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Alcohol Withdrawal: Assessment and Treatment in the Acute Care Setting

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Title: Alcohol Withdrawal: Assessment and Treatment in the Acute Care Setting


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 51

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

11
Alcohol Withdrawal Syndrome
  • Symptoms
  • Anxiety
  • Insomnia
  • Tremulousness
  • Headache
  • Nausea
  • Signs
  • Tremor
  • Diaphoresis
  • Agitation
  • Tachycardia
  • Hypertension
  • Low grade fever lt38.5

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

13
Timing of ETOH Withdrawal
  • 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

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 DTs
  • Acute concurrent Medical Illness
  • gt2 days since last drink
  • History of seizure of previous DTs
  • Heavier and longer drinking history
  • Agegt 60 increase risk for DTs 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 DTs
  • 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 DTs
  • All BZD are equally efficacious

23
Fixed Dose vs. Symptom triggered
  • Fixed dose with Librium q 6 plus q1 if CIWA gt8
  • Symptom triggered Librium q1 if CIWAgt8
  • 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 DTs 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 gt8
  • Advantage is fewer benzos given and shorter
    course
  • Disadvantage may be progression to DTs 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
  • CIWAgt25 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- dont just treat a number

29
CIWA-Ar
  • 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

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 gt8
  • 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 lt10, 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 Wernickes 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
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