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Martin T, Rebo KA, Stettler GR, Martin RS, Shilling EH, Hoth JJ, Nunn AM, McCullough MA, Miller PR. Reply to letter to the editor: Eliminating the benzos: A benzodiazepine-sparing approach to preventing and treating alcohol withdrawal syndrome. J Trauma Acute Care Surg 2024; 96:e43-e44. [PMID: 38369703 DOI: 10.1097/ta.0000000000004286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
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Wang M, Falank C, Simboli V, Ontengco JB, Spurling B, Rappold J, Chung B, Smith KE. "Should We Phenobarb-it-All?" A Phenobarbital-Based Protocol for Non-Intensive Care Unit Trauma Patients at High Risk of or Experiencing Alcohol Withdrawal. Am Surg 2024:31348241244639. [PMID: 38574377 DOI: 10.1177/00031348241244639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
BACKGROUND Alcohol use is frequent in trauma patients and alcohol withdrawal syndrome (AWS) is associated with significant morbidity. Benzodiazepines are commonly used for AWS, but may cause neurologic and respiratory adverse events (AEs). The objective was to evaluate the effectiveness and safety of a phenobarbital-based protocol for the treatment of AWS in non-intensive care unit (ICU) trauma patients. METHODS Adult non-ICU trauma patients at high risk of or experiencing AWS PRE and POST implementation of a phenobarbital-based protocol were included. Outcomes were AWS-related complications (AWS-RC), benzodiazepine use, adjunctive medication use, hospital length of stay (HLOS), and medication-related AEs. Subgroup analyses were performed on patients with traumatic brain injury (TBI), rib fractures, and at high risk of severe AWS. RESULTS Overall, 110 patients were included (51 PRE, 59 POST). AWS-RC developed in 17 PRE patients compared to 10 POST patients (33% vs 17%; P = .05). PRE patients were more likely to receive benzodiazepines (88% vs 42%, P < .0001) and higher total dose (11 vs 4 mg lorazepam equivalent; P = .001). No difference noted in HLOS (8 vs 8 days, P = .27), adjunctive medication use (49% vs 54%, P = .60), or AEs (57% vs 39%, P = .06). There was no difference in AWS-RC in the TBI subgroup (P = .19), less AEs in the rib fracture POST subgroup (P = .04), and less AWS-RC in the high risk of severe AWS POST subgroup (P = .03). DISCUSSION A phenobarbital-based protocol in trauma patients is effective in preventing AWS-RC and decreasing benzodiazepine use without increasing AEs.
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Affiliation(s)
- Michelle Wang
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Carolyne Falank
- Department of Surgery, Maine Medical Center, Portland, ME, USA
| | - Vincent Simboli
- Department of Pharmacy, Maine Medical Center, Portland, ME, USA
| | | | - Brandi Spurling
- Department of Surgery, Maine Medical Center, Portland, ME, USA
| | - Joseph Rappold
- Department of Surgery, Maine Medical Center, Portland, ME, USA
| | - Bruce Chung
- Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Kathryn E Smith
- Department of Pharmacy, Maine Medical Center, Portland, ME, USA
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McCullough MA, Miller PR, Martin T, Rebo KA, Stettler GR, Martin RS, Cantley M, Shilling EH, Hoth JJ, Nunn AM. Eliminating the benzos: A benzodiazepine-sparing approach to preventing and treating alcohol withdrawal syndrome. J Trauma Acute Care Surg 2024; 96:394-399. [PMID: 37934662 DOI: 10.1097/ta.0000000000004188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
BACKGROUND Alcohol withdrawal syndrome (AWS) represents significant cost to the hospitalized trauma population from a clinical and financial perspective. Historically, AWS has been managed with benzodiazepines. Despite their efficacy, benzodiazepines carry a heavy adverse effect profile. Recently, benzodiazepine-sparing protocols for the prophylaxis and treatment of AWS have been used in medical patient populations. Most existing benzodiazepine-sparing protocols use phenobarbital, while ours primarily uses gabapentin and clonidine, and no such protocol has been developed and examined for safety and efficacy specifically within a trauma population. METHODS In December of 2019, we implemented our benzodiazepine-sparing protocol for trauma patients identified at risk for alcohol withdrawal on admission. Trauma patients at risk for AWS admitted to an academic Level 1 trauma center before (conventional) and after (benzodiazepine-sparing [BS]) protocol implementation were compared. Outcomes examined include morphine milligram equivalent dosing rates and lorazepam equivalent dosing rates as well as the Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) scores, hospital length of stay, intensive care unit length of stay, and ventilator days. RESULTS A total of 387 conventional and 134 benzodiazepine sparing patients were compared. Injury Severity Score (13 vs. 16, p = 0.10) and admission alcohol levels (99 vs. 149, p = 0.06) were similar. Patients in the BS pathway had a lower maximum daily CIWA-Ar (2.7 vs. 1.5, p = 0.04). While mean morphine milligram equivalent per day was not different between groups (31.5 vs. 33.6, p = 0.49), mean lorazepam equivalents per day was significantly lower in the BS group (1.1 vs. 0.2, p < 0.01). Length of stay and vent days were not different between the groups. CONCLUSION Implementation of a benzodiazepine-sparing pathway that uses primarily clonidine and gabapentin to prevent and treat alcohol withdrawal syndrome in trauma patients is safe, reduces the daily maximum CIWA-Ar, and significantly decreases the need for benzodiazepines. Future studies will focus on outcomes affected by avoiding AWS and benzodiazepines in the trauma population. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Mary Alyce McCullough
- From the Department of Surgery (M.A.M., P.R.M., T.M., G.R.S., R.S.M., E.H.S., J.J.H., A.M.N.), and Department of Acute Care Pharmacy (K.A.R.), Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, NC; and Department of Clinical Pharmacy (M.C.), Virginia Commonwealth University Health, Richmond, VA
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Evans SL, Olney WJ, Bernard AC, Gesin G. Optimal strategies for assessing and managing pain, agitation, and delirium in the critically ill surgical patient: What you need to know. J Trauma Acute Care Surg 2024; 96:166-177. [PMID: 37822025 DOI: 10.1097/ta.0000000000004154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
ABSTRACT Pain, agitation, and delirium (PAD) are primary drivers of outcome in the ICU, and expertise in managing these entities successfully is crucial to the intensivist's toolbox. In addition, there are unique aspects of surgical patients that impact assessment and management of PAD. In this review, we address the continuous spectrum of assessment, and management of critically ill surgical patients, with a focus on limiting PAD, particularly incorporating mobility as an anchor to ICU liberation. Finally, we touch on the impact of PAD in specific populations, including opioid use disorder, traumatic brain injury, pregnancy, obesity, alcohol withdrawal, and geriatric patients. The goal of the review is to provide rapid access to information regarding PAD and tools to assess and manage these important elements of critical care of surgical patients.
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Affiliation(s)
- Susan L Evans
- From the Department of Surgery (S.L.E.), Carolinas Medical Center, Atrium Health, Charlotte, North Carolina; Department of Pharmacy (W.J.O.), Acute Care Surgery, UK HealthCare, Lexington, Kentucky; Department of Surgery (A.C.B.), University of Kentucky, Lexington, Kentucky; and Division of Pharmacy (G.G.), Atrium Health, Charlotte, North Carolina
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Bolds M. Substance Use Disorder in Critical Care. Crit Care Nurs Clin North Am 2023; 35:469-479. [PMID: 37838419 DOI: 10.1016/j.cnc.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Substance use disorders are increasing in the growing older adult population in the U.S. and abroad. Most interventions fail to account for the unique physical and psychosocial risk factors associated with substance use disorder. The older adult makes up a large portion of ICU admits and it is imperative to identify appropriate methods of prevention and treatment in this patient population. Important components of substance use disorder assessment and treatment in the older ICU patient were identified from the literature. Increased morbidity related to age-related conditions, pharmacologic concerns, withdrawals, and stigma were identified as essential items to consider when caring for the older ICU patient with substance use disorder.
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Affiliation(s)
- Monchielle Bolds
- Louisiana State University Health Sciences Center New Orleans, 1900 Gravier Street Office 327, New Orleans, LA 70112, USA.
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Steel TL, Bhatraju EP, Hills-Dunlap K. Critical care for patients with substance use disorders. Curr Opin Crit Care 2023; 29:484-492. [PMID: 37641506 DOI: 10.1097/mcc.0000000000001080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
PURPOSE OF REVIEW To examine the impact of substance use disorders (SUDs) on critical illness and the role of critical care providers in treating SUDs. We discuss emerging evidence supporting hospital-based addiction treatment and highlight the clinical and research innovations needed to elevate the standards of care for patients with SUDs in the intensive care unit (ICU) amidst staggering individual and public health consequences. RECENT FINDINGS Despite the rapid increase of SUDs in recent years, with growing implications for critical care, dedicated studies focused on ICU patients with SUDs remain scant. Available data demonstrate SUDs are major risk factors for the development and severity of critical illness and are associated with poor outcomes. ICU patients with SUDs experience mutually reinforcing effects of substance withdrawal and pain, which amplify risks and consequences of delirium, and complicate management of comorbid conditions. Hospital-based addiction treatment can dramatically improve the health outcomes of hospitalized patients with SUDs and should begin in the ICU. SUMMARY SUDs have a significant impact on critical illness and post-ICU outcomes. High-quality cohort and treatment studies designed specifically for ICU patients with SUDs are needed to define best practices and improve health outcomes in this vulnerable population.
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Affiliation(s)
- Tessa L Steel
- Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine
| | - Elenore P Bhatraju
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Kelsey Hills-Dunlap
- University of Colorado Anschutz Medical Campus, Division of Pulmonary Sciences & Critical Care, Department of Medicine, University of Colorado, Aurora, Colorado, USA
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Mohan G, Bhide P, Abu-Shanab A, Ghose M, Rajamohan A, Muhammad T, Khan AA, Khan M, Khalid F, Padappayil RP, Du D. Predictors of Escalation to Intensive Care Unit Level of Care Among Admissions for Alcohol Withdrawal. J Community Hosp Intern Med Perspect 2023; 13:8-14. [PMID: 37868680 PMCID: PMC10589036 DOI: 10.55729/2000-9666.1241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 06/16/2023] [Accepted: 07/05/2023] [Indexed: 10/24/2023] Open
Abstract
According to the 2019 National Survey on Drug Use and Health, 14.5 million people ages 12 and older had alcohol abuse disorder. Alcohol withdrawal syndrome (AWS) can be defined as a collection of physical symptoms experienced due to abrupt cessation of alcohol after long-term dependence. In instances where regular inpatient management fails to control AWS symptoms, patients are shifted to intensive care units (ICUs) for closer monitoring and prevention of life-threatening complications like withdrawal seizures and delirium tremens (DTs), labeled as severe alcohol withdrawal syndrome (SAWS). Although this represents a significant healthcare burden, minimal studies have been conducted to determine objective predictors. In this study, we aim to determine the effect of patient demographics, socio-economic status, biochemical parameters, and clinical factors on the need for escalation to ICU level of care among admissions for AWS. Our study showed that factors such as a history of DTs or alcohol-related seizures, the initial protocol of management, degree of reported alcohol usage, activation of rapid response teams, mean corpuscular value, alcohol level on admission, highest Clinical Institute Withdrawal Assessment Alcohol Revised (CIWA-Ar) scored during the hospital stay, and the total amount of sedatives used were significantly associated with escalation to ICU level of care. Clinicians must use these objective parameters to identify high-risk patients and intervene early. We encourage further studies to establish a scoring algorithm incorporating biochemical parameters to tailor management algorithms that might better suit high-risk patients.
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Affiliation(s)
- Gaurav Mohan
- Department of Internal Medicine, Rutgers-Monmouth Medical Center, Long Branch, NJ,
USA
| | - Poorva Bhide
- Department of Internal Medicine, Rutgers-Monmouth Medical Center, Long Branch, NJ,
USA
| | - Amer Abu-Shanab
- Office of Scientific Affairs and Research, King Hussein Cancer Center, Amman,
Jordan
| | - Medha Ghose
- Department of Internal Medicine, Rutgers-Monmouth Medical Center, Long Branch, NJ,
USA
| | - Adhithya Rajamohan
- Department of Internal Medicine, Rutgers-Monmouth Medical Center, Long Branch, NJ,
USA
| | - Tayyeb Muhammad
- Department of Internal Medicine, Rutgers-Monmouth Medical Center, Long Branch, NJ,
USA
| | - Anosh A. Khan
- Department of Internal Medicine, Rutgers-Monmouth Medical Center, Long Branch, NJ,
USA
| | - Mahrukh Khan
- Department of Internal Medicine, Rutgers-Monmouth Medical Center, Long Branch, NJ,
USA
| | - Farhan Khalid
- Department of Internal Medicine, Rutgers-Monmouth Medical Center, Long Branch, NJ,
USA
| | - Rana P. Padappayil
- Department of Internal Medicine, Rutgers-Monmouth Medical Center, Long Branch, NJ,
USA
| | - Doantrang Du
- Department of Internal Medicine, Rutgers-Monmouth Medical Center, Long Branch, NJ,
USA
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