Experience with an adult alcohol withdrawal syndrome practice guideline in internal medicine patients

A National Analysis of Alcohol Withdrawal Syndrome in Patients with Operative Trauma

Background

Alcohol withdrawal syndrome (AWS) presents with a complex spectrum of clinical manifestations that complicate postoperative management. In trauma setting, subjective screening for AWS remains challenging due to the criticality of injury in these patients. We thus identified several patient characteristics and perioperative outcomes associated AWS development.

Methods

The 2016-2020 National Inpatient Sample was queried to identify all non-elective adult (≥18 years) hospitalizations for blunt or penetrating trauma undergoing operative management with a diagnosis of AWS. Patients with traumatic brain injury or with a hospital duration of stay <2 days were excluded. Outcomes of interest included in-hospital mortality, perioperative complications, hospitalization costs, length of stay (LOS) and non-home discharge.

Results

Of an estimated 2,965,079 operative trauma hospitalizations included for analysis, 36,415 (1.23 %) developed AWS following admission. The AWS cohort demonstrated increased odds of mortality (Adjusted Odds Ratio [AOR] 1.46, 95 % Confidence Interval [95 % CI] 1.23-1.73), along with infectious (AOR 1.73, 95 % CI 1.58-1.88), cardiac (AOR 1.24, 95 % CI 1.06-1.46), and respiratory (AOR 1.96, 95 % CI 1.81-2.11) complications. AWS was associated with prolonged LOS, (β: 3.3 days, 95 % CI: 3.0 to 3.5), greater cost (β: +$8900, 95 % CI $7900-9800) and incremental odds of nonhome discharge (AOR 1.43, 95 % CI 1.34-1.53). Furthermore, male sex, Medicaid insurance status, head injury and thoracic operation were linked with greater odds of development of AWS.

Conclusion

In the present study, AWS development was associated with increased odds of in-hospital mortality, perioperative complications, and resource burden. The identification of patient and operative characteristics linked with AWS may improve screening protocols in trauma care.

Use of a Gabapentin Protocol for the Management of Alcohol Withdrawal: A Preliminary Experience Expanding From the Consultation-Liaison Psychiatry Service

BACKGROUND

Benzodiazepines are the conventional mainstay to manage alcohol withdrawal; however, patients are subsequently at increased risk for poor sleep, cravings, and return to drinking. Research on alternative pharmacologic agents to facilitate safe alcohol withdrawal is scant. Gabapentin is one medication shown in small studies to reduce the need for benzodiazepines in the setting of alcohol withdrawal. The continuation of gabapentin after alcohol withdrawal appears to be safe during early sobriety and may aid in reducing alcohol-related cravings or returning to alcohol consumption. Use of a gabapentin-based, benzodiazepine-sparing protool began in early 2015 by the Mayo Clinic, Rochester, Consultation-Liaison Psychiatry Service.

OBJECTIVE

A retrospective chart review was conducted to detect any safety concerns with use of a gabapentin protocol for alcohol withdrawal syndrome.

METHODS

Secondary outcomes were derived by comparing a matched cohort of patients who received benzodiazepines for alcohol withdrawal syndrome.

RESULTS

Seventy-seven patients had their alcohol withdrawal managed via a gabapentin protocol during the study period. No patients required transfer to a higher level of care or had a documented withdrawal seizure. Length of stay between the gabapentin protocol group and benzodiazepine group were similar.

CONCLUSION

This preliminary data has supported the frequent use of this protocol in the general internal medicine practice and formalization of an institutional order set of this protocol for mild to moderate alcohol withdrawal syndrome. Prospective studies are required to validate findings.

Development and implementation of an alcohol withdrawal protocol using a 5-item scale, the Brief Alcohol Withdrawal Scale (BAWS)

BACKGROUND

The standard of care for management of alcohol withdrawal is symptom-triggered treatment using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar). Many items of this 10-question scale rely on subjective assessments of withdrawal symptoms, making it time-consuming and cumbersome to use. Therefore, there is interest in shorter and more objective methods to assess alcohol withdrawal symptoms.

METHODS

A 6-item withdrawal scale developed at another institution was piloted. Based on comparison with the CIWA-Ar, this was adapted into a 5-item scale named the Brief Alcohol Withdrawal Scale (BAWS). The BAWS was compared with the CIWA-Ar and a withdrawal protocol utilizing the BAWS was developed. The new protocol was implemented on an inpatient unit dedicated to treating substance withdrawal. Data was collected on the first 3 months of implementation and compared with the 3 months prior to that.

RESULTS

A BAWS score of 3 or more predicted CIWA-Ar score ≥8 with a sensitivity of 85.3% and specificity of 65.8%. The demographics of the patients in the 2 time periods were similar: the mean age was 45.9; 70.6% were male; 30.9% received concurrent treatment for opioid withdrawal; and 14.2% were receiving methadone maintenance. During the BAWS phase, patients received significantly less diazepam (mean dose 81.4 vs. 60.3 mg, P < .001). There was no significant difference in length of stay. No patients experienced a seizure, delirium, or required transfer to a higher level of care during any of the 664 admissions in either phase.

CONCLUSIONS

This simple protocol utilizing a 5-item withdrawal scale performed well in this setting. Its use in other settings, particularly with patients with concurrent medical illnesses or more severe withdrawal, needs to be explored further.

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.

Outcomes After Implementation of an Alcohol Withdrawal Protocol at a Single Institution

Background: There are varying dosing strategies for the administration of benzodiazepines in the setting of alcohol withdrawal. In October 2014, a symptom-based alcohol withdrawal protocol (AWP) using the Clinical Institute Withdrawal Assessment of Alcohol, Revised (CIWA-Ar) scale was implemented at one institution. Objective: To evaluate the safety and efficacy of the AWP. Methods: Retrospective chart review was completed, including patients receiving at least one dose of diazepam for alcohol withdrawal pre- and post-protocol. The primary outcome of this study was the average daily and cumulative dose of diazepam during hospital stay. Secondary outcomes included length of stay and occurrence of seizures or delirium tremens. Results: The average daily dose and the average cumulative dose of diazepam were significantly lower in the post-protocol group (5.4 vs 12.1 mg, p < .001; 35.0 vs 77.6 mg, p < .001, respectively). Length of stay was similar between groups (6.5 vs 6.4 days, p = .91), however, duration of benzodiazepine use was decreased in the post-protocol group (2.2 vs 4.7 days, p < .001). Despite using reduced doses of benzodiazepines, there was no increase in adverse events. Conclusions: The implementation of a symptom-based AWP using the CIWA-Ar scale was associated with a reduced average daily and cumulative dose of diazepam without any apparent safety issues.

Evaluating nursing satisfaction and utilization of the Clinical Institute Withdrawal Assessment for Alcohol, revised version (CIWA-Ar)

Introduction

The Clinical Institute Withdrawal Assessment for Alcohol, revised version (CIWA-Ar), developed and validated for research, is used in our inpatient academic medical center. We sought to assess nursing satisfaction with the scale itself, training for using the scale, and nursing staff use of the CIWA-Ar.

Methods

A retrospective chart review included all patients with an order for CIWA-Ar between August 1, 2014, and September 30, 2014. Data collected included demographics, admitting diagnosis, vital signs, admission blood alcohol level, lorazepam total daily dose, and CIWA-Ar scores. Nursing staff was sent an anonymous, 26-question survey in January 2015. The survey collected demographics, training history, and recommendations for modifications to the CIWA-Ar.

Results

During the 2-month period, 274 patients had orders for CIWA-Ar, with 113 receiving at least one dose of lorazepam. Lorazepam was not given to 21% of patients when they scored >8 on the CIWA-Ar, whereas 71% of patients received a dose of lorazepam when they had a CIWA score <8. The survey was sent to 2011 clinical nurses, with 284 responses received (14% response rate). Only 36% of responding nurses felt adequately trained to administer the CIWA-Ar. Most nurses preferred on-the-job and online training methods.

Discussion

Nursing use of the CIWA-Ar could be optimized at this institution. Fewer than half of respondents reported feeling adequately training to administer the CIWA-Ar. Results will be used to improve training for nursing staff regarding scoring of the CIWA-Ar and administering lorazepam to treat alcohol withdrawal syndrome.

Clinical management of alcohol use disorders in the neurology clinic

Alcohol misuse adversely affects health outcomes, but alcohol misuse and alcohol use disorders (AUDs) are often ignored by healthcare providers in primary and specialty ambulatory care clinics. Data show that early identification and brief intervention for alcohol misuse in these settings can effectively reduce alcohol consumption and its medical sequelae. The aim of this chapter is to review the epidemiology of problematic alcohol use in ambulatory care settings, the diagnostic criteria for AUDs, the approach called SBIRT (screening, brief intervention and referral to treatment) as a model program to target alcohol misuse in everyday clinical practice, when and how to refer patients to resources beyond the clinic for their alcohol use problems, and the medical illnesses associated with AUDs.

Alcohol withdrawal delirium - diagnosis, course and treatment

OBJECTIVE

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

METHOD

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

CONCLUSIONS

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

Alcohol withdrawal

Alcohol withdrawal is a common clinical condition that has a variety of complications and morbidities. The manifestations can range from mild agitation to withdrawal seizures and delirium tremens. The treatments for alcohol withdrawal include benzodiazepines, anticonvulsants, beta-blockers and antihypertensives. Although benzodiazepines are presently a first-line therapy, there is controversy regarding the efficacies of these medications compared with others. Treatment protocols often involve one of two contrasting approaches: symptom-triggered versus fixed-schedule dosing of benzodiazepines. We describe these protocols in our review and examine the data supporting symptom-triggered dosing as the preferred method for most patients in withdrawal.The Clinical Institute Withdrawal Assessment for Alcohol scoring system for alcohol withdrawal streamlines care, optimizes patient management, and is the best scale available for withdrawal assessment. Quality improvement implications for inpatient management of alcohol withdrawal include increasing training for signs of withdrawal and symptom recognition, adding new hospital protocols to employee curricula, and ensuring manageable patient-to-physician and patient-to-nurse ratios.

Delirium in intensive care unit patients

Delirium is defined as a disturbance of consciousness with cognitive changes or perceptual disturbances, which has developed over a short period of time, and is caused by a medical condition or a postsurgical state. Although historically dismissed as an inconvenient and transient problem, recent studies have reported that delirium is associated with more complications, increased length of hospital stay, and higher mortality. Although delirium is a prevalent condition after cardiothoracic surgery and in the intensive care unit (ICU), the condition appears to be largely underdiagnosed. Several detection tools have been developed for routine monitoring of delirium by nonpsychiatric personnel in the ICU, such as the Confusion Assessment Method for the Intensive Care Unit and the Intensive Care Delirium Screening Checklist. Management includes treatment of underlying disorders, nonpharmacological measures and symptomatic drug therapy. There is a need for well-designed randomized, double-blind, placebo-controlled trials on drug treatment.

Inappropriate use of symptom-triggered therapy for alcohol withdrawal in the general hospital

OBJECTIVE

To determine if hospitalized medical and surgical patients were placed inappropriately on symptom-triggered therapy (STT) for alcohol withdrawal syndrome (AWS) and if certain conditions were more likely to be associated with inappropriate STT use or adverse events.

PATIENTS AND METHODS

We randomly selected 124 (25%) of the 495 Mayo Clinic inpatients who received STT according to the Revised Clinical Institute for Withdrawal Assessment for Alcohol (CIWA-Ar) protocol in 2003 and assessed them for STT appropriateness, defined as having both intact verbal communication and recent alcohol use. Adverse events, including delirium tremens, seizures, or death, were correlated with CIWA-Ar appropriateness.

RESULTS

Of the 124 randomly selected patients, only 60 (48%) met both inclusion criteria. Of the remaining 64 patients, 9 (14%) were drinkers but could not communicate, and 35 (55%) could communicate but had not been drinking. Twenty (31%) met neither criterion. Univariate analysis identified a significant association between inappropriate initiation and chronic heart failure, postoperative status (POS), liver disease (LD), nonmetastatic cancer, and chemical dependency consultation. On multivariate analysis, only LD (P equals .02) and POS (P equals .01) retained significance, with LD more and POS less likely to predict appropriateness. Seven of 11 patients who experienced adverse events had received STT according to the CIWA-Ar protocol (P equals .05). Univariate analysis identified a significant association between adverse events and a history of alcohol dependence or AWS. Multivariate analysis showed significance only for a history of alcohol dependence (P equals .049).

CONCLUSION

Fewer than half of the randomly selected patients met both of the inclusion criteria for the CIWA-Ar instrument, leading us to conclude that more stringent evaluation is needed. Particularly postoperatively, alternative explanations for putative AWS should be sought. Health care professionals should more aggressively seek information on recent alcohol use from medical records, family members, and patients themselves.

Dexmedetomidine: an updated review

OBJECTIVE

To review recent literature on the safety and efficacy of dexmedetomidine.

DATA SOURCES

Articles were identified through searches of MEDLINE (1966-January 2007). Key words included dexmedetomidine, medetomidine, alpha(2)-agonist, and sedation. References from selected articles were reviewed for additional references.

STUDY SELECTION AND DATA EXTRACTION

Experimental and observational studies that focused on the safety and efficacy of dexmedetomidine in humans were selected.

DATA SYNTHESIS

Dexmedetomidine is an alpha(2)-agonist for short-term sedation in critically ill patients. In postoperative patients, dexmedetomidine produced similar levels of sedation and times to extubation, with less opioid requirements compared with propofol. Dexmedetomidine has also been studied for sedation in critically ill medical and pediatric patients, as adjunct to anesthesia, and for procedural sedation. Hypotension, hypertension, and bradycardia are common adverse effects. Although dexmedetomidine is labeled only for sedation less than 24 hours, it has been administered for longer than 24 hours without apparent development of rebound hypertension and tachycardia.

CONCLUSIONS

Dexmedetomidine is a safe and effective agent for sedation in critically ill patients. Further, well designed studies are needed to define its role as a sedative for critically ill medical, neurosurgical, and pediatric patients, as an adjunct to anesthesia, and as a sedative during procedures.

Cardiovascular reactivity to mental stress is not affected by alpha2-adrenoreceptor activation or inhibition

RATIONALE

It has been postulated that cardiovascular reactivity to mental stress varies with tonic central sympathetic nervous system activity, but pharmacological evidence is missing.

OBJECTIVE

To test whether modulation of central sympathetic nervous system activity by alpha2-adrenergic agonism and antagonism affects cardiovascular reactivity to mental stress.

MATERIALS AND METHODS

On three five-stepped dose/concentration-response study days, 12 healthy male volunteers received intravenous infusions of dexmedetomidine (alpha2-agonist, target plasma concentrations: 0.04-0.32 ng/ml), yohimbine (alpha2-antagonist, doses: 0.016-0.125 mg/kg), and placebo, respectively. During each dose step, subjects performed a 5-Choice Reaction Time Task (CRTT) and a Paced Auditory Serial Addition Task (PASAT) to induce moderate mental stress. Prestress baseline, as well as stress-induced responses of heart rate, and noninvasive finger arterial blood pressure (Finapres) were assessed.

RESULTS

Prestress baseline heart rate and blood pressure decreased with increasing doses of dexmedetomidine and increased with increasing doses of yohimbine. However, dexmedetomidine and yohimbine did not affect stress-induced heart-rate and blood-pressure changes.

CONCLUSIONS

Cardiovascular reactivity to mental stress is not related to pharmacologically manipulated tonic central sympathetic nervous system activity by alpha2-adrenergic agonists and antagonists. These results do not support the assumption that cardiovascular reactivity is an index of tonic central sympathetic nervous system activity.