Treatment of Severe Alcohol Withdrawal

Impact of phenobarbital when used in combination with benzodiazepines for the treatment of alcohol withdrawal syndrome: A retrospective analysis

BACKGROUND AND OBJECTIVE

Alcohol withdrawal syndrome (AWS) is a serious complication of alcohol use disorder. Although benzodiazepines are the mainstay of treatment, some patients may be resistant to them, requiring rapidly escalating doses. Phenobarbital has emerged as an effective adjunct therapy in severe alcohol withdrawal, but studies have yielded inconsistent results and carry safety risks. The purpose of our study was to examine the effectiveness and the potential harm of phenobarbital in AWS.

METHODS

In this multi-center, retrospective cohort study, patients who were admitted for AWS and received phenobarbital with benzodiazepine were compared to patients who received benzodiazepine monotherapy. The primary outcome was time to AWS resolution. Other secondary and safety outcomes included length of stay (LOS), rate of mechanical ventilation, and incidence of aspiration pneumonia.

RESULTS

The phenobarbital group received significantly higher doses of benzodiazepines compared to the benzodiazepine monotherapy group (660 mg vs 340 mg, p < 0.0001). After adjustment, the use of phenobarbital was associated with significantly reduced time to AWS resolution (141.65 h vs 165.72 h, p < 0.0001). However, the use of phenobarbital was associated with the likelihood of mechanical ventilation (19.42 %vs. 0.96 %, p < 0.0001), aspiration pneumonia (22.33 % vs 5.77 %, p = 0.0006), and increased hospital LOS (8 days vs. 6 days, p = 0.0197). In the combination group, earlier phenobarbital initiation (within 24 h) was associated with significantly lower cumulative benzodiazepine dose (530 mg vs 887.50 mg, p = 0.002) and hospital LOS (6 days vs 10 days, p = 0.0017).

CONCLUSION AND RELEVANCE

In our study, patients who received phenobarbital in combination with benzodiazepines had a quicker resolution of AWS but also had a higher incidence of mechanical ventilation, prolonged hospital LOS, and an increased risk of aspiration pneumonia. For patients at high risk of severe alcohol withdrawal, earlier initiation of phenobarbital appeared to yield the most optimal benefit.

Alcohol and alcoholism associated neurological disorders: Current updates in a global perspective and recent recommendations

Alcohol use disorder (AUD) is a medical condition that impairs a person's ability to stop or manage their drinking in the face of negative social, occupational, or health consequences. AUD is defined by the National Institute on Alcohol Abuse and Alcoholism as a "severe problem". The central nervous system is the primary target of alcohol's adverse effects. It is crucial to identify various neurological disorders associated with AUD, including alcohol withdrawal syndrome, Wernicke-Korsakoff syndrome, Marchiafava-Bignami disease, dementia, and neuropathy. To gain a better understanding of the neurological environment of alcoholism and to shed light on the role of various neurotransmitters in the phenomenon of alcoholism. A comprehensive search of online databases, including PubMed, EMBASE, Web of Science, and Google Scholar, was conducted to identify relevant articles. Several neurotransmitters (dopamine, gamma-aminobutyric acid, serotonin, and glutamate) have been linked to alcoholism due to a brain imbalance. Alcoholism appears to be a complex genetic disorder, with variations in many genes influencing risk. Some of these genes have been identified, including two alcohol metabolism genes, alcohol dehydrogenase 1B gene and aldehyde dehydrogenase 2 gene, which have the most potent known effects on the risk of alcoholism. Neuronal degeneration and demyelination in people with AUD may be caused by neuronal damage, nutrient deficiencies, and blood brain barrier dysfunction; however, the underlying mechanism is unknown. This review will provide a detailed overview of the neurobiology of alcohol addiction, followed by recent studies published in the genetics of alcohol addiction, molecular mechanism and detailed information on the various acute and chronic neurological manifestations of alcoholism for the Future research.

Grouping motivational interviewing is only effective for younger patients with alcohol dependence in the rehabilitation stage

Alcohol dependence (AD) is a risk factor for death and disability. Relapse prevention for AD has been exclusively dominated by psychotherapy intervention for many years. Our study aimed to investigate the efficacy of group motivational interviewing (MI) on the psychological craving for alcohol and depressive symptoms in AD patients in the rehabilitation phase, as well as the impact of age. The participants included 108 individuals with AD in the rehabilitation phase. All participants were assigned to the MI intervention group or the control group and were treated for 6 weeks. The severity of psychological craving for alcohol was assessed by the Penn Alcohol Craving Scale (PACS), and psychological status was evaluated by the Hamilton Depression Rating Scale (HAMD). We found that group MI significantly reduced the psychological craving for alcohol in patients with AD in the rehabilitation phase (p < 0.05). In addition, when patients were divided into two groups according to their ages, we found that group MI interventions tended to be effective only in younger patients with AD, but not in older patients. Our findings provide further evidence that the efficacy of group MI interventions was influenced by the age of patients with AD in the rehabilitation stage.

Peri-operative identification and management of patients with unhealthy alcohol intake

INTRODUCTION

This consensus statement gives practical advice for the safe management of patients with harmful alcohol intake undergoing elective and emergency surgery. The wide spectrum of alcohol-related organ dysfunction observed in this cohort of patients may have a profound impact on care, and the additional effects of alcohol withdrawal may further exacerbate postoperative morbidity and mortality.

METHODS

A working party was assembled based on clinical and/or academic expertise in the area. Recommendations were formulated using a modified Delphi process. An initial list of recommendations was produced following targeted literature reviews for all relevant phases of patient care throughout the peri-operative pathway. These recommendations were distributed among the authors who rated each as 'include', 'exclude'; or 'revise'. Recommendations with ≥ 75% inclusion decision were included.

RESULTS

The working party produced a list of 10 key peri-operative management recommendations. These include recommendations on how to screen effectively for excessive alcohol usage in the surgical population. To achieve this, a validated point-of-care tool is used with additional weighting provided by considering surgical urgency. This is combined with the use of scoring systems to facilitate decisions regarding peri-operative care including postoperative location. This document also provides clear explanation of the physiological and pharmacological issues relating to alcohol excess, highlighting the direct effects of alcohol and its secondary effects on organ systems.

DISCUSSION

This consensus statement offers strategies and solutions to minimise the impact of harmful alcohol intake on the safe conduct of anaesthesia.

Alcohol Withdrawal

Audience

Emergency medicine residents and medical students on emergency medicine rotations.

Introduction

Alcohol use disorder (AUD) is common in the United States, with an estimated lifetime prevalence of 30%.1 The rate of use is higher among white males, Native Americans, and individuals of low socioeconomic status.1 Alcohol withdrawal symptoms manifest in 50% of individuals who misuse alcohol.1 While life-threatening sequelae of alcohol withdrawal are rare, the syndrome is a common reason for emergency department (ED) presentations. Alcohol withdrawal symptoms range from benign, cravings, nausea, anxiety and tremulousness, to life-threatening autonomic dysfunction, seizures, coma, and death.2 The pathophysiology of this clinical syndrome involves dysregulation of central nervous system (CNS) receptor function. Alcohol acts as a CNS depressant through activation of the CNS Gamma-aminobutyric acid (GABA) receptors. Chronic or heavy alcohol use results in downregulation of CNS inhibitory GABA receptors and upregulation of CNS excitatory N-methyl-D-aspartate (NMDA) receptors.2 Upon discontinuation of alcohol use, this imbalance results in CNS hyperexcitability, creating the clinical symptoms of alcohol withdrawal.2 Symptoms typically manifest within eight hours after alcohol cessation, reach their peak in one to three days, and can extend for up to two weeks.3 Mild symptoms include anxiety, tremors, diaphoresis, nausea and/or vomiting. Severe symptoms include hallucinations (typically 12-24 hours after last alcohol intake) in 2-8% of patients, seizures (12-48 hours after last intake) in up to 15% of patients, and delirium tremens.3 Delirium tremens is a potentially fatal encephalopathy in patients experiencing alcohol withdrawal and occurs in 3-5% of patients approximately 72 hours after last alcohol intake.3 Without recognition or prompt treatment, mortality from delirium tremens can be as high as 50%.4 Management of alcohol withdrawal requires prompt recognition and control of symptoms. Most often this is accomplished by administering benzodiazepines, though alternative medications such as barbiturates, ketamine, or propofol are also used. Severe withdrawal may progress to intubation and mechanical ventilation.5 Given the high prevalence of AUD in the United States and the potential for life-threatening withdrawal symptoms, ED practitioners must recognize the spectrum of this disease and be comfortable with managing an array of presentations.

Educational Objectives

At the end of this oral boards session, learners will: 1) demonstrate the ability to perform a detailed history and physical examination in a patient presenting with signs and symptoms of alcohol withdrawal, 2) investigate the broad differential diagnoses, including electrolyte abnormalities, trauma in the intoxicated patient, mild alcohol withdrawal, and delirium tremens, 3) list appropriate laboratory and imaging studies to include complete blood count (CBC), complete metabolic panel (CMP), magnesium level, computed tomography (CT) scan of the brain; 4) understand the management of hypoglycemia with concurrent administration of thiamine to prevent Wernicke's encephalopathy and subsequent Korsakoff syndrome, 5) appropriately treat acute alcohol withdrawal with intravenous (IV) hydration and benzodiazepines, phenobarbital, or alternative medications, and 6) understanding the need for the complex management of these patients, appropriately disposition the patient to the intensive care unit after consulting with critical care specialists.

Educational Methods

The case was written as an oral boards case to test learners in a simulated oral board format. In this manner, learners could be evaluated on their critical thinking skills one-on-one with an instructor, outside of the distractions of the emergency department. Oral board simulation can test multiple modalities, including data collection, data synthesization and pharmacologic treatment in order to assess residents' overall clinical care and competence. Learners were assessed both by the instructor with immediate feedback, as well as by using Google forms to tie critical actions to Emergency Medicine Milestones. Results were compiled and used during clinical competency evaluations.

Research Methods

Learners (n=40) and examiners were given the option to provide written feedback after the case was completed to assess for strengths and weaknesses of the oral boards case, and subsequent changes were made to improve the administration of the case.

Results

Residents and medical students rated this highly and found this to be an enjoyable, yet still challenging, way to stay current on their management skills of alcohol withdrawal. Learners rated the session 4.6 out of 5 using a five-point Likert scale (5 being excellent) after the session was completed (n=25).

Discussion

We found this oral board case to be an effective educational tool for reviewing alcohol use disorder among students and residents. Using an oral board case allows junior and senior residents to be tested quickly in a low-stakes environment. Learners and instructors both felt the content was appropriate, and using the completed forms in competency meetings improved the committee's ability to assess residents on specific milestones. Though we initially wrote this case requiring the examinee to have advance knowledge of the Clinical Institute Withdrawal Assessment Alcohol Scale Revised (CIWA-Ar), this was not deemed essential to emergency medicine residents or faculty, and it was removed. The current case formatting represents a more realistic case presentation and critical actions.

Topics

Alcohol withdrawal, electrolyte abnormalities, seizures, altered mental status.

A Diagnostic Dilemma: Persistent Fever in a Hospitalized Patient With Alcohol Use Disorder and Pneumonia

Hospitalized patients with alcohol use disorder (AUD) frequently pose diagnostic and therapeutic challenges due to the interplay of substance use, withdrawal, and coexisting medical conditions. This case presents a 49-year-old man with a history of chronic alcohol overuse and previous alcohol withdrawal seizures, admitted for a right middle lobe pneumonia. Initial management included empiric antibiotics, hydration, and nutritional supplementation. He was also placed on symptom-triggered benzodiazepine therapy, guided by the Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) protocol, to manage alcohol withdrawal. Despite the broad-spectrum antibiotic coverage, the patient continued to experience fever and tachycardia, raising concerns about an atypical infectious process versus the manifestation of severe alcohol withdrawal. Further consideration and evaluation ruled out antibiotic-resistant organisms, pneumonia-related complications, and alternative infections such as urinary tract infection, meningitis, and endocarditis. Blood cultures taken on admission remained persistently negative, and procalcitonin levels were significantly down-trending, indicating the resolution of a bacterial infectious etiology. By hospital day 3, the patient began exhibiting agitation, shakiness, and confusion, along with persistent spikes in temperature, heart rate, and blood pressure, raising strong suspicion for delirium tremens (DT). This necessitated escalating benzodiazepine dosage on the CIWA-Ar protocol. By hospital day 9, the patient's symptoms had largely resolved, and he was discharged with ongoing care for AUD and follow-up for a lung nodule incidentally identified on chest imaging. This case emphasizes the need for a systematic diagnostic approach to differentiate overlapping symptoms in AUD patients, particularly in the context of acute infections and withdrawal syndromes. Early recognition and aggressive management of DT are critical to prevent complications and improve outcomes in this high-risk population.

Is Phenobarbital an Effective Treatment for Alcohol Withdrawal Syndrome?

BACKGROUND

Alcohol use disorder is associated with a variety of complications, including alcohol withdrawal syndrome (AWS), which may occur in those who decrease or stop alcohol consumption suddenly. AWS is associated with a range of signs and symptoms, which are most commonly treated with GABAergic medications.

CLINICAL QUESTION

Is phenobarbital an effective treatment for AWS?

EVIDENCE REVIEW

Studies retrieved included two prospective, randomized, double-blind studies and three systematic reviews. These studies provided estimates of the effectiveness and safety of phenobarbital for treatment of AWS.

CONCLUSIONS

Based on the available literature, phenobarbital is reasonable to consider for treatment of AWS. Clinicians must consider the individual patient, clinical situation, and comorbidities when selecting a medication for treatment of AWS.

Clinical detoxification of bromazolam using diazepam: a case report

An increasing number of new psychoactive substances (NPS), such as designer benzodiazepines, are becoming available on the recreational drug market. These are new unregistered substances and thereby an attempt to evade legislation. Often there is very limited clinical information available regarding these NPS, which could result in undesirable clinical outcomes in the management of intoxications, dependencies and withdrawals following NPS use. In this case report we describe a 23-year-old woman, who was admitted to our residential addiction care facility for the detoxification of the designer benzodiazepine bromazolam. Her daily use of 6 mg bromazolam was converted to 20 mg diazepam. Although we expected a higher dose would have been needed, 20 mg was sufficient and was tapered without complications. This case report demonstrates the safe conversion of 6 mg of bromazolam to 20 mg of diazepam by combining the use of fixed-dose and symptom-triggered-dose regimens. More clinical data is necessary to formulate advisory management for the detoxification of bromazolam and other designer benzodiazepines.

SAEM GRACE: Phenobarbital for alcohol withdrawal management in the emergency department: A systematic review of direct evidence

OBJECTIVES

Alcohol withdrawal syndrome (AWS) is a commonly presenting condition in the emergency department (ED) and can have severe complications, including mortality. Benzodiazepines are first-line medications for treating AWS but may be unavailable or insufficient. This systematic review evaluates the direct evidence assessing the utility of phenobarbital for treating AWS in the ED.

METHODS

A systematic search was conducted and designed according to the patient-intervention-comparator-outcome (PICO) question: (P) adults (≥18 years old) presenting to the ED with alcohol withdrawal; (I) phenobarbital (including adjunctive); (C) benzodiazepines or no intervention; and (O) AWS complications, admission to a monitored setting, control of symptoms, adverse effects, and adjunctive medications. Two reviewers independently assessed articles for inclusion and conducted risk of bias assessments for included studies.

RESULTS

From 70 potentially relevant articles, seven studies met inclusion criteria: three retrospective cohort studies, two retrospective chart reviews, and two randomized controlled trials (RCTs), one examining phenobarbital monotherapy and one examining adjunctive phenobarbital. Across the retrospective cohort studies, treatment of AWS with phenobarbital resulted in lower odds of a subsequent ED visit. The retrospective chart reviews indicated that phenobarbital was associated with higher discharge rate compared to benzodiazepine-only treatments. For the two RCTs, phenobarbital did not differ significantly from benzodiazepine for most outcomes, although concomitant treatment with phenobarbital was associated with lower benzodiazepine use and intensive care unit admission. The heterogeneous designs and small number of studies prevented quantitative synthesis.

CONCLUSIONS

Relatively few studies provide direct evidence on the utility of phenobarbital for AWS in the ED, but the evidence that exists generally suggests that it is a reasonable and appropriate approach. Additional RCTs and other methodologically rigorous investigations are needed for more definitive direct evidence.

A Comparison of Injectable Diazepam and Lorazepam in the Goal-Directed Management of Severe Alcohol Withdrawal

BACKGROUND

Benzodiazepines are the gold standard for treatment of alcohol withdrawal, yet the selection of a preferred benzodiazepine is limited due to a lack of comparative studies.

OBJECTIVES

The primary objective of this study was to compare the efficacy and safety of injectable lorazepam (LZP) and diazepam (DZP) in the treatment of severe alcohol withdrawal syndrome (AWS).

METHODS

Retrospective cohort study of adult patients admitted to an intensive care unit with a primary diagnosis of AWS. Subjects who received at least 12 LZP equivalent units (LEU) of injectable DZP or LZP within 24 hours of initiation of the severe AWS protocol were included. The primary outcome was time with Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) scores at goal over the first 24 hours of treatment.

RESULTS

A total of 191 patients were included (DZP n = 89, LZP n = 102). Time with CIWA-Ar scores at goal during the first 24 hours was similar between groups (DZP 12 hours [interquartile range, IQR, = 9-15] vs LZP 14 hours [IQR = 10-17]), P = 0.06). At 24 hours, LEU requirement was similar (DZP 40 [IQR = 22-78] vs LZP 32 [IQR = 18-56], P = 0.05). Drug cost at 24 hours was higher in the DZP group ($204.6 [IQR = 112.53-398.97] vs $8 [IQR = 4.5-14], P < 0.01).

CONCLUSION AND RELEVANCE

DZP or LZP are equally efficacious for the treatment of severe AWS. LZP may be preferred due to cost but both medications can be used interchangeably based on availability.

Role of glycogen synthase kinase-3β in dependence and abuse liability of alcohol

BACKGROUND

Alcohol is a major abused drug worldwide that contributes substantially to health and social problems. These problems result from acute alcohol overuse as well as chronic use, leading to alcohol use disorder (AUD). A major goal of this field is to establish a treatment for alcohol abuse and dependence in patients with AUD. The central molecular mechanisms of acute alcohol actions have been extensively investigated in rodent models.

AIMS

One of the central mechanisms that may be involved is glycogen synthase kinase-3β (GSK-3β) activity, a key enzyme involved in glycogen metabolism but which has crucial roles in numerous cellular processes. Although the exact mechanisms leading from acute alcohol actions to these chronic changes in GSK-3β function are not yet clear, GSK-3β nonetheless constitutes a potential therapeutic target for AUD by reducing its function using GSK-3β inhibitors. This review is focused on the correlation between GSK-3β activity and the degree of alcohol consumption.

METHODS

Research articles regarding investigation of effect of GSK-3β on alcohol consumption in rodents were searched on PubMed, Embase, and Scopus databases using keywords "glycogen synthase kinase," "alcohol (or ethanol)," "intake (or consumption)," and evaluated by changes in ratios of pGSK-3βSer9/pGSK-3β.

RESULTS

In animal experiments, GSK-3β activity decreases in the brain under forced and voluntary alcohol consumption while GSK-3β activity increases under alcohol-seeking behavior.

CONCLUSIONS

Several pieces of evidence suggest that alterations in GSK-3β function are important mediators of chronic ethanol actions, including those related to alcohol dependence and the adverse effects of chronic ethanol exposure.

Molecular mechanisms of alcohol's effects on the human body: A review and update

Alcohol consumption has been linked to numerous negative health outcomes although it has some beneficial effects on moderate dosages, the most severe of which being alcohol-induced hepatitis. The number of people dying from this liver illness has been shown to climb steadily over time, and its prevalence has been increasing. Researchers have found that alcohol consumption primarily affects the brain, leading to a wide range of neurological and psychological diseases. High-alcohol-consumption addicts not only experienced seizures, but also ataxia, aggression, social anxiety, and variceal hemorrhage that ultimately resulted in death, ascites, and schizophrenia. Drugs treating this liver condition are limited and can cause serious side effects like depression. Serine-threonine kinases, cAMP protein kinases, protein kinase C, ERK, RACK 1, Homer 2, and more have all been observed to have their signaling pathways disrupted by alcohol, and alcohol has also been linked to epigenetic changes. In addition, alcohol consumption induces dysbiosis by changing the composition of the microbiome found in the gastrointestinal tract. Although more studies are needed, those that have been done suggest that probiotics aid in keeping the various microbiota concentrations stable. It has been argued that reducing one's alcohol intake may seem less harmful because excessive drinking is a lifestyle disorder.

Evaluation of phenobarbital dosing strategies for hospitalized patients with alcohol withdrawal syndrome

OBJECTIVE

Alcohol remains the fourth‑leading preventable cause of death in the U.S. The objective of this study was to compare the incidence of phenobarbital (PHB)-resistant withdrawal and determine risk factors for PHB-resistant alcohol withdrawal syndrome (AWS).

METHODS

This retrospective cohort study included adults admitted to an academic center with AWS who received PHB as part of an institution-specific treatment protocol. The primary outcome was incidence of AWS resistant to initial protocolized PHB load across two cohorts (standard-dose, 10 mg/kg vs. low-dose, 6 mg/kg).

RESULTS

Among 176 included patients, there was no difference in the incidence of PHB-resistant AWS based on initial PHB load [low-dose load, 21 (18.3%) vs. standard-dose load, 12 (19.7%), p = 0.82]. There were also no differences in observed PHB-related ADEs between the groups. Total benzodiazepine dose received (mg) in the 24 h prior to initial PHB load was the only risk factor significantly associated with AWS resistant to initial protocolized PHB load [adjusted OR 1.79 (95% CI 1.24, 2.60)]. PHB-resistant withdrawal occurred in 33 (18.8%) patients with a median cumulative PHB dose of approximately 20 mg/kg during hospitalization.

CONCLUSION(S)

There were no differences in the incidence of PHB-resistant AWS or PHB-related ADEs based on initial PHB loading dose.

GABAergic signaling in alcohol use disorder and withdrawal: pathological involvement and therapeutic potential

Alcohol is one of the most widely used substances. Alcohol use accounts for 5.1% of the global disease burden, contributes substantially to societal and economic costs, and leads to approximately 3 million global deaths yearly. Alcohol use disorder (AUD) includes various drinking behavior patterns that lead to short-term or long-lasting effects on health. Ethanol, the main psychoactive molecule acting in alcoholic beverages, directly impacts the GABAergic system, contributing to GABAergic dysregulations that vary depending on the intensity and duration of alcohol consumption. A small number of interventions have been developed that target the GABAergic system, but there are promising future therapeutic avenues to explore. This review provides an overview of the impact of alcohol on the GABAergic system, the current interventions available for AUD that target the GABAergic system, and the novel interventions being explored that in the future could be included among first-line therapies for the treatment of AUD.

Successful management of suspected propofol dependence with phenobarbital in an adult patient with COVID-19

PURPOSE

In critically ill patients, high sedation requirements for prolonged durations are often needed to achieve ventilator synchrony, a practice that was particularly common during the early stages of the coronavirus disease 2019 (COVID-19) pandemic. We report the successful use of phenobarbital to facilitate propofol weaning after prolonged medication exposure.

SUMMARY

A 64-year-old male with hypertension was admitted for the management of acute respiratory distress syndrome due to COVID-19 pneumonia. The patient received high doses of fentanyl and propofol with periods of concomitant midazolam and dexmedetomidine throughout his prolonged time on mechanical ventilation. Total days of exposure were 19 for fentanyl, 17 for propofol, 12 for midazolam, and 15 for dexmedetomidine. Upon improvement in lung function, attempts to wean the patient from propofol all failed due to symptoms such as tachypnea, tachycardia, and hypertension, with symptom resolution only upon return to the previous dose. Phenobarbital was trialed for possible propofol withdrawal syndrome, allowing for a dose reduction of 10 μg/kg/min within 2 hours of the first dose without any corresponding symptoms. The patient continued to receive intermittent doses of phenobarbital for another 36 hours until propofol was discontinued. He underwent tracheostomy shortly after weaning off all sedation and was discharged to rehab 34 days after his initial admission.

CONCLUSION

Information concerning propofol withdrawal syndrome in the literature is limited. Our experience demonstrates the successful use of phenobarbital to facilitate propofol weaning after prolonged exposure.

Risk factors for alcohol withdrawal-related hospital transfer in a correctional setting

INTRODUCTION

A major health concern among individuals with alcohol use disorder is alcohol withdrawal syndrome (AWS), where individuals with physical dependence on alcohol may experience withdrawal signs and symptoms upon stopping or reducing alcohol use. AWS has a range of severity, with the most severe cases referred to as complicated AWS, presenting as seizure or signs and symptoms indicative of delirium or new onset of hallucinations. In the general community, risk factors or predictors of complicated AWS among hospitalized patients have been described, but there is no literature that examines such risk factors in a correctional population. The Los Angeles County Jail (LACJ) is the nation's largest jail system and manages 10-15 new patients per day for AWS. Here we aim to identify the risk factors associated with alcohol withdrawal-related hospital transfers among incarcerated patients being managed for AWS in the LACJ.

METHODS

From January 1, 2019, to December 31, 2020, data were gathered about LACJ patients who required transfer to an acute care facility for alcohol withdrawal-related concerns while on the Clinical Institute Withdrawal Assessment for Alcohol revised (CIWA-Ar) protocol. Log regression analysis was performed to generate an odds ratio for acute care facility transfer for the following variables: race, sex assigned at birth, age, CIWA-Ar scores, highest systolic blood pressure (SBP), and highest heart rate (HR).

RESULTS

Out of 15,658 patients on CIWA-Ar protocol during this 2-year time frame, a total of 269 (1.7%) were transferred to an acute care facility for alcohol withdrawal-related concerns. Of those 269 patients, significant risk factors associated with withdrawal-related hospital transfer included: Other race (OR 2.9, 95% CI 1.5-5.5), male sex assigned at birth (OR 1.6, 95% CI 1.0-2.5), age ≥55 years (OR 2.3, 95% 1.1-4.9), CIWA-Ar score 9-14 (OR 4.1, 95% CI 3.1-5.3), CIWA-Ar score ≥15 (OR 21.0, 95% CI 12.0-36.6), highest SBP ≥150 mmHg (OR 2.3, 95% CI 1.8-3.0), highest HR ≥ 110 bpm (OR 2.8, 95% CI 2.2-3.8).

CONCLUSION

Among patients studied, the higher CIWA-Ar score was the most significant risk factor associated with alcohol withdrawal-related hospital transfer. Other significant risk factors identified are race other than Hispanic, white, and African American; male sex assigned at birth; age ≥55 years; highest SBP ≥150 mmHg; and highest HR ≥ 110 bpm.

Symptoms-triggered approach versus fixed-scheduled approach of benzodiazepines for management of alcohol withdrawal syndrome: Non-randomized controlled trial

BACKGROUND

Alcohol withdrawal syndrome, if untreated, can lead to potentially life-threatening complications. Benzodiazepines are the drugs of choice for the treatment of alcohol withdrawal syndrome. We aimed to compare the symptoms-triggered approach and fixed-dose approach of benzodiazepine administration for treatment of alcohol withdrawal syndrome in regard to the health care utilization measured by the total dose of benzodiazepines, length of hospital stays, and 90-day readmissions rate.

METHODS

A single-center prospective non-randomized controlled trial included all patients diagnosed with alcohol withdrawal syndrome. The group of patients admitted between October 1, 2019, and September 30, 2020, were treated with the fixed-scheduled approach (n = 150), while all patients admitted between November 1, 2020, to October 31, 2021, were treated with the symptoms-trigger approach (n = 50).

RESULTS

The fixed-dose approach group showed a significant higher 90-day readmissions rate (HR: 2.61; 95% CI = 1.18, 6.84; p = 0.01). Kaplan-Meier survival analysis showed a significantly shorter duration to the first readmission in the fixed-scheduled approach group (HR: 2.3; 95% CI = 5.6, 1.16; p = 0.02). The symptoms-triggered approach group required a significantly lower dose of diazepam (40 mg vs. 10 mg; p < 0.01) and a higher dose of thiamine (800 mg vs. 600 mg; p < 0.01). Length of hospital stay was significantly increased in the symptoms-triggered approach group (3.9 vs. 2.2 days; p < 0.01).

DISCUSSION

The use of a symptoms-triggered approach to treat alcohol withdrawal syndrome was associated with a lower 90-day readmission rate, prolonged period to the first readmission, and reduced total dose of benzodiazepines, but longer length of hospital stays.

CONCLUSION

The symptoms-triggered approach is safe, cost-effective, and associated with reduced alcohol dependence relapse.

Prevention of alcohol withdrawal syndrome in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document

Alcohol withdrawal syndrome is a common and challenging clinical entity present in trauma and surgical intensive care unit (ICU) patients. The screening tools, assessment strategies, and pharmacological methods for preventing alcohol withdrawal have significantly changed during the past 20 years. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews the best practices for screening, monitoring, and prophylactic treatment of alcohol withdrawal in the surgical ICU.

Management of Alcohol Withdrawal Syndrome in Patients with Alcoholic Liver Disease

Alcohol withdrawal syndrome (AWS) is a common condition that is seen in treatment-seeking patients with Alcohol use disorder (AUD) and alcoholic liver disease (ALD). AWS, which typically starts within 4-6 h of the last alcohol use, can range from mild symptoms such as insomnia, tremors, and autonomic hyperactivity to more severe symptoms such as seizures and delirium tremens. Clinical Institute Withdrawal Assessment Scale-Alcohol Revised (CIWA-Ar) is the most commonly used scale to assess AWS in clinical practice. The presence of moderate withdrawal as indicated by a score of more than 8 is an indication for pharmacotherapy. Lorazepam and oxazepam are preferred agents for the management of AWS in the setting of ALD. In severe ALD, benzodiazepines should be used cautiously with monitoring due to the risk of excessive sedation or precipitating hepatic encephalopathy.

A Medical Resident with a History of Alcohol Abuse and Suicidal Ideation: A Challenge for Both Psychiatry and Occupational Medicine in the Context of the First Wave of the COVID-19 Pandemic

This case study draws attention to the hazards of physicians with a history of alcohol addiction and a particular psychopathology framework in the context of occupational health surveillance, particularly during the challenging working conditions brought about by the COVID-19 pandemic. The case involves a hospital resident in her thirties, with a previous history of addiction and attempts at suicide, who was assigned to a COVID-19 unit of an Italian hospital. In this case study, we discuss the preventive intervention put in place in order to protect physicians' health and work. What emerges is the key role that rapid substantive communications between specialists play in formulating an effective strategy for dealing with these conditions. We believe this case is noteworthy for the lessons that can be learned for tailoring prevention and treatment pathways for health care workers with addiction.

Diagnostic Performance of AST Scale in Mexican Male Population for Alcohol Withdrawal Syndrome

Alcohol withdrawal syndrome (AWS) represents an adverse consequence of chronic alcohol use that may lead to serious complications. Therefore, AWS requires timely attention based on its early recognition, where easy-to-apply diagnostic tools are desirable. Our aim was to characterize the performance of a short-scale AST (Anxiety, Sweats, Tremors) in patients from public general hospitals. We conducted a cross-sectional study of patients attended at the Emergency Department diagnosed with AWS. Three scales were applied: CIWA-Ar (Clinical Institute Retirement Assessment Scale-Revised), GMAWS (Glasgow Modified Alcohol Withdrawal Syndrome) and AST. Cronbach’s alpha and Cohen’s kappa tests were used for reliability and concordance. Factorial analysis and diagnostic performance including ROC curve were carried out. Sixty-eight males with a mean age of 41.2 years old, with high school education and robust alcohol consumption, were included. Mean scores for CIWA-Ar, GMWAS and AST were 17.4 ± 11.2, 3.9 ± 2.3 and 3.8 ± 2.6, respectively, without significant differences. The AST scale showed an acceptable reliability and concordance (0.852 and 0.439; p < 0.0001) compared with CIWA-Ar and GMAWS. AST component analysis evidenced tremor (77.5% variance), sweat (12.1% variance) and anxiety (10.4% variance). Diagnostic performance of the AST scale was similar to the GMAWS scale, evidencing a sensitivity of 84%, specificity of 83.3% and Area Under the Curve (AUC) of 0.837 to discriminate severe AWS, according to CIWA-Ar. The performance of the AST scale to evaluate AWS is comparable with the commonly used CIWA-Ar and GMAWS scales. AST further represents an easy-to-apply instrument.

Ketamine plus Alcohol: What We Know and What We Can Expect about This

Drug abuse has become a public health concern. The misuse of ketamine, a psychedelic substance, has increased worldwide. In addition, the co-abuse with alcohol is frequently identified among misusers. Considering that ketamine and alcohol share several pharmacological targets, we hypothesize that the consumption of both psychoactive substances may synergically intensify the toxicological consequences, both under the effect of drugs available in body systems and during withdrawal. The aim of this review is to examine the toxicological mechanisms related to ketamine plus ethanol co-abuse, as well the consequences on cardiorespiratory, digestive, urinary, and central nervous systems. Furthermore, we provide a comprehensive discussion about the probable sites of shared molecular mechanisms that may elicit additional hazardous effects. Finally, we highlight the gaps of knowledge in this area, which deserves further research.

A retrospective evaluation of phenobarbital versus benzodiazepines for treatment of alcohol withdrawal in a regional Canadian emergency department

Evidence suggests that phenobarbital can be used to treat alcohol withdrawal syndrome as monotherapy; however, the therapeutic cornerstone remains benzodiazepines. To date, studies comparing the two treatment modalities in the emergency department (ED) are few. We sought to determine whether phenobarbital versus benzodiazepine monotherapy impacts ED length of stay and need for admission among adult presentations at a single regional hospital. In June 2019, a treatment algorithm offering both phenobarbital and diazepam pathways was introduced at the Battlefords Union Hospital ED, an 11-bed unit treating 27 000 patients annually in North Battleford, Saskatchewan, Canada. A subsequent retrospective observational study evaluated all adult alcohol withdrawal syndrome presentations between June 2019 and January 2021. Medical records were reviewed for visit date, age, sex, comorbidities, psychosocial factors, Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scores, secondary diagnoses, time of day, protocol adherence, attending physician, length of stay, disposition, and ED return. Descriptive statistics, log-rank testing, simple regression, and multiple regression were used in analysis. Of the 184 presentations, 30.4% were treated with phenobarbital. Median length of stay for phenobarbital versus benzodiazepine therapy was 4.4 h and 4.4 h, respectively (p = 0.21). Of the phenobarbital presentations, 9.4% were hospitalized versus 17.1% of the benzodiazepine presentations (p = 0.20). When adjusted for confounders, phenobarbital-treated presentations were 71.3% less likely to be admitted (p = 0.03). This research suggests that phenobarbital performs similarly to benzodiazepines regarding alcohol withdrawal ED length of stay and may result in reduced hospitalizations.

Delirium Tremens and Central Pontine Myelinolysis in a Patient with Alcohol Use Disorder and Pneumonia: a Case Report and a Narrative Review

INTRODUCTION

Delirium tremens (DT) is a serious condition occurring in alcohol withdrawal syndrome. Alcohol consumption may also cause additional health problems, such as respiratory infections or neuropsychiatric conditions such as central pontine myelinolysis. In this clinical scenario, managing DT can be expected to be more compelling and complex. Alcohol decreases coughing and mucociliary clearance and disrupts the immunity of the respiratory system.

CASE

Here we report on a middle-aged man with alcohol use disorder who had developed DT due to alcohol withdrawal and comorbid pneumonia.

DISCUSSION AND CONCLUSION

In this paper, DT, the relation between respiratory infections and alcohol intake, and the correlation of alcohol consumption and central pontine myelinolysis (CPM) are discussed. Also, the literature on alcohol consumption and the additional respiratory and neurologic problems resulting from it are presented.

Clinical management of the alcohol withdrawal syndrome

Up to half of individuals with a history of long-term, heavy alcohol consumption will experience the alcohol withdrawal syndrome (AWS) when consumption is significantly decreased or stopped. In its most severe form, AWS can be life-threatening. Medically assisted withdrawal (MAW) often forms the first part of a treatment pathway. This clinical review discusses key elements of the clinical management of MAW, necessary adjustments for pregnancy and older adults, likely outcome of an episode of MAW, factors that might prevent completion of the MAW process and ways of overcoming barriers to ongoing treatment of alcohol use disorder. The review also discusses the use of benzodiazepines in MAW. Although there is clear evidence for their use, benzodiazepines have been associated with abuse liability, blunting of cognition, interactions with depressant drugs, craving, delirium, dementia and disrupted sleep patterns. Because glutamatergic activation and glutamate receptor upregulation contribute to alcohol withdrawal, anti-glutamatergic strategies for MAW and other potential treatment innovations are also considered.

Clinical characteristics and health outcomes in patients with alcohol withdrawal syndrome: an observational study from Oman

BACKGROUND

Globally, alcohol withdrawal syndrome (AWS) is considered a serious medical diagnosis associated with increasing morbidity and mortality. Little information has been reported on the scope of the problem in Oman.

OBJECTIVE

Study clinical characteristics, management, quality of care, and health outcomes of patients managed for AWS.

DESIGN

Retrospective medical record review.

SETTINGS

University hospital.

PATIENTS AND METHODS

The study included all patients with AWS admitted from 1 October 2019 to 30 September 2020. We collected demographic and clinical characteristics and did a univariate analysis of factors related to 90-day readmission.

MAIN OUTCOME MEASURES

Length of hospital stay, 90-day read-mission, referral rate to alcohol rehabilitation center.

SAMPLE SIZE AND CHARACTERISTICS

150 male patients with median (IQR) age of 39.5 (32-48) years.

RESULTS

Most patients (70.7%, n=106) were smokers and 44 (29.3%) had a history of drug abuse. The average length of hospital stay was 2.3 (0.9-4.6) days. Approximately 9% of total hospital bed days were used to care for patients with AWS. Chronic liver disease (35.3%), diabetes mellitus (24.7%), and hypertension (24.0%) were common among AWS patients. The 90-day readmission rate (32.7%) was high, and there was low referral to alcohol rehabilitation (16.7%). Diabetes and epilepsy were associated with 90-day readmission.

CONCLUSION

AWS is an important diagnosis that represents an important burden on acute medical services. Establishing a drug and alcohol service in our institution is an essential step to optimise care for patients with alcohol-related disorders.

LIMITATIONS

Retrospective, so unable to collect data on manifestations of AWS such as delirium tremens, which is the most severe form of AWS. Also, the reason for the lack of referral to an outpatient alcohol rehabilitation program was not apparent.

CONFLICT OF INTEREST

None.

Alcohol withdrawal syndrome in ICU patients: Clinical features, management, and outcome predictors

Background

Alcohol withdrawal syndrome (AWS) is a common condition in hospitalized patients, yet its epidemiology in the ICU remains poorly characterized.

Methods

Retrospective cohort of patients admitted to the Nantes University Hospital ICU between January 1, 2017, and December 31, 2019, and coded for AWS using ICD-10 criteria. The objective of the study was to identify factors associated with complicated hospital stay defined as ICU length of stay ≥7 days or hospital mortality.

Results

Among 5,641 patients admitted to the ICU during the study period, 246 (4.4%) were coded as having AWS. Among them, 42 had exclusion criteria and 204 were included in the study. The three main reasons for ICU admission were sepsis (29.9%), altered consciousness (29.4%), and seizures (24%). At ICU admission, median Cushman’s score was 6 [4–9] and median SOFA score was 3 [2–6]. Delirium tremens occurred in half the patients, seizures in one fifth and pneumonia in one third. Overall, 48% of patients developed complicated hospital stay, of whom 92.8% stayed in the ICU for ≥7 days, 36.7% received MV for ≥7 days, and 16.3% died during hospital stay. By multivariable analysis, two factors were associated with complicated hospital stay: a higher number of organ dysfunctions at ICU admission was associated with a higher risk of complicated hospital stay (OR, 1.18; 95CI, 1.05–1.32, P = 0.005), whereas ICU admission for seizures was associated with a lower risk of complicated hospital stay (OR, 0.14; 95%CI, 0.026–0.80; P = 0.026).

Conclusions

AWS in ICU patients chiefly affects young adults and is often associated with additional factors such as sepsis, trauma, or surgery. Half the patients experienced an extended ICU stay or death during the hospital stay. The likelihood of developing complicated hospital stay relied on the reason for ICU admission and the number of organ dysfunctions at ICU admission.

Effects of acupuncture stimulation on brain activation induced by cue-elicited alcohol craving

Acupuncture has been shown to be effective on alcohol use disorder. However, the underlying mechanism remains poorly understood. To investigate the effects of Shenmen (HT7) acupoint on brain activation induced by cue-elicited alcohol craving, 30 right-handed healthy light to moderate alcohol drinkers were recruited from the community. They were randomly assigned to undergo acupuncture either at HT7 (experimental acupoint, n = 15) or Jingqu (LU8, control acupoint, n = 15) acupoints. This randomized controlled study was performed in Daegu Haany University and Daegu-Gyeongbuk Medical Innovation Foundation, Republic of Korea. Recruitment and data collection were conducted from December 2018 to May 2019. The results showed that after acupuncture at HT7 acupoint, the activation of orbitofrontal cortex and dorsolateral prefrontal cortex was greatly increased, while the activation of dorsolateral prefrontal cortex was obviously reduced, and subject's craving for alcohol was reduced when he/she seeing alcohol-related video clips involving various alcohols (beer, wine, or soju) or drinking scenarios. Acupuncture at HT7 more greatly reduced subject's alcohol cravings than acupuncture at LU8 acupoint. These findings suggest that acupuncture can improve the self-control of mild to moderate social drinkers through the activation of the orbitofrontal cortex and dorsolateral prefrontal cortex, thereby reducing the craving for alcohol. The study protocol was approved by the Institutional Review Board of Daegu Haany University Korean Medicine Hospital, Republic of Korea (approval No. DHUMC-D-18026-PRO-02) on November 30, 2018.

Assessment of Phenobarbital Administration to Reduce Opioid and Benzodiazepine Use in the Immediate Postoperative Period Following Stage 2 Single-Ventricle Palliation

OBJECTIVE

The Glenn procedure may lead to the development of elevated cerebral venous pressures, which is believed to result in "Glenn headaches." This manifests as excessive irritability, often requiring significant use of opioids and benzodiazepines. This study was designed to report our experience with the use of phenobarbital in the postoperative phase after the Glenn procedure.

METHODS

We performed a retrospective chart review to compare Glenn patients before and after implementation of a sedation protocol using phenobarbital. The 2 groups were compared for demographics, surgical characteristics, and cumulative sedation usage. Correlation coefficients between the preoperative catheterization variables and sedation usage were also calculated.

RESULTS

Groups A (pre-phenobarbital; n = 8) and B (post-phenobarbital; n = 11) were comparable in terms of demographics, cardiac anatomy, preoperative catheterization data, and hemodynamics. Patients in Group B received a median dose of 21.8 mg/kg of phenobarbital during their ICU stay. Although there was a decreased administration of morphine equivalents (2.60 mg/kg vs 2.25 mg/kg, p = 0.38), benzodiazepine (0.1 mg/kg vs 0.074 mg/kg, p = 0.43), and dexmedetomidine (47 mcg/kg vs 37.2 mcg/kg, p = 0.53) in Group B, the differences were not statistically significant. There was also no strong correlation between preoperative hemodynamic variables and the postoperative sedation requirement, and there was no statistically significant difference in overall outcomes between the 2 groups.

CONCLUSIONS

While phenobarbital may have mitigated the use of opioids, benzodiazepines, and alpha-agonist agents in some postoperative Glenn patients, the overall findings for all patients were not statistically significant. Further prospective studies are needed to ascertain the role of phenobarbital in these patients.

Efficacy and Safety of Anticonvulsants for the Inpatient Treatment of Alcohol Withdrawal Syndrome: A Systematic Review and Meta-analysis

AIM

To examine the efficacy and safety of antiepileptic drugs (AED) for the inpatient treatment of patients with moderate to severe alcohol withdrawal syndrome (AWS).

METHODS

We searched in databases and gray literature to include randomized controlled clinical trials in adults that compare the use of AED versus placebo or any other medication. Studies that did not specify severity or were performed on an outpatient basis were excluded. The outcomes were improvement of symptoms, delirium tremens, seizures and adverse events. Two researchers independently selected the references, extracted the data and assessed the risk of bias. A qualitative synthesis was made and, when the heterogeneity was mild or moderate, a meta-analysis was performed. The quality of the evidence obtained was evaluated with the Grading of Recommendations Assessment, Development and Evaluation tool.

RESULTS

In total, 26 studies with 1709 patients were included. No benefit is described in withdrawal syndrome severity measured by scales or in the development of delirium tremens. The only possible meta-analysis showed that there are no differences in the incidence of seizures (risk ratio [RR] = 1.0; confidence interval (CI) 95% 0.76-1.33), even when compared with placebo (RR = 0.95; CI95% 0.57-1.57). There were also no differences in adverse events, although a higher proportion of some mild cases were described with the use of carbamazepine and valproic acid.

CONCLUSIONS

The routine use of AED is not suggested in the treatment of patients with moderate or severe AWS unless indicated for comorbidity (weak recommendation against using moderate quality of evidence).

Inhibition of the Sodium Calcium Exchanger Suppresses Alcohol Withdrawal-Induced Seizure Susceptibility

Calcium influx plays important roles in the pathophysiology of seizures, including acoustically evoked alcohol withdrawal-induced seizures (AWSs). One Ca²⁺ influx route of interest is the Na⁺/Ca²⁺ exchanger (NCX) that, when operating in its reverse mode (NCX_rev) activity, can facilitate Ca²⁺ entry into neurons, possibly increasing neuronal excitability that leads to enhanced seizure susceptibility. Here, we probed the involvement of NCX_rev activity on AWS susceptibility by quantifying the effects of SN-6 and KB-R7943, potent blockers of isoform type 1 (NCX1_rev) and 3 (NCX3_rev), respectively. Male, adult Sprague-Dawley rats were used. Acoustically evoked AWSs consisted of wild running seizures (WRSs) that evolved into generalized tonic-clonic seizures (GTCSs). Quantification shows that acute SN-6 treatment at a relatively low dose suppressed the occurrence of the GTCSs (but not WRSs) component of AWSs and markedly reduced the seizure severity. However, administration of KB-R7943 at a relatively high dose only reduced the incidence of GTCSs. These findings demonstrate that inhibition of NCX1_rev activity is a putative mechanism for the suppression of alcohol withdrawal-induced GTCSs.

Optimal Sedation and Pain Management: A Patient- and Symptom-Oriented Paradigm

In the critically ill patient, optimal pain and sedation management remains the cornerstone of achieving comfort, safety, and to facilitate complex life support interventions. Pain relief, using multimodal analgesia, is an integral component of any orchestrated approach to achieve clinically appropriate goals in critically ill patients. Sedative management, however, remains a significant challenge. Subsequent studies including most recent randomized trials have failed to provide strong evidence in favor of a sedative agent, a mode of sedation or ancillary protocols such as sedative interruption and sedative minimization. In addition, clinical practice guidelines, despite a comprehensive evaluation of relevant literature, have limitations when applied to individual patients. These limitations have been most apparent during the coronavirus disease 2019 pandemic. As such, there is a need for a mindset shift to a practical and achievable sedation strategy, driven by patients' characteristics and individual patient needs, rather than one cocktail for all patients. In this review, we present key principles to achieve patient-and symptom-oriented optimal analgesia and sedation in the critically ill patients. Sedative intensity should be proportionate to care complexity with due consideration to an individual patient's modifiers. The use of multimodal analgesics, sedatives, and antipsychotics agents-that are easily titratable-reduces the overall quantum of sedatives and opioids, and reduces the risk of adverse events while maximizing clinical benefits. In addition, critical considerations regarding the choice of sedative agents should be given to factors such as age, medical versus operative diagnosis, and cardiovascular status. Specific populations such as trauma, neurological injury, and pregnancy should also be taken into account to maximize efficacy and reduce adverse events.

Implementation of a Protocol Using the 5-Item Brief Alcohol Withdrawal Scale for Treatment of Severe Alcohol Withdrawal in Intensive Care Units

BACKGROUND

There is variation in the treatment of patients with severe alcohol withdrawal and a need for effective protocols. The purpose of this study was to evaluate the implementation of a symptom-triggered benzodiazepine protocol using the 5-item Brief Alcohol Withdrawal Scale (BAWS) for treatment of alcohol withdrawal in intensive care units (ICUs).

METHODS

This retrospective study included admissions to ICUs of 2 hospitals over 6 months who had an alcohol withdrawal protocol ordered and experienced severe withdrawal. Records were reviewed to collect demographic data, benzodiazepine exposure, duration of treatment, and withdrawal severity.

RESULTS

The protocol was ordered and implemented in 279 admissions; 48 (17.9%) had severe withdrawal defined as a BAWS of 6 or more. The majority of the 48 patients were from the emergency department (79.2%); mean hospital length of stay was 11.2 days and mean ICU stay 6.6 days; 31.3% required mechanical ventilation. A little more than half were treated only with the protocol (53.2%); 25.0% received additional benzodiazepines, 20.8% dexmedetomidine, 10.4% propofol, 25.0% antipsychotics and 2.0% phenobarbital.

CONCLUSION

Among ICU patients treated for alcohol withdrawal with a symptom-triggered benzodiazepine protocol using a novel 5-item scale, most did not develop severe withdrawal, and of those who did, approximately half were treated with the protocol alone.

Alcohol Withdrawal Syndrome in Neurocritical Care Unit: Assessment and Treatment Challenges

Alcohol withdrawal syndrome (AWS) can range from mild jittery movements, nausea, sweating to more severe symptoms such as seizure and death. Severe AWS can worsen cognitive function, increase hospital length of stay, and in-hospital mortality and morbidity. Due to a lack of reliable history of present illness in many patients with neurological injury as well as similarities in clinical presentation of AWS and some commonly encountered neurological syndromes, the true incidence of AWS in neurocritical care patients remains unknown. This review discusses challenges in the assessment and treatment of AWS in patients with neurological injury, including the utility of different scoring systems such as the Clinical Institute Withdrawal Assessment and the Minnesota Detoxification Scale as well as the reliability of admission alcohol levels in predicting AWS. Treatment strategies such as symptom-based versus fixed dose benzodiazepine therapy and alternative agents such as baclofen, carbamazepine, dexmedetomidine, gabapentin, phenobarbital, ketamine, propofol, and valproic acid are also discussed. Finally, a treatment algorithm considering the neurocritical care patient is proposed to help guide therapy in this setting.

Perioperative Management of Alcohol Withdrawal Syndrome

Background

In the perioperative course, alcohol withdrawal syndrome (AWS) can occur in any setting, especially in aero-digestive and acute trauma surgery. Challenging issues are the overlap of other forms of delirium in perioperative and intensive care settings as well as general anesthesia masking the onset of withdrawal symptoms. In contrast to other etiologies of delirium, the pathophysiology and thus treatment strategy of AWS is different: the key point is the tolerance to GABAergic molecules of alcohol-dependent subjects resulting in central nervous hyperactivity once the effect of alcohol or other GABA-stimulating agents is decreased.

Summary

Despite limitations due to insufficient accuracy of self-reporting questionnaires and limited feasibility in emergency settings, the AUDIT and the shortened AUDIT-C are the standard tools for detection of alcohol use disorders (AUD), as well as predicting AWS risk and severity in approximately half of these AUD patients. The most important risk factors for AWS are a high blood alcohol concentration at hospital admission, AWS episodes in medical history, and lack of control of alcohol use. Patients considered at risk for severe AWS must be treated with prophylactic medication before the onset of symptoms. Thiamine supplementation is required for all malnourished alcohol-dependent patients. Writing down alcohol-related diagnoses in the medical records requires the patient's presumed consent after shared decision-making. These reports should remain strictly confidential if the patient desires. Psychological support for the perioperative period as well as the following course should be offered to all AUD patients including support in short- and long-term detoxification. Alternative diagnoses must be ruled out with no timely delay, especially if fever and coma are the leading symptoms. The backbone of AWS therapy is the symptom-triggered administration of intravenous benzodiazepines (BZO) in escalating doses until the aimed revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar) or Richmond Agitation-Sedation Scale (RASS) score is achieved. Clonidine, dexmedetomidine, baclofen, ketamine, and neuroleptics may be used as symptom-orientated adjuncts. The therapeutic administration of ethanol or clomethiazole is considered to be harmful in critically ill patients after the onset of AWS. General supportive and intensive care including high-dose thiamine supplementation are mandatory in severe AWS cases. The timely differential diagnosis of delirium is important - and AWS is a diagnosis of exclusion - because BZO are strongly recommended for AWS patients but may not be the treatment of choice in other etiologies of delirium.

Key Messages

Screening for AWS risk factors should be integrated in the preoperative and emergency assessment. Other severe diagnoses must be ruled out before the diagnosis of AWS can be established. Preventive treatment should be given to high-risk patients scoring positive for AUD and for patients with a lack of alcohol use control. The principles of AWS therapy are symptom-orientated doses of BZO and as adjuncts α₂-agonists, neuroleptics, and others guided by repeated reassessment with validated tools and thiamine administration. Length of stay and morbidity are reduced if AWS therapy is symptom-orientated and protocol-based.

Substance use disorders: diagnosis and management for hospitalists

Substance use disorder is a significant health concern. Hospitalists manage patient with various forms of substance use disorder on a daily basis. In this review, we have tried to synthesize evidence together to give a brief, yet succinct, review of commonly encounters disorders; alcohol intoxication and withdrawal, opioid intoxication and withdrawal, cocaine intoxication and methamphetamine intoxication. We describe clinical features, diagnosis and management, which would serve as a great resource for hospitalist when managing these complicated patients.

Front-loaded diazepam versus lorazepam for treatment of alcohol withdrawal agitated delirium

BACKGROUND

Front-loaded diazepam is used to rapidly control agitation in patients with severe alcohol withdrawal syndrome (AWS). Our institution began using front-loaded lorazepam in August 2017 secondary to a nation-wide shortage of intravenous (IV) diazepam. Currently, there are no studies comparing lorazepam to diazepam for frontloading in severe AWS.

METHOD

Retrospective cohort study of all adults presenting to the emergency department with a diagnosis of AWS and prescribed the institution's alcohol withdrawal agitated delirium protocol 8 months pre and post shortage of IV diazepam were eligible inclusion for the study. Of these, 106 patients were front-loaded with diazepam and 70 patients were front-loaded with lorazepam.

RESULTS

There was no difference in the mean change in Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised scores 24 h pre and post front-loading in the two groups (-13.9 ± -8.08 vs. -13.1 ± -8.91, p = 0.534). Patients who received front-loaded lorazepam had an increased incidence of ICU-delirium (positive for the Confusion Assessment Method in the ICU: 75% with lorazepam vs. 52.6% with diazepam, p = 0.009) and a higher risk of over-sedation, but this did not reach statistical significance (Richmond Agitation-Sedation Scale score < -1: 32.1% with lorazepam vs. 18.2% with diazepam, p = 0.063).

CONCLUSION

Front-loaded lorazepam was similar to front-loaded diazepam in controlling AWS symptoms. Lorazepam's delayed onset of action should be considered when determining how quickly repeat doses are administered to avoid the potential for adverse drug events.

Management of Alcohol Withdrawal in the Emergency Department: Current Perspectives

Alcohol withdrawal syndrome (AWS) is a common, heterogenous, and life-threatening complication of alcohol use disorder (AUD). AUD is a leading cause of worldwide mortality, and many patients with AUD will develop AWS during their ED course. This review summarizes the epidemiology, pathology, and management of AWS and AUD in the emergency setting. The time course of AWS and its impact on ED treatment is emphasized. Once AWS is diagnosed, symptom-triggered benzodiazepine administration remains the most commonly provided treatment but may not be appropriate for patients with significant medical or psychiatric comorbidity or pending discharge. In these cases, ED clinicians may consider short courses of barbiturates or alternative regimens based on novel anticonvulsants. Specific treatment protocols are enumerated for clinical practice. Finally, emergency providers must not only manage acute patients' AWS but also lay the foundation for successful treatment of AUD. An approach to the disposition of the patient with AUD is presented. The authors examine shortcomings in the extant literature and suggest opportunities for further study.

Review: Post-Intensive Care Syndrome: Unique Challenges in the Neurointensive Care Unit

Within the last couple of decades, advances in critical care medicine have led to increased survival of critically ill patients, as well as the discovery of notable, long-term health challenges in survivors and their loved ones. The terms post-intensive care syndrome (PICS) and PICS-family (PICS-F) have been used in non-neurocritical care populations to characterize the cognitive, psychiatric, and physical sequelae associated with critical care hospitalization in survivors and their informal caregivers (e.g., family and friends who provide unpaid care). In this review, we first summarize the literature on the cognitive, psychiatric, and physical correlates of PICS and PICS-F in non-neurocritical patient populations and draw attention to their long-term negative health consequences. Next, keeping in mind the distinction between disease-related neurocognitive changes and those that are associated directly with the experience of a critical illness, we review the neuropsychological sequelae among patients with common neurocritical illnesses. We acknowledge the clinical factors contributing to the difficulty in studying PICS in the neurocritical care patient population, provide recommendations for future lines of research, and encourage collaboration among critical care physicians in all specialties to facilitate continuity of care and to help elucidate mechanism(s) of PICS and PICS-F in all critical illness survivors. Finally, we discuss the importance of early detection of PICS and PICS-F as an opportunity for multidisciplinary interventions to prevent and treat new neuropsychological deficits in the neurocritical care population.

Dexmedetomidine as adjunctive therapy for the treatment of alcohol withdrawal syndrome: a systematic review protocol

OBJECTIVE

The purpose of this review is to evaluate the effectiveness and safety of dexmedetomidine as adjunctive therapy to the standard of care (benzodiazepines) compared to either the standard of care or other adjunctive treatment approaches (e.g. benzodiazepines plus propofol) for the treatment of alcohol withdrawal syndrome (AWS).

INTRODUCTION

Benzodiazepines have been the cornerstone of AWS therapy, but in some patients, AWS is refractory to high doses. Moreover, benzodiazepine use is burdened by excessive sedation, confusion and respiratory depression. Options for management of refractory AWS include the addition of phenobarbital, propofol and, more recently, dexmedetomidine to benzodiazepines therapy. The possible advantage of dexmedetomidine compared to benzodiazepines is that it does not cause respiratory depression, thus reducing the risk of intubation and hospitalization in the intensive care unit.

INCLUSION CRITERIA

This review will consider studies including patients who are 18 years or older and are diagnosed with AWS. The exclusion criteria are a history of psychoactive substances or withdrawal states and/or severe neurologic disorder (e.g. traumatic brain injury, acute stroke, severe dementia, seizure disorder).

METHODS

This review will include only studies published in English, with no restrictions on the year of publication. Both randomized controlled trials and observational studies (including cohort and case-control studies) assessing the drug effectiveness and safety will be included. The databases utilized will include: PubMed, Embase and Cochrane Central Register of Controlled Trials. In addition, the trial registers to be searched will include: World Health Organization International Clinical Trials Registry Platform (ICTRP), U.S. National Library of Medicine Drug Information Portal and ClinicalTrials.gov.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42018084370.

High-Dose Gabapentin for the Treatment of Severe Alcohol Withdrawal Syndrome: A Retrospective Cohort Analysis

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.

Practice Patterns in the Treatment of Patients With Severe Alcohol Withdrawal: A Multidisciplinary, Cross-Sectional Survey

PURPOSE

To characterize physicians' stated practices in the treatment of patients with severe acute alcohol withdrawal syndrome (sAAWS) and to use intravenous (IV) phenobarbital as an adjuvant treatment for sAAWS.

METHODS

A multidisciplinary, cross-sectional, self-administered survey at 2 large academic centers specializing in inner-city healthcare.

RESULTS

We analyzed 105 of 195 questionnaires (53.8% response rate). On average, clinicians managed 32 cases of AAWS over a 6-month period, of which 7 (21.9%) were severe. Haloperidol (Haldol; 40 [39%]), clonidine (Catapres; 31 [30%]), phenobarbital (Luminal, Tedral; 29 [27%]) and propofol (Diprivan; 29 [28%]) were the most commonly used adjuvant medications for sAAWS. Sixty-three (60%) of respondents did not use phenobarbital in practice. Of phenobarbital users, 23 (55%) respondents used it early in patients who were refractory to symptom-triggered benzodiazepine treatment. Others waited until patients experienced seizures (5 [10%]) or required intensive care unit admission (8 [18%]). Respondents who used phenobarbital preferred to use the IV versus oral form (66% vs 29%, P < .001). Most respondents, however, were unfamiliar with the pharmacokinetics, side effects, contraindications, and evidence supporting phenobarbital use for sAAWS. Although many respondents (64 [61%]) expressed discomfort using phenobarbital, 87 (83%) expressed comfort or neutrality with enrolling patients in a trial to evaluate IV phenobarbital in sAAWS.

CONCLUSIONS

Considerable stated practice variation exists in how clinicians treat patients with sAAWS. Our findings support conduct of a pilot trial to evaluate IV phenobarbital as an adjuvant treatment to symptom-triggered benzodiazepines for sAAWS and have informed trial design.

Alcohol withdrawal syndrome management: Is there anything new?

Patients with alcohol use disorder experience frequently alcohol withdrawal syndrome (AWS), which is a potentially life-threatening condition mainly caused by glutamate overactivity. The aim of therapeutic alcohol withdrawal is the entry into a process of complete and lasting abstinence. Therefore preparing withdrawal is crucial to optimize compliance and efficacy of aftercare. Indeed, performing repeated withdrawal per se without any project of subsequent abstinence may be deleterious, at least because of repeated exposure to glutamate neurotoxicity. Managing AWS mainly consists in anticipating severe withdrawal, decreasing the risk of complications, making this experience as comfortable as possible, preventing from long-term benzodiazepine use, and enhancing motivation to aftercare and long-term abstinence. In particular, there are specific guidelines to choose which benzodiazepine administration approach to adopt (i.e. symptom-triggered, fixed schedule or loading dosage) and which other drugs to deliver (e.g. thiamine, folate, magnesium). Specific precautions should be taken in the elderly.

Diagnosis and treatment of acute alcohol intoxication and alcohol withdrawal syndrome: position paper of the Italian Society on Alcohol

The chronic use of alcohol can lead to the onset of an alcohol use disorder (AUD). About 50% of subjects with an AUD may develop alcohol withdrawal syndrome (AWS) when they reduce or discontinue their alcohol consumption and, in 3-5% of them, convulsions and delirium tremens (DTs), representing life-threatening complications, may occur. Unfortunately, few physicians are adequately trained in identifying and treating AWS. The Italian Society on Alcohol has, therefore, implemented a task force of specialists to draw up recommendations for the treatment of AWS with the following main results: (1) while mild AWS may not require treatment, moderate and severe AWS need to be pharmacologically treated; (2) out-patient treatment is appropriate in patients with mild or moderate AWS, while patients with severe AWS need to be treated as in-patients; (3) benzodiazepines, BDZs are the "gold standard" for the treatment of AWS and DTs; (4) alpha-2-agonists, beta-blockers, and neuroleptics may be used in association when BDZs do not completely resolve specific persisting symptoms of AWS; (5) in the case of a refractory form of DTs, the use of anaesthetic drugs (propofol and phenobarbital) in an intensive care unit is appropriate; (6) alternatively to BDZs, sodium oxybate, clomethiazole, and tiapride approved in some European Countries for the treatment of AWS may be employed for the treatment of moderate AWS; (7) anti-convulsants are not sufficient to suppress AWS, and they may be used only in association with BDZs for the treatment of refractory forms of convulsions in the course of AWS.