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

Alcohol Withdrawal Assessment Tool (AWAT) Reliability and Validity: Implications for Nurses Caring for Inpatients With Mental Health Disorders

BACKGROUND

Alcohol use affects 14.5 million Americans and high prevalence of use and potential for withdrawal among hospitalized patients presents a challenge for health care professionals to anticipate and manage effectively. Due to the acuity and fast-paced nature of the hospital environment, nurses need assessment tools that can be readily completed and drive efficient protocol-based treatment. The purpose of this study was to examine psychometric properties of the alcohol withdrawal assessment tool (AWAT).

AIMS

The aims were to examine AWAT (1) reliability, (2) validity, and (3) usability.

METHODS

Patients (n = 55) and nurses (n = 47) were recruited from six hospitals within one health care system in the Midwest. Psychometric testing included inter-rater reliability and criterion-related validity testing, using the Clinical Institute Withdrawal Assessment of Alcohol Scale-Revised (CIWA-Ar) as a comparison. Usability was assessed with a 5-item Likert-type scale.

RESULTS

Findings supported strong agreement (ICC: .931) between raters on the AWAT and a moderate correlation (Pearson r: .548) between scores on the AWAT and CIWA-Ar. Nurses agreed/strongly agreed that the AWAT took 2 min or less to complete (n = 42; 89%), was easy to use for assessment (n = 42; 89%) was easy to learn (n = 40; 85%), and they were confident using the AWAT (n = 39; 83%).

CONCLUSIONS

Study findings provide evidence of reliability, validity, and usability of the AWAT in the hospital setting. The AWAT has potential to improve assessment efficiency and nurses caring for inpatients with mental health disorders should consider implementing the tool into practice.

Practice Patterns in the Diagnosis and Management of Alcohol Withdrawal Syndrome in Indian Intensive Care Units

Alcohol use disorders (AUDs) are prevalent in intensive care units (ICUs). Alcohol abuse and/or dependence, leading to alcohol withdrawal syndrome (AWS), is as high as 10% or more. There seem to be wide variations in management strategies used to manage these patients, prompting an evaluation of the knowledge gap as well as finding the barriers. Noting lack of such literature in the Indian setting, a survey is undertaken to evaluate practice patterns surrounding the identification and management of alcohol dependence/abuse and AWS in the Indian critical care scenario. The main respondents of the survey are independent practitioners with anesthesia as their base specialty and overwhelmingly practice in multidisciplinary ICUs. They estimated AUD prevalence to be under 10%. The reason most expressed for lack of AUD documentation is fear of insurance rejection. Very few used risk assessment tool in evaluation of AUDs and AWS. Awareness of ICD 10/DSM-V components of AWS diagnosis was negligible. Chlordiazepoxide and lorazepam were used either in a fixed- or symptom-based therapy. Compared to available literature, haloperidol use is excessive, while barbiturates rarely. The wide variation is seen with the dose and frequency of thiamine in AWS without neurological complications. The impact on mortality and morbidity is poorly understood. In conclusion, the survey reported a lower prevalence compared to international literature. Insurance rejection is one of the main factors in limiting adequate history taking or documenting AUDs. Alcohol withdrawal syndrome risk assessment, monitoring, and management is variable and suboptimal. Variability in all aspects of AUDs is attributable to the knowledge gap. Further studies are needed to bridge the research gap.

How to cite this article

Gopaldas JA, Padyana M, Rai PP. Practice Patterns in the Diagnosis and Management of Alcohol Withdrawal Syndrome in Indian Intensive Care Units. Indian J Crit Care Med 2023;27(11):816-820.

Driven by need, shaped by access: Heterogeneity in patient profiles and patterns of service utilization in patients with alcohol use disorders

BACKGROUND

Patients with alcohol-use disorders (AUDs) are highly heterogenous and account for an increasing proportion of general medical hospital visits. However, many patients with AUDs do not present with severe medical or psychiatric needs requiring immediate attention. There may be a mismatch between some patients' needs and the available services, potentially driving re-admissions and re-encounters. The current study aims to identify subgroups of AUD patients and predict differences in patterns of healthcare service use (HSU) over time.

METHODS

Latent class analysis (LCA) was conducted using hospital data incorporating sociodemographic, health behavior, clinical, and service use variables to identify subtypes of AUD patients, then class membership was used to predict patterns of HSU.

RESULTS

Four classes were identified with the following characteristics: (1) Patients with acute medical injuries (30 %); (2) Patients with socioeconomic and psychiatric risk factors, (11 %); (3) Patients with chronic AUD with primarily non-psychiatric medical needs (18 %); and (4) Patients with primary AUDs with low medical-treatment complexity (40 %). Negative binomial models showed that Class 4 patients accounted for the highest frequency of service use, including significantly higher rates of emergency department reencounters at 30 days and 12 months.

CONCLUSIONS

The profile and patterns of HSU exhibited by patients in class 4 suggest that these patients have needs which are not currently being addressed in the emergency department. These have implications for how resources are allocated to meet the needs of patients with AUDs, including those who make frequent visits to the emergency department without high acuity medical needs.

Psychiatric Emergencies: Emergency Department Management of Altered Mental Status

In the United States, encounters related to mental and substance use disorders are common in emergency departments (EDs). Altered mental status (AMS) is a frequent presentation seen in EDs across the country. Individuals may present to the ED with altered thought processes, which may be attributed to intoxication from substances and/or psychoses, conditions that require immediate care and management. Health care providers must always ascertain the etiology of AMS, which may be challenging owing to the various causes of this impairment. The current article provides an overview of the most common disorders associated with AMS, which include underlying medical conditions, substance use, and mental disorders. [Journal of Psychosocial Nursing and Mental Health Services, 59(9), 16-25.].

Delirium Tremens in the Older Adult

INTRODUCTION

Caring for patients experiencing alcohol withdrawal syndrome can be challenging. Patients 65 and older are at increased risk for alcohol withdrawal syndrome related complications. The higher prevalence of co-morbidities, including cognitive impairment, longer drinking history and greater sensitivity to alcohol withdrawal syndrome treatment are the result of decreased ability of the brain to adapt to stressors such as illness, trauma, or surgery.

DELIRIUM TREMENS

Symptoms may appear earlier from the last drink and present with a wide range of symptoms. The most effective interventions require high-quality nursing care delivery to prevent, decrease the severity and shorten the duration of delirium.

NURSING IMPLICATIONS

Strategies that help minimize these challenges starts with obtaining the patient's selfreport of their alcohol use history. Nurses should be diligent in their monitoring for signs of active alcohol withdrawal. Screening and assessment tools such as the Clinical Institute Withdrawal Assessment for Alcohol-Revised should guide pharmacological management. To support nurses in identifying delirium tremens, this manuscript seek to describe the underlying pathophysiology, key assessment components and nursing management of delirium tremens in the older adult.

Pharmacotherapeutic management of acute alcohol withdrawal syndrome in critically Ill patients

INTRODUCTION

Alcohol withdrawal syndrome is a common and life-threatening condition in patients suffering from alcohol use disorder. Treatment of this syndrome is challenging, especially in patients that are critically ill, either because of withdrawal symptoms or underlying conditions. For the treatment, several pharmacological agents exist, such as benzodiazepines, barbiturates, or dexmedetomidine. Nonetheless, as alcohol withdrawal syndromes can occur in every clinical setting, it is necessary to provide a guideline for clinicians confronted with this syndrome in varying clinical contexts.

AREAS COVERED

The authors provide a systematic review of the literature found in PubMed and Embase following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

EXPERT OPINION

For the treatment of alcohol withdrawal syndrome, medications targeting the GABA system are preferred. Benzodiazepines are regarded as the gold standard. However, as many adjunct therapeutic options exist, it is essential to find symptom-triggered approaches and treatment protocols for the variety of clinical contexts. Apart from that, it is necessary to compare protocols toward clinical variables rather than investigating medications that are in use for the treatment of alcohol withdrawal syndrome.

Risk Factors for Severe Alcohol Withdrawal Syndrome in an Acute Hospital Population

BACKGROUND

The literature lacks consensus to the factors that increase the risk of a patient developing severe alcohol withdrawal syndrome (SAWS).

AIM

The study set out to identify the variables that increase the risk of SAWS in patients who have alcohol dependence syndrome.

METHODS

A case-control study was designed to investigate the variables associated with SAWS in an acute hospital setting. Three hundred eighty-two case and 382 control patients were randomly selected retrospectively from referrals to the acute addiction liaison nursing service during a 12-month period (January 1, 2015, to December 31, 2015). Statistical significance (p < .05) and association with SAWS were calculated using chi-square, Cramer's V test, odds ratio, and Levene's test.

RESULTS

Twenty-four variables have been identified as associated with SAWS development. Five of the 24 variables had a moderate-to-strong association with SAWS risk: Fast Alcohol Screening Test, Glasgow Modified Alcohol Withdrawal Scale score, AWS admission, hours since the last drink, and systolic blood pressure. The study also identified that comorbidity was associated with not developing SAWS.

CONCLUSION/RECOMMENDATIONS

These findings confirm that noninvasive variables collected in the emergency department are useful in identifying a person's risk of developing SAWS. The results of this study are a useful starting point in the exploration of SAWS and the development of a tool for use in the emergency department that can stratify risk into high and low and is the next stage of this program of work.

Use of Propofol Plus Dexmedetomidine in Patients Experiencing Severe Alcohol Withdrawal in the Intensive Care Unit

Alcohol abuse and alcohol withdrawal syndrome are major problems in the United States. This retrospective chart review assessed efficacy and safety of propofol plus dexmedetomidine used in combination as adjunctive therapy to benzodiazepines compared with either agent used alone in the treatment of severe alcohol withdrawal. Patients admitted to the intensive care unit and experiencing severe alcohol withdrawal between September 1, 2015 and September 30, 2018 were assessed for eligibility. Primary end points were change in the revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar) score and incidence of bradycardia and hypotension. The combination of propofol and dexmedetomidine was associated with a change in CIWA-Ar score of -10.4 (95%CI -13.5 to -7.3) points compared with -4.7 (95%CI -6.6 to -2.8) points with propofol and -4.4 (95%CI -7.4 to -1.4) with dexmedetomidine (P = .21). Bradycardia was experienced by 11.1% of patients receiving the combination, 15.4% of patients receiving propofol, and 28.6% of patients receiving dexmedetomidine (P = .40). Patients receiving dexmedetomidine experienced hypotension at a rate of 21.4% compared with 22.2% of patients receiving the combination and 38.5% of patients receiving propofol (P = .08). Patients in the combination group also had a shorter length of hospital and intensive care unit stay and shorter time to extubation when compared with the propofol and dexmedetomidine groups. Although no statistical significance was found, the combination was associated with better efficacy and safety outcomes than produced by either agent used alone.

Development of an alcohol withdrawal risk stratification tool based on patients referred to an addiction liaison nursing service in Glasgow

Purpose

The purpose of this paper is to develop an alcohol withdrawal syndrome risk stratification tool that could support the safe discharge of low risk patients from the emergency department.

Design/methodology/approach

A retrospective cohort study that included all patients referred to the acute addiction liaison nursing service over one calendar month (n=400, 1–30 April 2016) was undertaken. Bivariate and multivariate modelling identified the significant variables that supported the prediction of severe alcohol withdrawal syndrome (SAWS) in the cohort population.

Findings

The Glasgow Modified Alcohol Withdrawal Scale (GMAWS), hours since last drink, fast alcohol screening test (FAST) and systolic blood pressure correctly identified 89 per cent of patients who developed SAWS and 84 per cent of patients that did not. Increasing each component by a score of one is associated with an increase in the odds of SAWS by a factor of 2.76 (95% CI 2.21, 3.45), 1.31 (95% CI 1.24, 1.37), 1.30 (95% CI 1.08, 1.57) and 1.22 (95% CI 1.10, 1.34), respectively.

Research limitations/implications

The research was conducted in a single healthcare system that had a high prevalence of alcohol dependence syndrome (ADS). Second, the developed risk stratification tool was unable to guarantee no risk and lastly, the FAST score previously aligned to severe ADS may have influenced the patients highest GMAWS score.

Practical implications

The tool could help redesign the care pathway for patients who attend the emergency department at risk of SAWS and link low risk patients with community alcohol services better equipped to deal with their physical and psychological needs short and long term supporting engagement, abstinence and prolongation of life.

Originality/value

The tool could help redesign the care pathway for emergency department patients at low risk of SAWS and link them with community alcohol services better equipped to deal with their physical and psychological needs, short and long term, supporting engagement, abstinence and prolongation of life.

Severe alcohol withdrawal syndrome: review of the literature

Purpose

The purpose of this paper is to identify published literature from a general hospital setting that may highlight variables implicated in the development of severe alcohol withdrawal syndrome (SAWS) in patients who have alcohol dependence syndrome (ADS).

Design/methodology/approach

A systematic literature review was carried out using the electronic databases: MEDLINE, Medline in Process, Cinahl, Embase and PsycINFO from 1989 to 2017. The focus of this search was on English language studies of individuals over 16 years admitted to general hospital with ADS, delirium tremens (DTs), alcohol-related seizure (ARS) or alcohol withdrawal syndrome (AWS).

Findings

Of the 205 studies screened, eight met the criteria for inclusion. Six studies were quantitative retrospective cohort and two were retrospective case-control. Six studies investigated risk factors associated with DTs, one examined SAWS and one alcohol kindling. Descriptive analysis was performed to summarise the empirical evidence from studies were 22 statistically significant risk factors were found; including the reason for admission to hospital, daily alcohol consumption, previous DTs and prior ARS. The last two factors mentioned appeared in two studies.

Research limitations/implications

Further research should consider the quality and completeness of the alcohol history data and competence of staff generating the data in retrospective studies.

Originality/value

The paper suggests that the factors linked to SAWS development from the literature may not fully explain why some individuals who have ADS develop SAWS, and others do not.

Screening, Diagnosis, and Management of Patients With Alcohol Use Disorders at Bwindi Community Hospital, Uganda

Introduction: The harmful use of alcohol is a growing global public health concern, with Sub-Saharan Africa at particular risk. A large proportion of adults in Uganda consume alcohol and the country has a high prevalence of alcohol use disorders (AUD), almost double that for the African region as a whole. Bwindi Community Hospital, in rural western Uganda, recently introduced a program of screening, diagnosis and management of AUD and we assessed how this worked.

Methods: This was a cross-sectional study in three departments (out-patients, adult in-patients and sexual & reproductive health) of Bwindi Community Hospital assessing numbers of patients screened, diagnosed and treated with AUD between January 2014 and June 2017. Data sources included the hospital electronic data base and departmental case files. Frequencies and proportions are reported and odds ratios used to compare specific factors associated with medical interventions.

Results: Altogether, 82,819 patients attended or were admitted to hospital, of whom 8,627 (10.4%) were screened and 273 (3.2%) diagnosed with AUD. The adult in-patient department recorded the largest number with AUD (n = 206) as well as a consistent increase in numbers in the last 18 months of the study. Of those with AUD, there were 230 (84%) males, 130 (48%) aged 36–60 years, and 131 (48%) with medical non-alcohol related diagnostic categories. Medical/supportive interventions included guidance and counselling to 168 (62%), community social support to 90 (33%), mental health service referrals for 75 (27%), detoxification for 60 (22%) and referral to Alcoholics Anonymous for 41 (15%). There were 36 (15%) patients who received no medical/supportive interventions, with significantly higher proportions in patients with surgical alcohol-related disease and pregnancy-related conditions (P < 0.05).

Conclusion: Bwindi Community Hospital has implemented a program for AUD in three departments, with most individuals screened and managed in the adult in-patient department. While a variety of interventions were given to those with AUD, 15% received no intervention and this deficiency must be addressed. Program performance could improve through better screening processes, ensuring that 100% of those with AUD receive a medical/supportive intervention and raising public awareness.