Alcohol Withdrawal

True or false: alcohol withdrawal syndrome is a neurologic disorder

true

Define alcohol withdrawal syndrome

continuum of progressively worsening effects when alcohol use is reduced or d/c in a person who is alcohol dependent

What is the impact of AWS on healthcare?

increased length of stay, morbidity, and mortality

The presence of any alcohol use disorder in ICU patients with organ failure = _____x increased mortality rate

2

AWS is the ___th leading cause of death and disability globally

7

What is alcohol (in relation to the body)

CNS depressant

Define alcohol dependence

Constant presence of ethanol is required to preserve homeostasis; the body will upregulate certain receptors to maintain the normal state of arousal

Abrupt cessation or lower concentrations results in what?

overactivity of CNS

What is the major inhibitory NT in the brain?

GABA

What NT is one of the major excitatory amino acids?

glutamate

What does ethanol inhibit?

glutamate-induced excitation

What is the effect of chronic ethanol use on GABA?

• insensitivity at the GABA receptor

• More ethanol is required to maintain inhibitory tone (tolerance)

• Cessation leads to decreased inhibitory tone

What is the effect of chronic ethanol use on NMDA?

• upregulation of glutamate receptors to maintain the normal state of consciousness

• Withdrawal leads to hyperarousal

What is the diagnosis per DSM-V?

• cessation of heavy/prolonged alcohol use resulting, within a period of a few hours to several days, the development of 2 or more of the following:

  • Anxiety

  • hallucinations

  • N/V

  • seizures (tonic-clonic)

  • autonomic hyperactivity

  • insomnia

  • psychomotor agitation

  • tremor

How is alcohol withdrawal syndrome classified?

Timing and severity

When do delirium tremens tend to occur in withdrawal?

~3 days

What constitutes delirium tremens ?

• tachycardia

• HTN

• low-grade fever

• tremor

• diaphoresis

• delirium

• agitation

Early, uncomplicated withdrawal can begin as early as ____ hours after cessation of alcohol and may start before BAC reach zero

6

When does alcoholic hallucinosis usually occur?

12-24 hours

What kind of hallucinations occur in about 25% of alcohol withdrawal patients?

transient

When does alcoholic hallucinosis usually resolve

24-48 hours

True or false: patients do not have clear sensorium

false

Tx of tonic-clonic seizures

• benzos, phenobarbital, and propofol (in that order)

  • phenytoin is NOT effective

What is the most serious manifestations of alcohol withdrawal?

delirium tremens

When do delirium tremens tend to occur?

48-96 hours after cessation

How long can delirium tremens last?

1-5 days, sometimes longer

What distinguishes delirium tremens from alcoholic hallucinosis?

time of onset

How is delirium tremens defined?

• reduced level of consciousness with reduced ability to focus, sustain, or shift attention, delirium, confusion, or psychosis

• change in cognition NOT caused by pre-existing condition

What are some other clinical manifestations of delirium tremens?

• elevated cardiac indices, oxygen delivery, and oxygen consumption

• increased arterial pH due to hyperventilation, which leads to decreased cerebral blood flow

What are some risk factors for DT?

• hx of sustained drinking

• hx of alcohol withdrawal seizures

• hx of prior episode of DTs

• age >30 years

• presence of concurrent illness

• significant alcohol withdrawal symptoms despite elevated BAC

• longer period of time since last alcoholic drink (>2days)

What are some common fluid and electrolyte abnormalities seen in withdrawal?

• hypovolemia

• hypokalemia

• hypomagnesemia (leads to arrhythmias and seizures)

• hypophosphatemia (from malnutrition, cardiac failure and rhadbdo)

Thiamine prevents the development of or treats _________

Wernicke’s encephalopathy

What characterizes Wernicke’s encephalopathy?

mental confusion, ophthalmoplegia, gait ataxia

Thiamine is vitamin _____

B1

What is common in chronic alcohol use presumed from dietary deficiency of folic acid?

hyperhomocystinemia

What puts someone at a greater risk of mortality from DT?

• older age

• preexisting cardiopulmonary disease

• core body temp >40 degrees Celsius

• coexisting liver disease

This should NOT be used to diagnose alcohol withdrawal but used to treat the associated symptoms

CIWA-Ar

What is the limitation of the CIWA-Ar?

Can only be used in patients who are able to answer subjective Qs

Inpatient treatment in non-critical care areas may be limited by what 2 things?

1. medication location

2. frequency of medication administration and/or patient monitoring

What medications are used in the management aspect?

• benzos

• Oral med route effective for early or mild withdrawal

• symptom-triggered approach for most patients

What benzos are commonly used?

• chlordiazepoxide

• diazepam

• lorazepam (most common)

Which benzos are preferred in advanced cirrhosis or acute hepatitis due to shorter half-life and no active metabolites

lorazepam and oxazepam

Which benzos are PO only

• chlordiazepoxide

• oxazepam

Which benzos are long acting with active metabolite?

• chlordiazepoxide

• diazepam

What is the goal of therapy?

sedate patient, but breathing spontaneously with normal vital signs

What is the initial management of withdrawal?

rapid titration with a benzo to achieve sedation

What formulation is preferred for outpatient and inpatient settings in patients with mild to moderate symptoms

oral

ALL patients with seizures or DTs should receive what formulation of therapy?

IV

What administration should be avoided?

IM

What are some dosing strategies?

• symptom-triggered

• front-loading

• fixed dosing

What dosing strategy is preferred for most patients?

symptom-triggered

When would you use front-loading strategy?

for patients at higher risk for complications if severe withdrawal occurs

• Ex: older adult with significant CVD

When is fixed dosing typically used?

patients with severe or refractory withdrawal or prior history of severe withdrawal, seizures, and/or DTs

True or false: you can use phenobarbital as monotherapy for alcohol withdrawal

false

What is the typical dose for phenobarbital

130mg-260mg IV q 15-20mins until symptoms controlled then 130mg-260mg per day in 2-3 divided doses

• do not exceed 15mg/kg in 24 hours

• Monitor CV or respiratory failure

What sedative-hypnotic is used in conjunction with BZD and can only be used in intubated patients on mechanical ventilation?

propofol

Propofol is given as an IV continuous infusion at _______ mcg/kg/min

5-50

Which medication causes a global reduction in adrenergic tone, reducing BP and HR

dexmedetomidine

Dexmedetomidine must be used in combo with ______ since there is no activity at GABA receptor

BZD

Dosing of dexmedeomidine

continuous IV infusion at 0.2-1.5 mcg/kg/hr

True or false: you can use dexmedetomidine in non-intubated patients and there is no effect on respiratory drive

true

Dexmedetomidine may mask what symptoms?

withdrawal

especially vital signs that may precede seizures

What are some antiepileptics used?

• carbamazepine

• valproic acid

• gabapentin

What medications should you avoid in alcohol withdrawal?

• ethanol

• antipsychotics

You should administer what type of fluids until euvolemia is achieved?

isotonic IV fluids

What makes up a banana bag?

• thiamine

• folate

• multivitamin