Search

Objective: To determine if a novel symptom‐based alcohol withdrawal syndrome (AWS) protocol in a US Veterans cohort leads to significant clinical improvements in patient outcomes and safety. Background: Prior studies of AWS management, oftentimes using the revised version of the Clinical Institute Withdrawal Assessment for Alcohol (CIWA‐Ar) index, have demonstrated the effectiveness of symptom‐triggered therapy for AWS. The Minnesota Detoxification Scale (MINDS) is an alternative to the CIWA‐Ar index but remains unevaluated outside of the intensive care unit (ICU) setting. This study assesses outcomes in AWS management prior to and after the implementation of a novel MINDS‐based AWS protocol (SDAWP) utilizing a revised MINDS index (MINDS‐rev) in an inpatient medical ward setting. Methods: Retrospective cohort study including encounters prior to (n = 342) and after (n = 338) the implementation of the protocol. Pre‐ and post‐protocol encounters were selected by combinations of diagnostic codes and charting elements. Outcome measures of AWS management were obtained in both groups. The primary endpoint was median total benzodiazepine exposure. Secondary outcomes included median length of hospitalization, median duration of benzodiazepine administration, and the incidence of complications. Results: The median total benzodiazepine exposure in the post‐SDAWP group was significantly lower than the pre‐SDAWP group (21.2 vs. 12.0 mg, p < 0.0001) and for a significantly shorter median duration of time (4.0 vs. 3.0 days, p < 0.0001). There was no significant difference in the median length of stay (4.0 vs. 4.0 days, p = 0.50). The incidence of delirium tremens (21 vs. 7, p = 0.01) and need for transfer to a higher level of care (33 vs. 12, p = 0.002) was significantly lower in the post‐SDAWP group. Conclusion: The SDAWP has provided significant improvements in AWS management in our institution and may potentially serve as a template for wider use in other inpatient settings. [ABSTRACT FROM AUTHOR]

Study Objective: Gabapentin has been proved to be beneficial in promoting abstinence, decreasing alcohol cravings, and improving mood and sleep quality when given at higher doses; however, data are limited regarding the efficacy and safety of using high‐dose gabapentin as part of the treatment of alcohol withdrawal syndrome (AWS). The aim of this study was to evaluate the impact of high‐dose gabapentin on benzodiazepine requirements, alcohol withdrawal symptoms, and hospital length of stay in patients hospitalized with AWS. Design: Retrospective cohort study. Setting: Large academic medical center. Patients: All adults presenting to the emergency department between January 2015 and April 2018 with a diagnosis of severe AWS (Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised [CIWA‐Ar] score ≥ 15) and prescribed the institution's alcohol withdrawal agitated delirium protocol were eligible for inclusion in the study. Of these, 50 patients who received high‐dose gabapentin (≥ 1800 mg/day) in the first 48 hours of hospital admission (treatment group) were propensity score–matched to 50 patients who did not receive gabapentin (control group). Measurements and Main Results: Patients who received high‐dose gabapentin required a significantly lower overall amount of benzodiazepines (mean ± SD 109.5 ± 53.4 mg vs 88.5 ± 35.6 mg [lorazepam equivalents], p=0.023) and had a significantly lower mean CIWA‐Ar score (10.1 ± 4.7 vs 7.7 ± 3.9, p=0.010) and maximum CIWA‐Ar score (16.0 ± 7.0 vs 12.6 ± 6.1, p=0.016) on day 3 of hospitalization. The high‐dose gabapentin regimen was well tolerated, without an increased risk of oversedation, compared with the control group (Richmond Agitation‐Sedation Scale score < −1: 34% in the treatment group vs 20% in the control group, p=0.115). Patients receiving high‐dose gabapentin had a shorter length of hospital stay (7.4 ± 4.0 days vs 6.0 ± 2.6 days, p=0.034) and increased likelihood of being discharged home (66% vs 88%, p=0.009) compared with the control group. Conclusion: Early initiation of high‐dose gabapentin was associated with a significant reduction in benzodiazepine exposure, faster stabilization of alcohol withdrawal–related symptoms, and shorter hospital length of stay. Future studies evaluating gabapentin's effect on long‐term safety and hospital readmission are warranted. [ABSTRACT FROM AUTHOR]

Approximately 16-31% of patients in the intensive care unit ( ICU) have an alcohol use disorder and are at risk for developing alcohol withdrawal syndrome ( AWS). Patients admitted to the ICU with AWS have an increased hospital and ICU length of stay, longer duration of mechanical ventilation, higher costs, and increased mortality compared with those admitted without an alcohol-related disorder. Despite the high prevalence of AWS among ICU patients, no guidelines for the recognition or management of AWS or delirium tremens in the critically ill currently exist, leading to tremendous variability in clinical practice. Goals of care should include immediate management of dehydration, nutritional deficits, and electrolyte derangements; relief of withdrawal symptoms; prevention of progression of symptoms; and treatment of comorbid illnesses. Symptom-triggered treatment of AWS with γ-aminobutyric acid receptor agonists is the cornerstone of therapy. Benzodiazepines (BZDs) are most studied and are often the preferred first-line agents due to their efficacy and safety profile. However, controversy still exists as to who should receive treatment, how to administer BZDs, and which BZD to use. Although most patients with AWS respond to usual doses of BZDs, ICU clinicians are challenged with managing BZD-resistant patients. Recent literature has shown that using an early multimodal approach to managing BZD-resistant patients appears beneficial in rapidly improving symptoms. This review highlights the results of recent promising studies published between 2011 and 2015 evaluating adjunctive therapies for BZD-resistant alcohol withdrawal such as antiepileptics, baclofen, dexmedetomidine, ethanol, ketamine, phenobarbital, propofol, and ketamine. We provide guidance on the places in therapy for select agents for management of critically ill patients in the presence of AWS. [ABSTRACT FROM AUTHOR]

The authors evaluated all available evidence on the use of propofol as an adjuvant for the treatment of resistant alcohol withdrawal syndrome ( AWS) in comparison to other therapies. A comprehensive PubMed search (1966-December 2015) was conducted using the search terms propofol, alcohol withdrawal, and drug therapy. Articles were cross-referenced for other citations. Clinical studies, case series, and case reports published in the English language assessing the use of propofol in adult patients for treatment of AWS were reviewed for inclusion. Propofol is a sedative-hypnotic that exerts its actions through agonism of GABAA receptors at a different binding site than benzodiazepines and reduces glutamatergic activity through N-methyl- d-aspartase ( NMDA) receptor blockade. Dosages from 5 to 100 μg/kg/minute reduced AWS symptoms with frequent development of hypotension and requirement for mechanical ventilation. Patients on propofol often experienced longer durations of mechanical ventilation and length of stay, which may be attributed to more-resistant cases of AWS. When propofol was compared with dexmedetomidine as adjuncts in AWS, both agents showed similar benzodiazepine- and haloperidol-sparing effects. Dexmedetomidine was associated with more numerical rates of bradycardia, while propofol was associated with more numerical instances of hypotension. Dexmedetomidine was used more frequently in nonintubated patients. The available data assessing the utility of propofol for AWS exhibited significant heterogeneity. Propofol may be useful in a specific population of patients with AWS, limited to those who are not clinically responding to first-line therapy with benzodiazepines. Specifically, propofol should be considered in patients who are refractory to or not candidates for other adjuvant therapies, patients already requiring mechanical ventilation, or those with seizure activity or refractory delirium tremens. In severe, refractory AWS, adjuvant therapy with propofol may be considered but requires further research to recommend its use either preferentially or as monotherapy. [ABSTRACT FROM AUTHOR]

Study Objective To compare efficacy and safety outcomes in nonintubated patients with severe alcohol withdrawal syndrome ( AWS) who required a continuous infusion of a benzodiazepine or dexmedetomidine in addition to standard medical therapy for AWS. Design Retrospective cohort study. Setting Two hospitals within the same network that used different treatment strategies for AWS. Patients A total of 61 nonintubated adults who received a continuous infusion of either a benzodiazepine (BZD) (lorazepam or midazolam; 33 patients) or dexmedetomidine (DEX) (28 patients) for severe AWS between April 1, 2011, and October 31, 2012, as well as standard medical therapy for AWS. Measurements and Main Results The primary outcome was a composite end point including rates of respiratory distress requiring endotracheal intubation or occurrence of alcohol withdrawal seizures. No significant differences in the composite end point were noted between the BZD and DEX groups (9.1% and 7.1%, respectively, p>0.99) or its individual components of respiratory distress (9.1% and 7.1%, respectively, p>0.99) or alcohol withdrawal seizures (0% and 3.6%, respectively, p=0.46). The DEX group received a lower median total dose of lorazepam equivalents after initiation of the study drug (median [interquartile range] 105 [60-199.5] mg in the BZD group vs 3.5 [0-12] mg in the DEX group), but this did not translate into a reduced requirement for endotracheal intubation or decreased length of stay. DEX was associated with more adverse drug events including hypotension and bradycardia. Of concern, DEX may impair the ability to assess symptoms appropriately and administer BZDs in a symptom-triggered fashion. Although the total cost of hospitalization was similar between groups, DEX was associated with a higher study drug cost per patient. Conclusion DEX demonstrated a BZD-sparing effect in the treatment of AWS; however, this surrogate end point should be interpreted with caution. Although this study cannot disprove the possibility of a protective effect of DEX in preventing the requirement for endotracheal intubation in patients with AWS, an increased rate of adverse drug events and increased study drug costs were observed. If DEX is used in clinical practice, it should only be used as adjunctive therapy with BZDs that have a proven benefit in AWS. [ABSTRACT FROM AUTHOR]

Alcohol withdrawal syndrome (AWS) is a major cause of morbidity and mortality in the acute care setting. We describe a 28-year-old man who was brought to the emergency department with a new-onset seizure and clinical signs and symptoms consistent with advanced delirium tremens. A symptom-triggered intensive care unit treatment protocol consisting of a benzodiazepine and antiadrenergic agents was started. The manifestations of delirium tremens persisted with titration of a lorazepam infusion in excess of 40 mg/hour. Intravenous phenobarbital was administered in escalating doses of 65 mg followed by 130 mg 15 minutes later, resulting in control of severe agitation in the face of benzodiazepine resistance. Subsequent scheduled phenobarbital administration allowed for a successful and orderly weaning of the continuous benzodiazepine infusion and adjunctive agents used in AWS management. With continued clearing of consciousness, the patient was successfully discharged. The administration of phenobarbital in this patient allowed improved symptom control, minimized the potential for propylene glycol toxicity, was not associated with respiratory depression, and facilitated successful weaning of benzodiazepines. Barbiturates offer a mechanism of action that is different from that of benzodiazepines. Although the cornerstone of treatment for AWS remains benzodiazepines, this case highlights the potential utility of phenobarbital in patients with resistant AWS. [ABSTRACT FROM AUTHOR]

Study Objective. To compare outcomes of treating alcohol withdrawal delirium (AWD) with a symptom-driven benzodiazepine protocol versus nonprotocol benzodiazepine infusions in the intensive care unit (ICU). Design. Retrospective observational study of a quality improvement project. Setting. Medical intensive care unit at a Veterans Affairs medical center. Patients. Thirty-six patients who had 40 ICU admissions for AWD between January 1, 1994, and May 31, 2003. Sixteen episodes (15 patients [historical controls]) occurred before implementation of the symptomdriven protocol in 1998, and 24 episodes (21 patients) occurred after implementation. Measurements and Main Results. Outcomes evaluated were time to reach symptom control, total dose of benzodiazepine, amount of time receiving continuous benzodiazepine infusion, length of ICU and hospital stay, polypharmacy (use of multiple benzodiazepines), and complications of treatment. The historical control group was treated according to physician preference, which consisted of continuous-infusion midazolam without a protocol. The symptom-driven protocol used lorazepam administered initially as intermittent intravenous doses, progressing to a continuous intravenous infusion according to a locally developed symptom scale. The mean ± SD values for the outcomes in the historical control group versus the protocol group were as follows: time to control symptoms 19.4 ± 9.7 versus 7.7 ± 4.9 hours (p=0.002), cumulative benzodiazepine dose in lorazepam equivalents 1677 ± 937 versus 1044 ± 534 mg (p=0.014), time receiving benzodiazepine continuous infusion 122.1 ± 64.4 versus 52.0 ± 35.1 hours (p=0.001), length Of stay in the ICU 7.7 ± 6.3 versus 5.6 ± 1.7 days (p=0.21), and length of hospital stay 15.3 ± 8.9 versus 11.2 ± 3.4 days (p=0.43). Conclusions. Use of a symptom-driven protocol was associated with significantly decreased time to symptom control, amount of sedative required, and time spent receiving benzodiazepine infusion compared with historical controls. The use of the protocol is effective but requires close monitoring to ensure protocol compliance and to avoid potential propylene glycol toxicity. [ABSTRACT FROM AUTHOR]

Study Objective. To standardize treatment of alcohol withdrawal syndrome (AWS) in internal medicine patients using an adult AWS practice guideline with a symptom-triggered management approach. Design. Prospective interventional (pilot group) and retrospective (control group). Setting. University teaching hospital. Patients. Thirty-two internal medicine patients identified as being at risk for AWS and treated according to the AWS practice guideline who were compared with 49 internal medicine patients managed with nonstandardized approaches. Intervention. Patients in the pilot group were assessed using the AWS type indicator. They received lorazepam, clonidine, or haloperidol, based on AWS type indicator assessment and adult AWS practice guideline criteria. Measurements and Main Results. Data collected and analyzed were drugs administered to control AWS symptoms, use of sitters and physical restraints, length of hospital stay, and discharge from hospital receiving tapered drug therapy. Pilot patients received 46.6% less benzodiazepine (p=0.001), 20% more clonidine (p=0.01), and 18.2% more haloperidol (p=0.002) than control patients. No drug therapy was required in 19% of pilot patients compared with 2% of controls (p=0.01). Significantly more control (71.4%) than pilot patients (18.8%) were discharged with tapered benzodiazepine therapy (p≤0.01). No significant differences were found between groups for sitters, restraints, or hospital length of stay. Conclusion. This pilot project suggests that internal medicine patients at risk for AWS can be managed with a standardized, symptom-triggered approach using decreased amounts of benzodiazepine in combination with adjunctive agents to treat adrenergic hyperactivity and delirium. Further data are necessary to determine the impact of the practice guideline on patient outcome measurements. [ABSTRACT FROM AUTHOR]

Critically ill patients with alcoholism are at greater risk of morbidity and mortality from alcohol withdrawal syndrome than are patients without alcoholism. Benzodiazepines are considered the drugs of choice for the prevention and treatment of alcohol withdrawal syndrome, but some studies have suggested that intravenous ethanol may be as effective as those agents, as well as being less sedating. We evaluated the evidence regarding the use of intravenous ethanol for the prevention and treatment of alcohol withdrawal syndrome in critically ill patients in order to determine its role in this patient population. Because of the paucity of well-designed clinical trials, and because of intravenous ethanol's questionable efficacy, inconsistent pharmacokinetic profile, and relatively narrow therapeutic index, routine use of this drug is not recommended in critically ill patients who have alcohol withdrawal syndrome or are at risk for it. [ABSTRACT FROM AUTHOR]

Reports on a study which examined the impact of an alcohol withdrawal syndrome practice guideline on surgical patient outcomes. Symptoms of alcohol withdrawal syndrome; Implementation of the guideline; Results and discussion; Conclusions.

Comments on the article "Impact of an Alcohol Withdrawal Syndrome Practice Guideline on Surgical Patient Outcomes." Views on the authors' utilization of a symptom-triggered regimen to manage alcohol withdrawal syndrome (AWS); Shortcoming of the authors' recommended guideline; Use of benzodiazepine in the pharmatherapeutic regimen of patients exhibiting symptoms of AWS.