodiazepine-based protocol group, 25 patients (48.2%) developed AWD and 38 (73.1%) developed uncomplicated AWS, as compared to 0 patients in the phenobarbital-based protocol (P = 0.0001). There were 10 (19.2%) patients with medication adverse side effects in the benzodiazepine-based protocol group versus 0 patients in the phenobarbital-based protocol group. There were no statically significant differences between the 2 groups as pertains to rates of other AWS-related complications, patient mortality, or length of stay.

CONCLUSION

The use of a phenobarbital-based protocol in trauma patients with underlying active alcohol use disorder resulted in a statistically significant decrease in the incidence of AWD and uncomplicated AWS secondary to AWS when compared to patients treated with a fixed-dose benzodiazepine-based protocol.

Intermittent hypoxia training: Powerful, non-invasive cerebroprotection against ethanol withdrawal excitotoxicity

Ethanol intoxication and withdrawal exact a devastating toll on the central nervous system. Abrupt ethanol withdrawal provokes massive release of the excitatory neurotransmitter glutamate, which over-activates its postsynaptic receptors, causing intense Ca2+ loading, p38 mitogen activated protein kinase activation and oxidative stress, culminating in ATP depletion, mitochondrial injury, amyloid β deposition and neuronal death. Collectively, these mechanisms produce neurocognitive and sensorimotor dysfunction that discourages continued abstinence. Although the brain is heavily dependent on blood-borne O2 to sustain its aerobic ATP production, brief, cyclic episodes of moderate hypoxia and reoxygenation, when judiciously applied over the course of days or weeks, evoke adaptations that protect the brain from ethanol withdrawal-induced glutamate excitotoxicity, mitochondrial damage, oxidative stress and amyloid β accumulation. This review summarizes evidence from ongoing preclinical research that demonstrates intermittent hypoxia training to be a potentially powerful yet non-invasive intervention capable of affording robust, sustained neuroprotection during ethanol withdrawal.

Pharmacotherapy for Alcohol Withdrawal

This feature examines the impact of pharmacologic interventions on the treatment of the critically ill patient — an area of health care that has become increasingly complex. Recent advances in drug therapy for adult ICU patients (including evolving and controversial data) will be reviewed and assessed in terms of clinical, humanistic, and economic outcomes. Direct questions or comments to Gil Fraser, PharmD, at fraseg@mmc.org .

Impact of an Alcohol Withdrawal Treatment Pathway on Hospital Length of Stay: A Retrospective Observational Study Comparing Pre and Post Pathway Implementation

OBJECTIVE

To determine if the implementation of a hospital-specific alcohol withdrawal treatment pathway used in a medical-surgical patient population decreased hospital length of stay (LOS) compared with the standard of care.

METHODS

This retrospective observational study, conducted in a large academic tertiary care hospital, involved 582 subjects who met criteria for study inclusion, with 275 subjects in the 2010 cohort and 307 in the 2012 cohort. The Alcohol Withdrawal Project Team was formed with the goal of creating a standardized approach to the recognition and treatment of alcohol withdrawal at Duke University Hospital. The group created a computerized physician order entry alcohol withdrawal treatment pathway with 4 possible treatment paths chosen on the basis of current withdrawal symptoms, vital signs, and alcohol withdrawal history. The 4 treatment paths are 1 prophylaxis; 2 mild-to-moderate withdrawal; 3 moderate-to-severe withdrawal, and 4 severe withdrawal/alcohol withdrawal delirium. Each treatment path corresponds to a different lorazepam dose and dose schedule and symptom assessment. This pathway was implemented in the hospital at the end of 2011.

RESULTS

Using a Cox proportional hazards model and adjusting for covariates, there was a 1 day [95% confidence interval (CI), 1-2 d] reduction in median hospital LOS between the 2010 and 2012 cohorts, 5 versus 4 days, respectively. The average ratio in hospital LOS between the 2 cohorts was 1.25 (95% CI, 1.25-1.67). The CI was estimated by bootstrapping and indicated a significantly longer LOS in the 2010 cohort compared with the 2012 cohort. Nonsignificant changes were found in the proportion of subjects admitted to the intensive care unit (24% in 2010 vs. 29.3% in 2012), LOS in the intensive care unit (7.1±8 d in 2010 vs. 5.6±6.9 d in 2012), and proportion of patients discharged with a diagnosis of delirium tremens (17.8% in 2010 vs. 15.3% in 2012).

CONCLUSIONS

This study demonstrates the successful implementation of an alcohol withdrawal treatment pathway in a medical-surgical population hospitalized in a large tertiary care facility with significant impact on hospital LOS.

Postoperative delirium in patients with history of alcohol abuse

INTRODUCTION

Postoperative delirium (POD) is an acute confusional state characterized by changes in consciousness and cognition, which may be fluctuating, developing in a small period of time. The aim of this study was to evaluate the relationship between alcohol abuse and the development of POD.

METHODS

We prospectively evaluated consecutively all postoperative patients admitted in the Post-anesthesia Care Unit over a 1-month period for delirium, using the Portuguese versions of the the Nursing Delirium Screening Scale. Before surgery, alcohol consumption was inquired and alcohol abuse was assessed by the CAGE (Cutting Down, Annoyance, Guilt and Eye-opener) questionnaire; a score ≥2 defined alcohol abuse. Fischer exact test or chi-square was applied for comparisons. Risk factors were analyzed in a multivariate analysis using a logistic regression with odds ratios (OR) and 95% confidence intervals (95%CI).

RESULTS

Two hundred twenty-one patients were enrolled. Delirium was seen in 11% patients. The incidence of alcohol abuse was 10%. Patients with alcohol abuse were more frequently men (P<.001) and had a higher ASA physical status III/IV (P=.021). POD was more frequent in patients with alcohol abuse (30% vs. 9%; P=.002). Age (OR: 5.9; 95%CI: 2.2-15.9; P<.001 for patients ≥65years), ASA physical statusIII/IV (OR: 4.2; 95%CI: 1.7-10.7; P=.002) and alcohol abuse (OR: 4.2; 95%CI: 1.4-12.9; P=.013) were found to be independent predictors for POD.

CONCLUSIONS

Older patients, higher ASA physical status and alcohol abuse were more frequent in patients with POD. Alcohol abuse was considered an independent risk factor for POD.

Concurrence of Intraoperative Hypotension, Low Minimum Alveolar Concentration, and Low Bispectral Index Is Associated with Postoperative Death

BACKGROUND

An intraoperative concurrence of mean arterial pressure less than 75 mmHg, minimum alveolar concentration less than 0.8, and bispectral index less than 45 has been termed a "triple low" state. An association between triple low and postoperative mortality has been reported but was not replicated in a subsequent study. The authors pooled existing data from clinical trials to further evaluate the purported association in an observational study.

METHODS

This retrospective observational study included 13,198 patients from three clinical trials: B-Unaware, BAG-RECALL, and Michigan Awareness Control Study. Patients with greater than 15 not necessarily consecutive minutes of triple low were propensity matched to controls with similar characteristics and comorbidities. A multivariable Cox proportional hazards model was used to evaluate the association between triple low duration and postoperative mortality.

RESULTS

Thirty-day mortality was 0.8% overall, 1.9% in the triple low cohort, and 0.4% in the nontriple low cohort (odds ratio, 5.16; 95% CI, 4.21 to 6.34). After matching and adjusting for comorbidities, cumulative duration of triple low was significantly associated with an increased risk of mortality at 30 days (hazard ratio, 1.09; 95% CI, 1.07 to 1.11, per 15 min) and 90 days (hazard ratio, 1.09; 95% CI, 1.08 to 1.11, per 15 min).

CONCLUSION

There is a weak independent association between the triple low state and postoperative mortality, and the propensity-matched analysis does not suggest that this is an epiphenomenon.

Is it prime time for alpha2-adrenocepter agonists in the treatment of withdrawal syndromes?

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.

Comparison of clinical outcomes in nonintubated patients with severe alcohol withdrawal syndrome treated with continuous-infusion sedatives: dexmedetomidine versus benzodiazepines

STUDY OBJECTIVE

To compare efficacy and safety outcomes in nonintubated patients with severe alcohol withdrawal syndrome (AWS) who required a continuous infusion of a benzodiazepine or dexmedetomidine in addition to standard medical therapy for AWS.

DESIGN

Retrospective cohort study.

SETTING

Two hospitals within the same network that used different treatment strategies for AWS.

PATIENTS

A total of 61 nonintubated adults who received a continuous infusion of either a benzodiazepine (BZD) (lorazepam or midazolam; 33 patients) or dexmedetomidine (DEX) (28 patients) for severe AWS between April 1, 2011, and October 31, 2012, as well as standard medical therapy for AWS.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was a composite end point including rates of respiratory distress requiring endotracheal intubation or occurrence of alcohol withdrawal seizures. No significant differences in the composite end point were noted between the BZD and DEX groups (9.1% and 7.1%, respectively, p>0.99) or its individual components of respiratory distress (9.1% and 7.1%, respectively, p>0.99) or alcohol withdrawal seizures (0% and 3.6%, respectively, p=0.46). The DEX group received a lower median total dose of lorazepam equivalents after initiation of the study drug (median [interquartile range] 105 [60-199.5] mg in the BZD group vs 3.5 [0-12] mg in the DEX group), but this did not translate into a reduced requirement for endotracheal intubation or decreased length of stay. DEX was associated with more adverse drug events including hypotension and bradycardia. Of concern, DEX may impair the ability to assess symptoms appropriately and administer BZDs in a symptom-triggered fashion. Although the total cost of hospitalization was similar between groups, DEX was associated with a higher study drug cost per patient.

CONCLUSION

DEX demonstrated a BZD-sparing effect in the treatment of AWS; however, this surrogate end point should be interpreted with caution. Although this study cannot disprove the possibility of a protective effect of DEX in preventing the requirement for endotracheal intubation in patients with AWS, an increased rate of adverse drug events and increased study drug costs were observed. If DEX is used in clinical practice, it should only be used as adjunctive therapy with BZDs that have a proven benefit in AWS.

Brief review: Obstetric care and perioperative analgesic management of the addicted patient

PURPOSE

Addiction to alcohol and illicit drugs occurs in approximately 10% of the Canadian population and thus likely affects numerous perioperative patients. Provision of perioperative analgesia to these patients is challenging for physiological and behavioural reasons. Seven electronic databases were searched to identify papers addressing the perioperative management of analgesia in addicted patients.

PRINCIPAL FINDINGS

There are few controlled trials on addiction care in obstetrical management, and controlled trials are lacking in obstetrical analgesia and addiction and in perioperative analgesia and addiction. The focus of the limited number of publications in the obstetrical population is on addiction management during pregnancy and does not address analgesic requirements. There are principle-based discussions on factors affecting analgesic management in patients receiving chronic opioid therapy and multimodal analgesic therapy. This discourse includes consideration of the physiological and affective factors that impact perioperative management. A number of empirically derived protocols available for managing alcohol withdrawal are based on response to the physical manifestations of withdrawal. Protocols for management of patients receiving opioid replacement therapy for opioid addiction are also well described. Nevertheless, evaluations of these protocols are lacking in clinical trials, and the impact of addiction on perioperative outcomes is unknown.

CONCLUSION

Perioperative analgesic management of addicted patients remains poorly understood. Most clinical trials specifically exclude addicted patients. Suggestions for management are provided.

Perioperative management of alcohol withdrawal in an achondroplastic dwarf with an unstable cervical spine: a difficult management dilemma

Patients presenting with alcohol withdrawal syndrome have an increased risk of perioperative events related to hemodynamic and respiratory instability. We present the case of a 49-year-old achondroplastic dwarf in alcohol withdrawal with cervical spinal cord injury and aortic dissection requiring emergency surgery. Due to conflicting perioperative management goals, a decision was made to delay surgery until the patient became clinically stable. Additional options might have been explored and resulted in better outcome.

Alcohol, nicotine, and iatrogenic withdrawals in the ICU

OBJECTIVES

The neurophysiology, risk factors, and screening tools associated with alcohol withdrawal syndrome in the ICU are reviewed. Alcohol withdrawal syndrome assessment and its treatment options are discussed. Description of nicotine withdrawal and related publications specific to the critically ill are also reviewed. A brief comment as to sedative and opiate withdrawal follows.

DATA AND SUMMARY

The role of currently published alcohol withdrawal syndrome pharmacologic strategies (benzodiazepines, ethanol, clomethiazole, antipsychotics, barbiturates, propofol, and dexmedetomidine) is detailed. Studies on nicotine withdrawal management in the ICU focus mainly on the safety (mortality) of nicotine replacement therapy. Study characteristics and methodological limitations are presented.

CONCLUSION

We recommend a pharmacologic regimen titrated to withdrawal symptoms in ICU patients with alcohol withdrawal syndrome. Benzodiazepines are a reasonable option; phenobarbital appears to confer some advantages in combination with benzodiazepines. Propofol and dexmedetomidine have not been rigorously tested in comparative studies of drug withdrawal treatment; their use as additional or alternative strategies for managing withdrawal syndromes in ICU patients should therefore be individualized to each patient. Insufficient data preclude recommendations as to nicotine replacement therapy and management of iatrogenic drug withdrawal in ICU patients.

Intraoperative alcohol withdrawal syndrome: a coincidence or precipitation?

As the prevalence of alcohol dependence is approximately half in surgical patients with an alcohol use disorder, anesthetist often encounters such patients in the perioperative settings. Alcohol withdrawal syndrome (AWS) is one of the most feared complications of alcohol dependence and can be fatal if not managed actively. A 61-year-old man, alcoholic with 50 h of abstinence before surgery, received spinal anesthesia for surgery for femoral neck fracture. To facilitate positioning for spinal anesthesia, fascia iliaca compartmental block with 0.25% bupivacaine (30 mL) was administered 30 min prior to spinal block. Later, in the intraoperative period the patient developed AWS; however, the features were similar to that of local anesthetic toxicity. The case was successfully managed with intravenous midazolam, esmolol, and propofol infusion. Due to similarity of clinical features of AWS and mild local anesthetic toxicity, an anesthetist should be in a position to differentiate the condition promptly and manage it aggressively.

Care for hospitalized patients with unhealthy alcohol use: a narrative review

There is increasing emphasis on screening, brief intervention, and referral to treatment (SBIRT) for unhealthy alcohol use in the general hospital, as highlighted by new Joint Commission recommendations on SBIRT. However, the evidence supporting this approach is not as robust relative to primary care settings. This review is targeted to hospital-based clinicians and administrators who are responsible for generally ensuring the provision of high quality care to patients presenting with a myriad of conditions, one of which is unhealthy alcohol use. The review summarizes the major issues involved in caring for patients with unhealthy alcohol use in the general hospital setting, including prevalence, detection, assessment of severity, reduction in drinking with brief intervention, common acute management scenarios for heavy drinkers, and discharge planning. The review concludes with consideration of Joint Commission recommendations on SBIRT for unhealthy alcohol use, integration of these recommendations into hospital work flows, and directions for future research.

Alcoholic delirium tremens with hollow viscus perforation scheduled for emergency laparotomy

Alcohol is a drug consumed at some time in life by up to 80% of the population according to western statistics. Wide differences in socioeconomic status in India contribute to various degrees and severity of alcoholism and its associated complications. The symptoms of alcohol withdrawal range from such minor ones as insomnia and tremulousness to severe complications such as withdrawal seizures and delirium tremens. Although alcohol withdrawal syndrome has been reported in the literature in post-operative periods and in Intensive Care Unit, there is paucity of information on treatment and preparation of a patient with alcohol withdrawal syndrome coming for emergency surgical procedures. The surgical stress and deranged liver function in such cases poses an additional challenge to the anaesthesiologist. Here, we report the successful management of a case of acute alcoholic delirium tremens who presented with hollow viscous perforation for emergency exploratory laparotomy.

Prevention and therapy of alcohol withdrawal on intensive care units: systematic review of controlled trials

BACKGROUND

Alcohol withdrawal syndrome (AWS) occurs in 16 to 31% of intensive care unit (ICU) patients after cessation of sedation. There exist many preventive and therapeutic strategies, but no systematic review (SR) has been published on this topic so far. We aimed to perform a synopsis of all controlled trials of AWS prevention and therapy in ICU published between 1971 and 30 March 2011 following the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) statement.

METHODS

We performed a MEDLINE search with the terms "alcohol" AND "ICU" as well as "alcohol withdrawal" AND "intensive care." All publications that matched our eligibility criteria were analyzed according to our predefined criteria.

RESULTS

We identified 6 controlled trials about AWS prevention and 8 about AWS therapy in ICUs. For AWS prevention, benzodiazepines (BZO), ethanol (EtOH), and clonidine were evaluated as single agents, and BZO, clonidine, clomethiazol and haloperidol were studied in drug combinations. All evaluated single agents and combinations were found to be effective for AWS prevention. Clomethiazol was found to be associated with a higher tracheobronchitis rate and thus disadvised for critically ill patients. For AWS therapy, BZO, gamma-hydroxybutyric acid (GHB), and clomethiazol were evaluated in randomized controlled trials as single agents and phenobarbital, clonidine, and haloperidol as adjuncts. All evaluated regimens were found to be effective for AWS therapy. Overall, in the ICU, BZO were found to be superior to GHB and clomethiazol regarding safety and efficacy. Furthermore, 4 cohort trials with historical control groups evaluated the effect of the implementation of a standardized protocol of BZO therapy for AWS in ICUs. All of these 4 studies found better outcome for the intervention groups.

CONCLUSIONS

Based on the evidence of this SR, EtOH or BZO can be advised for AWS prevention on ICU patients with alcohol dependence, but EtOH is not allowed for therapy of AWS. AWS therapy should be standardized and based on symptom-triggered BZO administration. Alpha2-agonists and haloperidol should be added for autonomic and productive psychotic symptoms.

Alcohol acute intoxication before sepsis impairs the wound healing of intestinal anastomosis: rat model of the abdominal trauma patient

Introduction

Most trauma patients are drunk at the time of injury. Up to 2% of traumatized patients develop sepsis, which considerably increases their mortality. Inadequate wound healing of the colonic repair can lead to postoperative complications such as leakage and sepsis.

Objective

To assess the effects of acute alcohol intoxication on colonic anastomosis wound healing in septic rats.

Methods

Thirty six Wistar rats were allocated into two groups: S (induction of sepsis) and AS (alcohol intake before sepsis induction). A colonic anastomosis was performed in all groups. After 1, 3 or 7 days the animals were killed. Weight variations, mortality rate, histopathology and tensile breaking strength of the colonic anastomosis were evaluated.

Results

There was an overall mortality of 4 animals (11.1%), three in the group AS (16.6%) and one in the S group (5.5%). Weight loss occurred in all groups. The colon anastomosis of the AS group didn’t gain strength from the first to the seventh postoperative day. On the histopathological analysis there were no differences in the deposition of collagen or fibroblasts between the groups AS and S.

Conclusion

Alcohol intake increased the mortality rate three times in septic animals. Acute alcohol intoxication delays the acquisition of tensile strength of colonic anastomosis in septic rats. Therefore, acute alcohol intoxication before sepsis leads to worse prognosis in animal models of the abdominal trauma patients.

Delayed treatment of delirium increases mortality rate in intensive care unit patients

Delirium in the intensive care unit (ICU) is a serious complication associated with a poor outcome in critically ill patients. In this prospective observational study of the effect of a delay in delirium therapy on mortality rate, 418 ICU patients were regularly assessed using the Delirium Detection Score (DDS). The departmental standard required that if delirium was diagnosed (DDS >7), therapy should be started within 24 h. In total, 204 patients (48.8%) were delirious during their ICU stay. In 184 of the delirious patients (90.2%), therapy was started within 24 h; in 20 patients (9.8%), therapy was delayed. During their ICU stay, patients whose delirium treatment was delayed were more frequently mechanically ventilated, had more nosocomial infections (including pneumonia) and had a higher mortality rate than patients whose treatment was not delayed. Thus, it would appear that a delay in initiating delirium therapy in ICU patients was associated with increased mortality.

Perioperative management of patients with alcohol, tobacco and drug dependency

PURPOSE OF REVIEW

One in five patients in the perioperative setting has a alcohol use disorder (AUD), one in three patients has a nicotine use disorder (NUD) and one in 10 patients has a drug use disorder (DUD) with a high risk of dependency. Patients with dependencies challenge physicians with various complications within the perioperative setting.

RECENT FINDINGS

Adequate treatment of alcohol, nicotine and drug dependency during the perioperative and intraoperative course requires established screening tools in order to evaluate patients' susceptibility to developing complications. Particularly in these patients, secondary prevention and early treatment is warranted.

SUMMARY

Alcohol, nicotine and drug dependency are very treatable. Numerous effective therapeutic options are available and should be offered to patients. Intensive care treatment can be shortened or even avoided by initiating preventive measures. A multimodal approach includes implementation of screening tools, motivational interviewing, preoperative abstinence, individual anaesthesiological treatment, stress reduction preventing delirium and postoperative infection, prevention and treatment of withdrawal syndrome, replacement therapies and provision of preoperative or postoperative detoxification. The implementation rate is very low and urgently requires strategies for improvement.

Gamma-hydroxybutyric acid versus clomethiazole for the treatment of alcohol withdrawal syndrome in a medical intensive care unit: an open, single-center randomized study

BACKGROUND

Clomethiazole (CLO) has been shown to be effective in treating alcohol withdrawal syndrome (AWS). Gamma-Hydroxybutyric acid (GHB) has also been introduced in the treatment of alcoholic patients and is effective in surgical intensive care unit (ICU) patients in preventing and treating AWS. There are no comparative studies between CLO and GHB in a medical ICU setting.

METHODS

Twenty-six alcoholic patients with severe AWS and concomitant medical diseases were randomally enrolled in the study. CLO was given orally to 12 patients in a dosage of 250 mg every 4 hours as a liquid; GHB (initially 30 mg/kg body weight (BW) followed by 15 mg/kg BW) was administered intravenously to 14 patients. Four major AWS symptoms (tremor, sweating, nausea, restlessness) were scored, and the administration of additional medication was registered.

RESULTS

GHB was more effective in treating AWS symptoms. In the GHB group, AWS score dropped from 6.6 +/- 2.6 to 1.8 +/- 2.1 (p <.01), while in the CLO group, the score dropped from 6 +/- 2.5 to 4.1 +/- 2.4 (n. s.). Differences between groups were significant (p =.021, two-way ANOVA). The treatment did not alter outcome or the duration of ICU stay. No serious side effects were detected.

CONCLUSION

GHB effectively controls AWS symptoms in medical ICU patients. The rapid initial treatment response of GHB in contrast to CLO has no influence on duration of patient withdrawal.

Alcohol use disorder and perioperative immune dysfunction

The anesthesiological sequelae of long-term alcohol abuse include a three to fivefold increased risk of postoperative infection, prolonged intensive care unit stays and longer hospital stays. The cause of the higher infection rates is an altered immune response in long-term alcoholic patients. Preoperatively, the T helper cells 1 to T helper cells 2 ratio is depressed in long-term alcoholic patients and remains suppressed after surgery. The lower preoperative T helper cells 1 to T helper cells 2 ratio is predictive of later onset of infections. Postoperatively, the cytotoxic lymphocyte (Tc1/Tc2) ratio is decreased in long-term alcoholic patients and remains depressed for 5 days. The interleukin (IL)-6/IL-10 ratio and the lipopolysaccharide-stimulated interferon gamma/IL-10 ratio in whole blood cells are decreased after surgery in long-term alcoholic patients. Depressed Tc1/Tc2, IL-6/IL-10 and lipopolysaccharide-stimulated interferon gamma/IL-10 ratios in the postoperative period are predictive of subsequent postoperative infections. Perioperative interventions should aim to minimize dysregulation of the immune system.

[Weaning from the ventilator modalities and consequences]

Only few studies have focused on the issues raised by discontinuing sedation in ICU patients. Several lines of evidence allow defining the risk factors for the occurrence of a weaning syndrome due to discontinuation of sedatives and analgesics in ICU patients. These primarily include a prolonged (more than seven days) period of continuous intravenous administration of high doses of hypnotics and opioids. Weaning from sedation is tightly linked to weaning from the ventilator and this area should be the target of research work in the near future.

Influence of vaccination and surgery on HLA-DR expression in patients with upper aerodigestive tract cancer

Major surgery is associated with an increased risk of post-operative immunosuppression and infections. We investigated the influence of influenza vaccination on cell-mediated immune responses in cancer patients undergoing either surgical or conservative therapy. Forty patients with an upper aerodigestive tract tumour were allocated to either a surgical or non-surgical treatment course. Patients within each group were randomized to the vaccination or non-vaccination group. Vaccination was performed twice before surgery or conservative treatment. Human leucocyte antigen receptor (HLA-DR) expression on monocytes was analysed by flow cytometry. In the surgical patients, HLA-DR expression on day 1 after surgery decreased in both the vaccinated and non-vaccinated groups. Vaccinated non-surgical patients showed significantly increased HLA-DR expression levels compared with the non-vaccinated patients. This pilot study demonstrated that vaccination increased monocyte HLA-DR expression in conservatively-treated cancer patients whereas surgery abrogated this response. Vaccination before surgery, therefore, might not help to maintain immune reactivity after surgery.

Clinicians' evaluation and management of mental health, substance abuse, and chronic pain conditions in the intensive care unit

OBJECTIVE

The purpose of this study was to describe clinicians' evaluation and management of co-existing mental health, substance abuse (MHSA), and chronic pain (CP) conditions in patients with prolonged critical illness. Little is known about the evaluation and management of these conditions in the intensive care unit, and practice guidelines do not address management in the context of critical illness, optimal sedation/analgesia, or ventilator weaning.

DESIGN

Longitudinal qualitative description.

SETTING

Intensive care unit of an urban academic medical center.

PATIENTS

Total of 12 patients with co-existing MHSA or CP conditions who were weaning from mechanical ventilation.

INTERVENTIONS

Intensive care unit clinicians, patients, and family members were formally interviewed and directly observed in the critical care setting for 56 consecutive weeks.

MEASUREMENTS AND MAIN RESULTS

Transcribed interviews, field notes, and clinical records, representing >400 documents, were reviewed and coded using constant comparative analysis to identify the facilitators, barriers, contextual factors, and consequences associated with the evaluation and management of MHSA and CP conditions. Numeric clinical data supplemented and clarified thematic findings. Facilitators of MHSA and CP evaluation and management included family as history keepers, the use of subspecialty consultations, and anticipated alcohol withdrawal. Barriers included limited history taking and assessment of MHSA and CP conditions and the use of cognitive shortcuts. Consequences included nonintegration of MHSA and CP medications and diagnoses, episodic pharmacologic responses to psychobehavioral symptoms, and clinician-patient interpersonal tension. Contextual factors involved ambiguous psychobehavioral symptomatology, patients' critical illness and inability to speak, and competing clinical goals.

CONCLUSIONS

The explicit evaluation and management of MHSA and CP conditions was highly variable and inconsistent across cases. Findings suggest that MHSA and CP conditions require monitoring and management similar to that required for other chronic conditions. Multidisciplinary, individual-level, and system-level responses are warranted to address the complex interplay of barriers, consequences, and context.

Propofol increased the interleukin-6 to interleukin-10 ratio more than isoflurane after surgery in long-term alcoholic patients

This study investigated the effect of an anaesthetic regimen on the immune response in 40 long-term alcoholic patients undergoing surgery. Patients were randomly allocated to receive either propofol or isoflurane during surgery. Plasma cytokines interleukin (IL)-6 and IL-10 were measured at defined times and rates of post-operative infections were documented. The IL-6/IL-10 ratio significantly increased with propofol compared with isoflurane on day 1 after surgery and the IL-10 level significantly increased with isoflurane on day 1 after surgery. The overall post-operative infection rate was significantly higher in isoflurane-treated patients. Our findings indicate that propofol anaesthesia might be the more favourable regimen, with the IL-6/IL-10 ratio indicating an attenuation of the immune imbalance after surgery in long-term alcoholic patients. These results support the undertaking of a properly powered clinical trial to determine if propofol anaesthesia can reduce the postoperative infection rate in this special patient population.

The Effect of Stress-Reducing, Low-Dose Ethanol Infusion on Frequency of Bleeding Complications in Long-Term Alcoholic Patients Undergoing Major Surgery

Perioperative low-dose ethanol infusion is a feasible option for stress reduction and prophylaxis of alcoholism-associated complications. Because alcohol has inhibitory effects on hemostasis, our study focused on the effect of perioperative low-dose ethanol infusion on bleeding complications, defined as transfused blood units and reoperations, in alcoholic patients undergoing major surgery. We included 44 long-term alcoholic patients scheduled for tumor resection of the aerodigestive and gastrointestinal tract. Patients were randomly assigned to the ethanol or control group. Ethanol infusion (0.5 g ethanol/kg body weight/24 hours) started before surgery and was continued until the postoperative Day 3. Regarding all patients, there was no statistically significant difference in the amount of transfused blood between the ethanol and control groups. However, the effect of ethanol infusion on bleeding complications depended on the site of surgery. Ethanol infusion resulted in an increased number of transfused blood units in gastrointestinal patients and a decreased number of transfused units in patients undergoing tumor resection of the aero-digestive tract. In conclusion, perioperative ethanol infusion in long-term alcoholic patients with tumor resections of the aerodigestive tract is an option for stress reduction without increased risk for blood transfusion. In contrast, ethanol infusion in patients with tumor resections in the gastrointestinal tract could increase the risk for bleeding complications.

Alcohol abuse in the critically ill patient

Alcohol abuse and dependence disorders are common in the 10% of hospitalised patients who need admission to the intensive care unit (ICU), but these disorders are often undiagnosed. The systemic effects from the excessive use of alcohol increase susceptibility to, or directly cause various important disorders in the critically ill. Early recognition of alcohol abuse and dependence is necessary and should prompt consideration of several alcohol-specific diagnoses that have important prognostic and therapeutic implications for these patients. We discuss the use of screening tests to improve the identification of alcohol abuse and dependence disorders, the epidemiology and pathogenesis of important alcohol-related disorders, differences in the presentation of several common alcohol-related diagnoses in the ICU, and important alcohol-specific therapies.

[Alcohol use disorder: risks in anesthesia and intensive care medicine]

Approximately 20% of medical and surgical patients in hospital have an alcohol use disorder (AUD). Diagnosis of chronic alcohol abuse is performed by specific medical history, examination and validated tests. Biomarkers are a means of diagnosing chronic alcoholism in sedated, intubated and emergency patients. Chronic alcohol consumption damages the central nervous and cardiovascular system, the liver and the immune system. In medical ICUs more than 50% of liver injuries and chronic pancreatitis are due to chronic alcohol abuse. The alcohol withdrawal syndrome is emerging in 25% of AUD patients in intensive care after reduction of sedative drugs. Long term alcohol abuse also leads to cardiac arrhythmias, dilatative cardiomyopathy and hypotonic circulatory dysregulation. Bleeding complications are two-fold increased during and after surgery. Immune suppression results in an increased incidence of infectious complications like pneumonia, wound infection and urinary tract infection. In particular, septic encephalopathy is often misinterpreted as alcohol withdrawal syndrome. Due to the fact that AUD patients show a two to five-fold higher rate of postoperative complications they require increased attention to avoid latency of treatment and the development of multiple organ failure. Prophylaxis in terms of drug therapy or abstinence intervals and brief intervention strategies can help to prevent or ease some of these complications and can decrease the rate of long-term injuries.

Development of an alcohol withdrawal protocol: CNS collaborative exemplar

PURPOSE

The purpose of this process improvement project was to develop an Alcohol Withdrawal Syndrome (AWS) management protocol for acute care.

SIGNIFICANCE

The prevalence of alcohol abuse in our society presents challenges for health professionals, and few nurses have received formal education on the identification and treatment of AWS, which has frequently resulted in ineffective, nonstandardized care. However, nurses practicing in medical-surgical, emergency, trauma, and critical care settings must be astute in the assessment and management of AWS. DESIGN/BACKGROUND/RATIONALE: Following an analysis of existing management protocols, a behavioral health clinical nurse specialist was asked to lead a work team composed of physicians, pharmacists, and nurses to develop a new evidence-based alcohol withdrawal protocol for acute care.

METHODS/DESCRIPTION

By implementing a standardized assessment tool and treatment protocol, clinical nurse specialists empowered nursing staff with strategies to prevent the serious medical complications associated with AWS. FINDINGS/OUTCOMES: The development and integration of a safe and effective treatment protocol to manage AWS was facilitated by collaborative, evidence-based decision making.

CONCLUSION

Clinical experience and specialty expertise were integrated by clinical nurse specialists skilled in group dynamics, problem-solving, and the implementation of change. Improving care of patients in AWS is an exemplar for clinical nurse specialist roles as change agent and patient advocate.

Substance Use and Abuse in Trauma: Implications for Care

Trauma long has been associated with substance use and abuse. Caring for trauma patients who are intoxicated, withdrawing, or otherwise experiencing the negative outcomes of their substance use is difficult under the best of circumstances. The burden of this association can be described in many terms, from economic consequences, to health outcomes, to personal problems. Evidence indicates that untreated substance-associated trauma carries with it extended hospital stays, diminished quality of life, repeat emergency department use, and significant mortality and morbidity. No matter how one examines the burden of the association between substance use and trauma, one is left with the awareness that nurses can improve patient care through better screening, assessment, intervention, an evaluation. Because of the complex nature of the association between substance use and trauma, nursing care for these patients is difficult. Fig. 1 provides an overview of the factors to consider when planning care for these patients. Nurses need to focus on issues of temporality, directionality, and correlates of care as they plan for the needs of their patients. Only with careful considerations of these factors can the nurse clarify the confounding clinical presentation of the trauma overlaid on substance use. Evidence supports the need for all trauma patients to be screened for substance use and for those who have positive screens to receive early intervention. Although there is almost universal awarenes of the of the association between substance use and trauma and of the value of screening, screening rates for trauma patients are surprisingly low. Screening for substance use followed by BMI intervention is cost effective and should be implemented routinely. The high prevalence of substance-associated trauma, coupled with the heterogeneous nature of that association, warrants more study, particularly nursing research, to determine best-care practices. More research is needed to increase the understanding of patterns of use, etiologic models, and effective clinical care strategies. The need for this research is heightened by the awareness that substance-associated trauma is preventable, and the risk is modifiable. Nurses, everyday, are faced with the daunting challenge of meeting the health needs of trauma patients who have associated substance use. More research is needed to help nurses separate out the confounding health needs of these complex patients. That work has begun, and it assuredly will continue to support the need for high-quality nursing interventions to improve the health of trauma patients.

THE EFFECTIVENESS OF A TAILORED INTERVENTION FOR EXCESSIVE ALCOHOL CONSUMPTION PRIOR TO ELECTIVE SURGERY

AIM

To assess the effectiveness of a tailored pre-operative intervention for excessive alcohol consumption in reducing post-operative complications and alcohol consumption thereafter.

METHODS

Patients scheduled for elective surgery requiring at least overnight hospitalisation were screened for alcohol misuse. Consenting, eligible participants with > or =7 days to surgery at the time of screening were offered an intervention and those with <7 days to surgery were provided usual care.

RESULTS

Over a period of 2 years and 10 months, 3139 patients were screened to recruit 136 participants. Baseline analysis revealed a mean age of 53 (+/-15.8) years and a mean consumption of 71 g/day (+/-48.1). The intervention group (n = 45) did not differ significantly from controls (n = 91) in age, consumption, and number of current smokers, but there were significantly more women in the control group. There was no difference between the groups in major or minor complications experienced, or length of stay after controlling for age, gender, and baseline consumption. At 6-month follow-up there was a significant reduction in drinking for the entire study population.

CONCLUSION

The study did not demonstrate any beneficial effect of the pre-operative intervention on post-operative complications. The relatively short time to surgery, intervention by a non-member of the surgical team, challenges to recruitment and reduced consumption in the control group may have limited the ability of the study to detect a significant effect of the intervention.

An ethanol protocol to prevent alcohol withdrawal syndrome

BACKGROUND

Alcohol withdrawal syndrome (AWS) occurs in dependent patients during the initial period of sudden onset abstinence. It is usually manifested by mild symptoms such as disorientation, agitation, and tachycardia, but, if untreated, can lead to severe confusion, seizures, and even cardiovascular collapse. Prevention of AWS has been shown to improve morbidity and mortality and shorten hospital and ICU stays. We examined the efficacy of ethanol as a method of prophylaxis.

STUDY DESIGN

Our patient population was divided into two groups. Group 1 consisted of surgical patients receiving alcohol prophylaxis for AWS between January 2001 and July 2004 (n=124), as identified by retrospective chart review. We then developed a protocol for the initiation, dosage, and weaning of intravenous ethanol in patients at risk for AWS, based on blood alcohol levels and clinical assessment of withdrawal symptoms and signs. Group 2 consisted of all patients treated prospectively with this protocol during the subsequent year (n=76). Patients who did not fit inclusion criteria for the protocol were excluded from analysis, resulting in 92 and 68 patients in group 1 and group 2, respectively. We compared initiation criteria, efficacy, dosage, route, duration, and referral pattern to the substance abuse clinic before and after initiation of the protocol.

RESULTS

Our initial use of intravenous ethanol was very variable in dosage, duration, and indication. The protocol decreased the duration of treatment between the two groups from 7 days to a mean of 3 days. The failure rate dropped from 20% to 7%. Referral to the substance abuse clinic rose from 7.6% to 20%. The only complication was asymptomatic hyponatremia in one patient.

CONCLUSIONS

Intravenous ethanol is a viable option for AWS prophylaxis when administered in a systematic protocol.