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Acute Alcohol Withdrawal:Guidelines For Evaluation and Treatment. By: David Bridgers, M.D. NCBH 1:00 A.M. Nurse: “We have Mr. Johnson here in 709, and you know, I think he’s going into the DTs.” Intern: “What’s he doing?”

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ncbh 1 00 a m
NCBH 1:00 A.M.

Nurse: “We have Mr. Johnson here in 709, and you know, I think he’s going into the DTs.”

Intern: “What’s he doing?”

Nurse: “ I don’t know. He’s a little shaky, and I think he’s hallucinating.”

Intern: “ Well, how bad is he?”

Nurse: “ I don’t know…..not too bad. Can I give him something?”

Intern: “ Yeah…..just give him some ativan. 2 mg IV will be fine.”

ncbh 1 30 a m
NCBH 1:30 A.M.

Intern: “ Hey, I got a guy from the ED. I think he’s an alcoholic. I just gave him some Ativan.”

Upper Level: “ (Yawn) That’s fine. Just put him on….I don’t know…..a couple of milligrams q 2 hours, or something. You know, for DT prophylaxis. He’ll be fine, and you can get some sleep……and so can I.”

Intern: “Will that be too much?”

Upper Level: “ Nah….a sleeping drunk is a good drunk. Call me if you need me. I’m going back to bed.”

ncbh four days later
NCBH: Four Days Later

Attending (Grabarczyk): “Why is Mr. Johnson so out of it?”

Intern: “ I’m not sure. He should be up and around by now. We’ve treated his pneumonia, and he hasn’t had any fever for two days.”

Attending: “ Is he getting anything to make him sleepy?”

Intern: “ Not really. He’s just been getting a little Ativan for DT prophylaxis.”

Attending: “Well how much?”

ncbh four days later5
NCBH: Four Days Later

Intern: “Just 2 mg. He was getting it q 2 hours IV until yesterday when I made it p.o. and PRN.”

Attending: “Well how much has he gotten since then?”

Intern: (Flipping through MAR)“Uh…….It looks like he’s still gotten it every 2 hours.”

Attending: “So now tell me…..Why is he still so out of it!?”

a little bit o background information
A Little Bit o’ Background Information
  • In 1990 there were an estimated 11-18 million in the U.S. reporting heavy alcohol abuse and dependence
  • Lifetime prevalence of 14% and 8% respectively
  • 15-20% of hospitalized and primary care patients (400,000 at any time) have alcoholism or withdrawal as their primary or supporting diagnosis
  • This lead to 1 million discharges from acute care facilities with alcohol related diagnoses
slide7
But what do the statistics mean?WE AS PHYSICIANS MUST BE ABLE TO IDENTIFY AND TREAT THIS COMMON CONDITION!
how do we go about this knowledge is power
How do we go about this?Knowledge is Power!
  • Understand the effects of alcohol on the patient
  • Know how to identify the symptoms of alcohol withdrawal
  • Know how to adequately assess the severity of withdrawal, and the tools used in doing so
  • Know how to treat withdrawal and prevent complications
how alcohol effects the brain
How Alcohol Effects the Brain

Low Level Ingestion

  • Euphoria
  • Anesthesia
  • Amnesia
how alcohol effects the brain10
How Alcohol Effects the Brain

High Level Ingestion

  • Severe Intoxication
  • Respiratory Depression
  • Coma
metabolic abnormalities
Metabolic Abnormalities

Hypokalemia: due to:

  • alterations in aldosterone level
  • renal and extra-renal losses
  • changes in the distribution of potassium levels across the cell membrane

Hypomagnesemia: may predispose the patient to withdrawal seizures

metabolic abnormalities13
Metabolic Abnormalities

Hypophosphatemia:

  • common due to malnutrition
  • frequently symptomatic
  • predisposing the patient to fatal cardiac failure and rhabdomyolysis

Volume Depletetion:

  • resulting from hyperthermia, diaphoresis, vomiting, and tachypnea
mild withdrawal symptoms
Due to increased central nervous system and sympathetic activity

usually resolve w/i 24-48 hrs

vary from episode to episode

Headache

Anorexia

Agitation

Increased sweating

Tachycardia

Increased hand tremor

GI upset

Insomnia

Palpitaions

Mild Withdrawal Symptoms
alcoholic hallucinosis
Alcoholic Hallucinosis
  • transient tactile visual or auditory hallucinations
  • usually visual
  • NOT synonymous with DTs

*other signs may or may not be present

* not usually associated with clouding of the sensorium

withdrawal seizures
Withdrawal Seizures
  • w/i 48 hours of last drink
  • generalized tonic-clonic
  • 3% of chronic alcoholics develop this
  • 3% of those who seize develop Status Epilepticus
  • Seizures can be attributed to alcohol withdrawal if the patient has:
  • a normal EEG
  • history of documented seizure activity in withdrawal
  • no other cause for their seizures can be determined
delirium tremens
Delirium Tremens
  • 5% of patients who withdraw develop DTs
  • Early figures of associated mortality were as high as 37%
  • earlier diagnosis, improved pharmacological, and non-pharmacological management, and improved treatment of co-morbidities has lead to mortality now being apx. 1%
  • Death is usually due to arrhythmia or secondary complications. (pneumonia,liver failure)
risk factors for developing dts
Risk Factors For Developing DTs
  • History of sustained drinking
  • Previous DTs
  • Age >30
  • Greater number of days since last drink
  • Presence of other illnesses
hallmarks of dts
Hallmarks of DTs
  • Hallucinations
  • Disorientation
  • Tachycardia
  • Hypertension
  • Low Grade Fever
  • Agitation
  • Diaphoresis
  • Sensorium Clouding
hallmarks of dts21
Hallmarks of DTs

Physiologic Changes:

  • Elevated cardiac indices, oxygen delivery and oxygen consumption
  • Hyperventilation and Respiratory alkalosis which result in reduced cerebral blood flow
early studies on the natural history of alcohol withdrawal
Early Studies on the Natural History of Alcohol Withdrawal
  • Victor and Adams 1953
  • described four different “states” (tremulous, hallucinatory, epileptic, and delirious) seen either separately from one another, or in combination
  • Course described was ambiguous
  • Found mortality to be 15%
natural history of the alcohol withdrawal process foy et al 1997
Natural History of the Alcohol Withdrawal Process: Foy et al 1997
  • Describe a more accurate view of the natural history of alcohol withdrawal
  • Timing of major events
  • Incidences of seizures, hallucinations, delirium
  • Risk factors for these events
foy et al 1997 timing of withdrawal onset and resolution
Foy et al 1997:Timing of Withdrawal Onset and Resolution

Onset:

  • Overall median time of onset of withdrawal was 5 hours and 90% were withdrawing by 24 hours
  • Longer for those with complications (7 hours versus 4 hours)
  • Measured BAL of 0: On admission (75% were in withdrawal within 1 hour)

Resolution:

  • Resolution shorter for those without complications (22 hours versus 33 hours)
foy et al 1997 incidences of complications
Foy et al 1997: Incidences of Complications
  • Of the 426 patients in the study, 113 experienced complications with a few experiencing more than one complication
  • Seizures: 10
  • Delirium: 45
  • Hallucinations: 90
foy et al 1997 timing of complications
Foy et al 1997: Timing of Complications
  • Seizures occurred the earliest with 50% occurring on admission and 90% by 9 hours
  • Hallucinations were next with 50% occurring by 20.5 hours and 90% by 64 hours

*They were mostly short-lived with a median duration of 6 hours and 90th percentile of 46 hours

  • Delirium had the latest onset. 50% occurred within 46 hours and 90% by 85 hours

*The duration of delirium was wider and more variable with a median duration of 23 hours and 90th percentile of 100 hours

foy et al 1997 risk factors for complications
Foy et al 1997: Risk Factors For Complications
  • Age greater than 70
  • Need for assisted ventilation
  • Pathology of the CNS, hypoxia, and femur fractured conveyed a greater risk of delirium
  • Delaying initial assessment and subsequent diagnosis for more than 24 hours
assessment of alcohol withdrawal
Assessment of Alcohol Withdrawal

Uh..uh..

I don’t know

Is that dude

withdrawing?

severity assessment scoring systems
Severity Assessment Scoring Systems
  • Objective way to quantify the severity of alcohol withdrawal by interacting with the patient and giving them a total severity assessment score
  • Ideal scale should:

1. Be able to not only asses the patient initially for signs of alcohol withdrawal, but also follow their course of withdrawal

2. Be administered rapidly by nursing staff

3. Help guide Physicians in administering appropriate treatment

early severity assessment scales
Early Severity Assessment Scales
  • Formulated by Gross et al in 1973
  • Total Severity Assessment Scale (TSA) and Selective Severity Assessment Scale (ASA)
  • Faulted in the fact that some of the characteristics were only applicable daily and did not follow the course of withdrawal on a hour to hour basis
  • Difficult to administer
ciwa a
CIWA-A
  • Clinical Institute Withdrawal Assessment for Alcohol Withdrawal
  • 15 item scale developed by Shaw 1981
  • Designed to follow the course of withdrawal by being able to be administered several times a day
  • Administration time apx. 6 minutes
ciwa a assessment categories
Tremor

Sweating

Clouding of the sensorium

Quality of contact

Agitation

Seizures

Nausea and vomiting

Tactile disturbances

visual disturbances

auditory disturbances

Headache

Flushing of face

Convulsions

Thought disturbances

General Hallucinations

CIWA-A Assessment Categories
ciwa a scoring
CIWA-A Scoring
  • Scoring was based on a seven point scale
  • Points were given according to severity of category
  • The total score was tallied to determine severity of withdrawal as defined in their study results as:

·        Mild-20.4 (+/-2.6)

·        Moderate 24.2 (+/- 5.4)

·        Severe 29 (+/- 7.6)

shaw et al 1981
Shaw et al 1981
  • The premise of their study was that patients admitted with alcohol withdrawal could, if objectively assessed with the CIWA-A, be treated by a program of “supportive care” without using medications
  • The supportive care program consisted of minimizing environmental stimuli, and administering comfort measures such as fluids, blankets and smoking when desired every 30 minutes
shaw et al 1981 results
Shaw et al 1981:Results
  • The group defined supportive care as a success when the CIWA-A score after 8 hours was reduced to <10 and there was no rebound during the 72 hours of admission
  • 38 patients were admitted to the study
  • 28 patients were declared a success by the above
  • 10 had no response to the supportive care program, but were managed well using diazepam as described without complication 
shaw et al 1981 conclusions
Shaw et al 1981:Conclusions
  • The systematic evaluation of patients using the CIWA-A scale to score the severity of their withdrawal coupled with “supportive” nursing care was effective in the treatment of patients suffering from alcohol withdrawal
  • 75% of the patients in their study required no medication
  • Nurses could be trained to administer the scale in a timely fashion without direct physician supervision
shaw et al 1981 conclusions38
Shaw et al 1981:Conclusions
  • The scale was valid when compared to physician assessments
  • Using the scale was also important because frequent nursing intervention was beneficial to the patient. The interaction reoriented the patient and helped calm them, thus preventing the need for medication in many circumstances
shaw et al 198139
Shaw et al 1981

Weaknesses of study:

  • Small size of patients
  • Patient population was selected to minimize co-morbidities
  • Study was in a alcohol treatment facility and did not incorporate the same population seen in a general medical facility, thus leading one to question its applicability there
foy et al 1988
Determine that CIWA testing was valid in this population

Prospective study

Royal Newcastle Hospital in Australia

203 adult general medical and surgical patients

age 20-75

various other common co-morbidities and met criteria for alcohol withdrawal

Outcomes assessed :

Occurrence of severe withdrawal (confusion, hallucination, or seizures after admission)

highest score prior to developing complications, or discharge

use of benzodiazepines for symptoms

Foy et al 1988
foy et al 1988 conclusions
Foy et al 1988: Conclusions
  • Patients who developed severe alcohol withdrawal had higher scores than other patients even before the development of complications; therefore, a severity scale used in a general hospital does predict who is at greater risk for severe withdrawal.
  • The higher the score the greater the risk that an untreated patient would develop severe withdrawal.
  • The scale can be used as a guide to treatment in a general medical facility.
foy et al 1988 conclusions45
Foy et al 1988: Conclusions
  • Benzodiazepines do appear to prevent complications when given early as determined by a high CIWA-A score.
  • The only limitations to using the CIWA-A in a general hospital were in dealing with patients who were critically ill (hypoxia, shock or septicemia) or had femur fractures, and thus require special attention.
ciwa evolution ciwa ar
CIWA Evolution: CIWA-Ar
  • In 1987 Sullivan et al identified that the original CIWA-A had several items that were redundant and by eliminating these, it could be more efficient to administer without losing accuracy of assessing the withdrawal severity
  • convulsions, quality of contact, general hallucinations, flushing, and thought disturbances were eliminated
  • His scale consists of vomiting, sweats, tremor, anxiety, agitation, tactile disturbances, auditory hallucinations, visual hallucinations, headache, and clouding of the sensorium
sullivan 1991
Sullivan 1991
  • He put his CIWA-Ar to test to see if it not only be valid in the assessment of alcohol withdrawal, but also serve as a guide in the treatment of the condition
  • He identified that patients receiving fixed-dosing of benzodiazepines may be over-medicated and thus would benefit from using the CIWA-Ar to help titrate the medication administered in a more appropriate fashion
sullivan 1991 study design
Sullivan 1991: Study Design
  • Retrospective reviewed the medical record of 117 patients treated for alcohol withdrawal in the previous 24 months prior to CIWA-AR initiation (S- control group)
  • they were treated with fixed-dosing of benzodiazepines without criteria for drug administration
  • The S+ group consisted of 133 patients followed prospectively after the initiation of the CIWA-Ar scale over the next 24 months
sullivan 1991 protocol
Sullivan 1991: Protocol
  • Patients were evaluated hourly during the initial phases of the withdrawal period, and then as needed with the CIWA-Ar
  • If they had a score>10 they received Diazepam 20 mg, or Librium 100 mg orally
sullivan 1991 results
Sullivan 1991:Results
  • Total dosage was calculated as diazepam equivalents (DZE)
  • S+ group required a mean dose of 50 mg
  • S- group required a mean of 75mg
  • There was no difference in the rate of complications between the groups
sullivan 1991 conclusions
Sullivan 1991: Conclusions
  • The CIWA-Ar was an effective guide in assessing alcohol withdrawal and directing medication administration.
  • Using the CIWA-Ar led to an improvement in the appropriateness of pharmacotherapy without a difference in morbidity.
  • When the scale was used, patients with greater dependence, and hence worse withdrawal received greater amounts of medicine and vice versa. Thus, there was titration of drug administration to therapeutic requirement in a more appropriate manner when the CIWA-Ar was used.
sullivan 1991 conclusions cont
Sullivan 1991: Conclusions (cont.)
  • A lower average of medication used in the CIWA-Ar would lead to financial savings without increasing the rate of complications
  • The use of the CIWA-Ar scale can also help in writing the appropriate amount of PRN medication
study overload
STUDY OVERLOAD!!!!

Assessment Scales:

objective way to asses withdrawal severity

  • follow the course of withdrawal more adequately and minimize complications
  • Help guide treatment
  • If used with medication guidelines reduce total amount of medications administered
evidence based medicine
EVIDENCE BASED MEDICINE

Internal Medicine Residency

Evidence Based Medicine

treatment of alcohol withdrawal
Treatment of Alcohol Withdrawal
  • Working Group on Pharmacological Management of Alcohol Withdrawal (Mayo-Smith)

- JAMA July 9,1997

- Goal was to create evidence based guidelines for the treatment of Alcohol withdrawal syndromes

working group on etoh withdrawal syndromes cont
Working Group on ETOH Withdrawal Syndromes cont.
  • 134 articles, 65 Prospective controlled trials with documented reporting of the outcome in question were investigated further

Outcomes studied:

  • Severity of withdrawal syndrome
  • Alcohol Withdrawal Delirium
  • Withdrawal Seizures
  • Completion of withdrawal
  • Entry into Rehab
  • Cost
choice of agents
Choice of Agents
  • Benzodiazepines recommended
  • Caveats:

1. Long acting (Chlodiazepoxide) may be more effective in controlling seizures

2. Long acting contributes to smoother withdrawal and less rebound

3. Short-acting Benzos have higher potential for abuse

4. Long-acting could cause excess sedation in special populations such as the elderly or those with marked liver disease

other agents examined
Other Agents Examined

-Blockers:

  • may reduce the autonomic manifestations of withdrawal
  • no studies showed they conferred any benefit in reducing seizure activity
  • Delirium is a known side effect of the more centrally penetrating -Bs such as propanolol
other agents examined60
Other Agents Examined

Clonidine:

  • helped ameliorate the symptoms in mild to moderate withdrawal
  • no data on the ability to reduce or increase the incidence of delirium or seizures
  • well-documented rebound hypertension effect
other agents examined61
Other Agents Examined

Carbamazepine:

  • Widely used in Europe
  • equal in efficacy to barbital and oxazepam in patients with mild to moderate withdrawal
  • limited data comparing its efficacy in reducing seizures (except in animal studies) and preventing delirium
  • There was no abuse potential
other agents examined62
Other Agents Examined
  • Neuroleptic Agents: They have some effectiveness in reducing signs and symptoms, but less effective than benzodiazepines in preventing delirium. Furthermore they increase the incidence of seizures No controlled studies showed their effectiveness in calming patients
  • Magnesium: No data showed benefit in reducing signs and symptoms, or reducing seizures and delirium
  • Thiamine: It is useful in preventing Wernike-Korsakoff syndrome, but does not reduce delirium or seizures
other agents examined63
Other Agents Examined

Ethyl Alcohol:

  • case reports of ETOH given orally or IV in preventing withdrawal symptoms
  • trials are very small and uncontrolled without objective or quantitative assessment of withdrawal severity
  • no trials comparing it to benzodiazepines or placebo
  • IV infusions require very close monitoring and are very expensive to administer. They are associated with tissue damage at the infusion site, and has well known and severe side effects and toxicity
  • counterintuitive in the treatment of alcohol abuse for the hospitalized patient
timing of medication fixed vs symptom triggered
Timing of Medication:Fixed vs. Symptom-Triggered
  • compared the fixed-dosing of medication to symptom-triggered therapy
  • symptom triggered therapy is equally effective as fixed-dosing
  • patients receiving symptom-triggered therapy required less medication, had a shorter duration of medication treatment with no significant increase in complications, had decreased treatment intensity, and a shorter hospital course
slide65
Cost
  • They compared the average cost of Chlordiazepoxide 25 mg ($0.033), Diazepam 5 mg ($.071), and lorazepam 1 mg ($0.115)
  • Chlordiazepoxide is cheaper and is equally efficacious
  • some practitioners routinely use continuous infusions of short acting agents such as lorazepam, which can result in large hospital costs
slide66
Cost
  • They reviewed a study by Hoey, in which hospital guidelines were established that led practitioners to use Librium whenever it was appropriate in the treatment of alcohol withdrawal
  • This led to an average cost of $59.79 where the average cost of treatment before implementing the guidelines was $1008.72 due to physicians regularly using short acting agents often in infusion form. They had equivalent outcomes and no increase in adverse effects in their study after the guidelines were implemented
  • They found no evidence that infusion of short acting agents provides better outcomes than oral or IV bolus therapy with longer acting agents
final recomendations
Final Recomendations
  • Monitoring:
  • Monitor patient every 4-8 hours by means of CIWA-Ar until score has been<8-10 for 24 hours; use additional assessments as needed
  • -For patients with CIWA-Ar<8-10, supportive non-pharmacologic monitoring is acceptable
  • -Patients with CIWA-Ar scores 8-15 benefit from medication thus reducing risk of complications
  • -CIWA-Ar scores 15 have a significant risk of major complications if left untreated
final recomendations68
Final Recomendations
  • Symptom Triggered Regimens: 
  • Administer one of the following every hour when the CIWA-Ar 8-10:
  • Librium 50-100 mg
  • Diazepam 10-20 mg
  • Lorazepam 2-4 mg
  • Repeat CIWA-Ar 1 hour after every dose to assess need for further medication
final recommendations
Final Recommendations
  • Fixed Schedule Regimens: 
  • If necessary to give medication on a fixed schedule then administer one of the following: 
  • Librium 50 mg every 6 hours for 4 doses then 25 mg every 6 hours for 8 doses
  • Diazepam 10 mg every 6 hours for 4 doses then 5 mg every 6 hours four 8 doses
  • Lorazepam 2 mg every 6 hours for 4 doses then 1 mg every 6 hours for 8 doses
  • Provide additional medication as needed CIWA-Ar8-10 with above
conclusion
Conclusion
  • 1.      The nursing and medical staff in our institution be educated in the use of the CIWA-Ar scale for scoring the severity of alcohol withdrawal, as well as the use of guideline based medication administration.
  • 2.      The CIWA-Ar be employed to assess all patients who are suspected to be experiencing alcohol withdrawal, with special attention paid to those who have severe co-morbidities such as severe hypoxia, septicemia, shock, or femur fractures.
conclusion71
Conclusion
  • 3. The guide lines for alcohol withdrawal treatment, as put forth by the American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal be put in effect. Since symptom-triggered therapy is shown to be as effective as fixed dosing, appropriate patients receive this mode of medication administration.
  • 4. Longer acting benzodiazepines, such as Librium be preferred in oral or bolus administration over the shorter acting agents when appropriate.    
conclusion72
Conclusion
  • Development of a ETOH withdrawal protocol
  • initiated upon arrival of the patient
  • protocol after being initiated by the managing physician can be carried out by the nursing staff until the alcohol withdrawal episode has subsided, as evidenced by the patient’s CIWA-Ar scores
slide73
Special Thanks:

Dr. Peter Lichstein

Dr. Melissa Zorn

Extra-Special Thanks:

Kristy, Alli, Caroline, and Winn

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