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Alcohol Withdrawal: Assessment and Treatment in the Acute Care Setting
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  1. Alcohol Withdrawal: Assessment and Treatment in the Acute Care Setting Withdrawal and prevention of complications from Alcohol Use Disorders Presented by: Brett Kronenberger MD – Chief Hospitalist St. James Healthcare – Butte, Montana October 11, 2011

  2. Objectives At the end of this continuing nursing education event, the participant should be able to: • Recognize scope and prevalence of both alcohol related admissions and alcohol withdrawal in hospitalized patients • Define the progression of alcohol withdrawal • Differentiate use of the withdrawal assessment tools (CIWA and RASS scales) • List two drugs indicated for prevention of alcohol withdrawal seizures • Identify treatment options for patients in withdrawal which is not responsive to standard treatment

  3. Written Disclosures Disclosure of presenter(s)/participant(s): (List each individually) • Brett Kronenberger MD, has nothing to disclose. Disclosures of those in a position to control educational content: • • Susan DePasquale RN MSN CGRN – Nurse Planner has nothing to disclose. • • Phil Dean, RN – Clinical Nurse Educator has nothing to disclose. Criteria for Successful Completion: • View 100% of the video-taped education event. • Complete the Independent Study Evaluation Form Enduring Material for Independent Study Expires: 10/11/14

  4. Prevalence in US • 8 Million Alcoholics in US • 500,000 episodes of withdrawal requiring medication per year in US • 15-36% of people admitted have Alcohol Use disorders (AUD) with 8% general admits getting withdrawal • 16% post-surgical patients get withdrawal • 43% of trauma patients have AUD and 31% have withdrawal • Male predominance 5:1

  5. Alcohol Withdrawal Ingredients • Alcohol dependence • Abstinence: • Voluntary • Enforced by injury • Enforced by incarceration • Enforced by illness

  6. Diagnosis • History • Physical Exam • Stigmata of liver disease • Evidence of trauma • Laboratory values • Liver associated enzyme elevation • Alcohol level

  7. Systems Altered by ETOH • CNS • Gastrointestinal • Hepatic • Hematological • Cardiovascular • Nutritional • Metabolic

  8. Withdrawal Differential Diagnosis • Acute speed intoxication • Sepsis • Thyrotoxicosis • Heat Stroke • Hypoglycemia • Intracranial process

  9. Cage Questionnaire • Have you ever felt like you should CUT down on your drinking? • Have people ANNOYED you by criticizing your drinking? • Have you ever felt bad or GUILTY about your drinking? • Have you ever had a drink first thing to steady your nerves or treat a hangover? (EYE OPENER)

  10. Likelihood ratio by Score 0 1 2 3 4 Percent ratio by Score .14 1.5 4.5 13.2 101 Diagnostic Value

  11. Symptoms Anxiety Insomnia Tremulousness Headache Nausea Signs Tremor Diaphoresis Agitation Tachycardia Hypertension Low grade fever <38.5 Alcohol Withdrawal Syndrome

  12. Alcohol Withdrawal Syndrome • Stage I: Tremulousness • Stage II: Hallucinations • Stage III: Seizures • Stage IV: Delirium Tremens

  13. Syndrome I. Tremulousness II. Hallucinations III. Seizures IV. Delirium Tremens Onset after last drink 6-36 Hours 12-48 Hours 6-48 Hours 3-5 days Timing of ETOH Withdrawal

  14. Stage I: Tremulousness • Symptoms appear within 6-36 hours of last drink • 13-71% of alcohol dependent patients withdrawal symptoms • Caused by autonomic hyperactivity

  15. Stage II: Alcohol Hallucinations • Occur within 12-48 hours of last drink • 3-10% of withdrawal develop hallucinations • Duration is variable • Usually visual (pink dolphins) • Occasionally auditory, tactile (formication), or olfactory

  16. Stage III: Seizures “Rum Fits” • Occurs within 6 to 48 hours of last drink • 3-15% of untreated patients develop seizures • Grand Mal • Risk is increased by duration of ETOH abuse • 40% are single • 30% of untreated patients go on to Delirium Tremens

  17. Stage III: Seizures “Rum Fits” • Retrospective or 308 city hospital patients • 51-100gm/day intake = 3 fold increase • 101-200 gm/day intake = 8 fold increase • 201-300 gm/day intake = 20 fold increase note 10gram = one beer Stephen KC, et al Alcohol Consumption and Withdrawal in New Onset Seizures. NEJM, 1988: 319; 666-73

  18. Stage IV: Delirium Tremens • Begins 3-5 days after last drink • Occurs in less than 5% of withdrawal • Marked by disorientation and global confusion • Mortality 2-10% • Death: Cardiovascular, metabolic or infection complications

  19. Risk Factors for DT’s • Acute concurrent Medical Illness • >2 days since last drink • History of seizure of previous DT’s • Heavier and longer drinking history • Age> 60 increase risk for DT’s and fall • Elevated admit blood ETOH level

  20. Treatment Strategy • Reduce symptoms • Prevent seizures • Prevent Delirium tremens • Prevent medical complications

  21. Supportive Care • Quiet environment • Hydration- may have 6 L volume deficit with DT’s • Electrolyte correction • Nutrition • Reassurance/orientation • Monitor for signs/symptoms of withdrawal

  22. Benzodiazepines: Cornerstone of treatment • Reduction of withdrawal symptoms • Overall reduction of seizures • Reduction of DT’s • All BZD are equally efficacious

  23. Fixed Dose vs. Symptom triggered • Fixed dose with Librium q 6 plus q1 if CIWA >8 • Symptom triggered: Librium q1 if CIWA>8 • Advantages symptom triggered was shorter treatment time, lower BZD dose needed

  24. Treatment • Benzodiazepines (Benzos) • Treat the psychomotor agitation • Prevent progression from minor to major withdrawal symptoms • Valium, Librium and Ativan most common • For DT’s: IV diazepam, 5-10mg IV every 5 minutes until calm can be used

  25. Treatment • Fixed schedule therapy, in which benzos are given at fixed intervals even if symptoms are absent, is most useful if patients at high risk for major withdrawal • Healthy patients should be lightly sedated • Patients with comorbitities, especially cardiac should be more heavily sedated

  26. Treatment of Symptoms • Symptom triggered therapy- use Clinical Institute Withdrawal Assessment and give treatment when >8 • Advantage is fewer benzos given and shorter course • Disadvantage may be progression to DT’s if worsening withdrawal is not detected

  27. Clinical Institute Withdrawal Assessment (CIWA-AR) Revised • 10 items with 0-7 rating system for withdrawal severity • Score correlates with severity of withdrawal • Enhances communications with staff • Brief and easy to use • CIWA>25 predicts severe withdrawal and delirium

  28. CIWA-Ar Caveats • Not diagnostic of withdrawal • Assessment tool only • Must interpret score in clinical content • Co-morbid illness can confound the scoring • Bottom Line: Interpret- don’t just treat a number

  29. 1. Nausea/vomiting 2. Tremor 3. Paroxysmal sweating 4. Anxiety 5. Agitation 6. Tactile disturbances 7. Visual disturbances 8. Auditory disturbances 9. Headache 10. Orientation CIWA-Ar

  30. Modified Ramsay scale for ICU • Scale used for ICU or patients who are unable to communicate • Scale has 1-6 score where 1 is anxious, restless or agitated and 6 has no response to noxious stimuli.

  31. Richmond Agitation Sedation Scale (RASS) • +4 to -5 scale which is useful for non-communicative or intubated patients • Goal is -1 to -2 with mild to light sedation

  32. Specific Fixed dose regimens • Chlordiazepoxide 50mg q6 x 8 doses • Diazepam 10mg q6x 4 then 5mg q6 x 8 doses • Lorazepam 2mg q6 x4 then 1mg q6 x 8 • Provide additional benzodiazepines as needed for CIWA >8 • Best for high risk

  33. Long acting benzo: Chlordiazepoxide and Valium • Chlordiazepoxide (Librium) • Oral dosing only • Intermediate onset • Long-acting parent compound and metabolites • Smother withdrawal, less seizures, better cognitive function • Potential accumulation in elderly and severe liver disease • Valium similar but can be given IV

  34. Shorter Acting Benzos • Lorazepam (Ativan) • Versatile dosing- PO, IV, IM, SL • Fast to intermediate onset • Intermediate half-life, no metabolites • Less likely to accumulate in elderly or liver disease • Breakthrough seizures may occur • Oxazepam

  35. Benzodiazepines-Dosing options • “Fixed Schedule” Regimens • Traditional approach • Administer BZD around the clock • Additional doses prn • Taper by 25% per day when stable • Risk for under-dosing, over-sedation and drug accumulation

  36. Benzodiazepines- Dosing options • “Symptom-Triggered” Therapy • Administer Benzo only when symptoms present • Structured protocals, staff-intensive, frequent CIWA assessments • Less medication, and shorter duration

  37. New Symptoms driven protocals • Three Clinical Scenarios with 3 different order sets • Risk, but no active withdrawal • Mild-moderate withdrawal • Severe withdrawal • CIWA assessments done q4 if score <10, if CIWA 11-14 reassessments q2 and to q1 for higher CIWA scores

  38. Librium Front-Loading • May be used concurrently with symptom triggered dosing with Ativan or Librium • Not for elderly or patient with significant liver disease • Consider with history of DT, seizures, or severe withdrawal. Useful if withdrawal is beyond mild before treatment begins

  39. Intractable Anxiety, Agitation • When patient continues reporting anxiety and further Benzos are not justified • Consider Haloperidol can be used • Transfer to ICU if evidence of airway compromise, high doses of benzos

  40. Challenges • Missed diagnosis • Under-treatment- more restraints, higher mortality • Over-treatment- Benzodiazepine intoxication, sedation, respiratory failure • Wrong diagnosis or missed co-morbidities

  41. Withdrawal Seizure Prophylaxis orders • The Swedish Alcohol Withdrawal Seizure Prophylaxis Orders draw from Swedish Addiction • Recovery Services clinical experience where use of carbamazepine or divalproex sodium is associated • with an absence of seizures in patients who: • have a history of seizure • are concurrently withdrawing from benzodiazepines • are unable to communicate clearly about CIWA symptomatology secondary to mental health, medical illness, or language barriers • An additional benefit of using carbamazepine or divalproex sodium is a reduction in insomnia and anxiety • compared to patients randomized to lorazepam.

  42. Haloperidol • Reduce agitation • Dose .5-5mg IV/IM/po q 2-4 hours prn • Recommended for severe agitation as an adjunct to benzodiazepines • May lower seizure threshold

  43. Thiamine • Evidence of defiency within one week • Etiology is poor absorption and poor nutrition • 30-80% patients deficient • Reduces risks of Wernicke’s encephalopathy • Give 100mg IV/IM then po for 3 days • Thiamine before glucose

  44. Magnesium • Levels are often low in 25-30% of patients • Similar symptoms to ETOH withdrawl • Treat to help with K replacement

  45. Propofol • ICU transfer if refractory to • Refractory delirium • Patients requiring high doses of Benzos • Used as continuous infusion