History of Delirium Tremens in AUD Patients in Treatment: Relationship to AUD Severity and Other Factors

Former smoking, but not active smoking, is associated with delirium in postoperative ICU patients: a matched case-control study

Objective

To examine the relationship between current and former smoking and the occurrence of delirium in surgical Intensive Care Unit (ICU) patients.

Methods

We conducted a single center, case-control study involving 244 delirious and 251 non-delirious patients that were admitted to our ICU between 2018 and 2022. Using propensity score analysis, we obtained 115 pairs of delirious and non-delirious patients matched for age and Simplified Acute Physiology Score II (SAPS II). Both groups of patients were further stratified into non-smokers, active smokers and former smokers, and logistic regression was performed to further investigate potential confounders.

Results

Our study revealed a significant association between former smoking and the incidence of delirium in ICU patients, both in unmatched (adjusted odds ratio (OR): 1.82, 95% confidence interval (CI): 1.17-2.83) and matched cohorts (OR: 3.0, CI: 1.53-5.89). Active smoking did not demonstrate a significant difference in delirium incidence compared to non-smokers (unmatched OR = 0.98, CI: 0.62-1.53, matched OR = 1.05, CI: 0.55-2.0). Logistic regression analysis of the matched group confirmed former smoking as an independent risk factor for delirium, irrespective of other variables like surgical history (p = 0.010). Notably, also respiratory and vascular surgeries were associated with increased odds of delirium (respiratory: OR: 4.13, CI: 1.73-9.83; vascular: OR: 2.18, CI: 1.03-4.59). Medication analysis showed that while Ketamine and Midazolam usage did not significantly correlate with delirium, Morphine use was linked to a decreased likelihood (OR: 0.27, 95% CI: 0.13-0.55).

Discussion

Nicotine's complex neuropharmacological impact on the brain is still not fully understood, especially its short-term and long-term implications for critically ill patients. Although our retrospective study cannot establish causality, our findings suggest that smoking may induce structural changes in the brain, potentially heightening the risk of postoperative delirium. Intriguingly, this effect seems to be obscured in active smokers, potentially due to the recognized neuroprotective properties of nicotine. Our results motivate future prospective studies, the results of which hold the potential to substantially impact risk assessment procedures for surgeries.

Successful treatment of severe alcohol withdrawal delirium with very high-dose diazepam (260-480 mg) administration

INTRODUCTION

Alcohol withdrawal delirium, commonly known as "delirium tremens (DT)", is the most severe clinical condition of alcohol withdrawal syndrome (AWS). Symptoms of DT include changes in consciousness and cognitive and perceptual impairments that fluctuate during the day. Treatment includes general support, such as helping the patient to re-orientate, close monitoring of vital signs and adequate hydration, and symptomatic treatment for agitation, autonomic instability, and hallucinations. In symptomatic treatment of DT, benzodiazepines are most commonly preferred due to their GABA-ergic effects. Diazepam, a benzodiazepine, has a faster onset of action than other benzodiazepines when administered intravenously (iv) and effectively controls symptoms. Although low doses of diazepam usually relieve DT symptoms, very high doses may be required in some patients. This case series discusses patients receiving high doses of diazepam to relieve DT symptoms.

CASE REPORT

Four male patients aged from 43 to 57 years who regularly consumed alcohol with a daily average of 20-100 standard drinks and developed DT afterwards and were followed up in the intensive care unit are presented. In these patients, the symptoms of DT were relieved, and somnolence was achieved with the administration of very high-dose IV diazepam (260-480 mg/day), contrary to routine treatment doses. All patients were successfully treated and discharged without any morbidity.

CONCLUSION

Severe AWS can potentially result in death otherwise managed quickly and adequately. Diazepam is a suitable agent for severe AWS or DT treatment. Clinicians should keep in mind that high-dose diazepam treatment may be required in the treatment of DT that develops after a long-term and high amount of alcohol consumption. Publications reporting the need for very high doses of diazepam in DT are limited and usually published long ago; in this context, our findings are significant. The evidence is often based on case reports and uncontrolled studies, so controlled trials are needed to determine optimal treatment doses in severe DT.

Mortality and alcohol-related morbidity in patients with delirium tremens, alcohol withdrawal state or alcohol dependence in Norway: A register-based prospective cohort study

BACKGROUND AND AIMS

Little is known about long-term consequences of delirium tremens (DT). This study aimed to compare all-cause and cause-specific mortality and alcohol-related morbidity between patients with: (i) DT, (ii) alcohol withdrawal state (AWS) and (iii) alcohol dependence (AD).

DESIGN

A national longitudinal health registry study with linked data from the Norwegian Patient Registry and the Norwegian Cause of Death Registry.

SETTING

Norway.

PARTICIPANTS

All patients registered in the Norwegian Patient Registry between 2009 and 2015 with a diagnosis of AD (ICD-10 code F10.2), AWS (F10.3) or DT (F10.4) and aged 20-79 years were included (n = 36 287).

MEASUREMENTS

Patients were categorized into three mutually exclusive groups; those with DT diagnosis were categorized as DT patients regardless of whether or not they had received another alcohol use disorder diagnosis during the observation period or not. Outcome measures were: annual mortality rate, standardized mortality ratios (SMR) for all-cause and cause-specific mortality and proportion of alcohol-related morbidities which were registered in the period from 2 years before to 1 year after the index diagnosis.

FINDINGS

DT patients had higher annual mortality rate (8.0%) than AWS (5.0%) and AD (3.6%) patients, respectively. DT patients had higher mortality [SMR = 9.8, 95% confidence interval (CI) = 8.9-10.7] than AD patients (SMR = 7.0, 95% CI = 6.8-7.2) and AWS patients (SMR = 7.8, 95% CI = 7.2-8.4). SMR was particularly elevated for unnatural causes of death, and more so for DT patients (SMR = 26.9, 95% CI = 21.7-33.4) than for AD patients (SMR = 15.2, 95% CI = 14.2-16.3) or AWS patients (SMR = 20.1, 95% CI = 16.9-23.9). For all comorbidities, we observed a higher proportion among DT patients than among AWS or AD patients (P < 0.001).

CONCLUSIONS

People treated for delirium tremens appear to have higher rates of mortality and comorbidity than people with other alcohol use disorders.

Magnitude and associated factors of delirium among patients attending emergency department at Jimma medical center, Jimma, southwest Ethiopia, 2022

BACKGROUND

Delirium is a severe neuropsychiatric condition that occurs frequently in all medical settings. It has been associated to serious consequences like higher mortality, institutionalization, and longer hospital stays. Delirium is missed in emergency rooms in 57% to 83% of patients, despite its frequent incidence and detrimental repercussions.

OBJECTIVES

The purpose of this study was to determine the prevalence and contributing causes of delirium in patients who visited the emergency room at Jimma Medical Center in Jimma, southwest Ethiopia, in 2022.

METHODS

From August 1 through September 30, 2022, a cross-sectional study was undertaken at a hospital. The study enrolled 422 participants, who were chosen through a systematic random sampling. The Richmond Agitation Sedation Scale (RASS) was used to evaluate different subtypes of delirium and level of arousal. The Confusion Assessment Method (CAM) was used to determine the presence or absence of delirium. Epi Data V3.1 was used to enter the data, and Version 20 of the Statistical Package for Social Scientists was used to export it (SPSS V20). Bivariate and multivariable logistic regressions were performed to identify the related factors. Variables with a p-value of less than 0.05 were considered to be significant.

RESULT

26.6% of participants (n = 107) were found to have delirium. Alcohol use (AOR = 3.6, 95% CI (2.5-8.1), visual impairment (AOR = 2.34, 95% CI (1.89-3.68), frequent admission (AOR = 3.47, 95% CI (1.24-7.34), bladder catheterization (AOR = 1.4, 95% CI (1.21-2.89), and benzodiazepine exposure (AOR = 1.5, 95% CI (1.01-2.3) had a significant association with delirium.

CONCLUSION

According to this study, delirium was very common among patients in the emergency room. Benzodiazepine exposure, numerous admissions, visual impairment, current alcohol consumption, bladder catheterization, and frequent admissions all significantly increased the risk of delirium. To address identifiable causes and enhance patients' health outcomes, early recognition is crucial.