Alcohol Withdrawal

HPI

  • How much usually drink?
  • When was last drink?
  • History of withdrawal? Seizures? Hospitalization?
  • Why did you stop drinking? Consider underlying reason for EtOH cessation (infection, meningitis, GIB etc)
  • Hyperdynamic VS can include fever, can be difficult to differentiate from meningitis (can have both – e.g. meningitis precipitating w/d)
  • Most w/d seizures are single event
  • Simple visual hallucinations w/ preserved orientation are not DTs
  • Pts w/ DTs have hyperdynamic VS and are completely disconnected from their environment
  • If withdrawal is occurring at higher BAC, that predicts more difficult to control

DDx

  • ICH/Trauma
  • Wernicke’s
  • Hypoglycemia
  • Hepatic encephalopathy

Treatment

  • Check chemistry, Mg, Phos
  • Give thiamine, folate and probably would benefit from Mg++ containing fluids

Benzo first strategy

  • Benzodiazepines increase frequency of GABA channel opening
  • Should be titrated to pt who is calm and sleepy, but arousable to voice. DO NOT titrate to HR. Pt can be tachycardic for other reasons and if remains tachy after goals reached, need to consider why
  • Diazepam
    • Diazepam dosing – dose escalation q 5-10 min until goal reached:
      • 10mg x2-> 20mg x 3 -> 40 mg x 3
      • Can consider 80 mg dose x2 after that to max around 400 mg
    • Has auto taper effect
    • May not be ideal in someone with ESLD due to impaired clearance of metobolites
  • Lorazepam
    • Peak not until 20-30 minutes – high risk of staking doses
    • Shorter t1/2 (~14 hrs) means there is risk of BZD withdrawal
    • Only real benefit is in ESLD b/c doesn’t need hepatic metabolism for clearance
    • There is a risk of propylene glycol toxicity at infusion rates > 10 mg/hr
  • Risk of propylene glycol toxicity if high doses of lorazepam or very high of diazepam – keep lorazepam < 166 mg/day and diazepam < 830 mg/day

Benzo refractory

  • Phenobarbital
    • If benzos already given, start with 260 mg IV over 10 minutes
    • Peak effect in ~ 30 minutes
    • Can then redose in aliquots q 30 minutes
      • 260 mg q 30 for severe sxs
      • 130 mg q 30 for moderate sxs
  • Dexmedetomodine
    • Can add on top of benzo strategy for sedative properties
    • Does not address actual physiology of withdrawal so needs to be used in conjunction with benzo/phenobarb to address underlying risk of seizure
  • Propofol
    • RSI w/ propofol induction followed by propofol infusion
  • Antipsychotics
    • DTs can bleed into just hospital/ICU delirium during the admission
    • Benzos may actually be a risk for causing delirium
    • Can try antipsychotics if it looks like w/d physiology has abated by pt still delirious
    • In one trial they even gave flumazenil to w/d pts with refractory delirium with good effects and no seizures

Phenobarbital first strategy

Phenobarb increases duration of GABA channel opening

  • Pharmacokinetics also provide self-wean phenomenon
  • Theoretical advantage in seizure ppx
  • Give as 10 mg/kg load over 30 minutes
  • Can then follow up with benzo titration or additional phenobarb for desired effect
  • Additional phenobarb is:
    • 260 mg q 30 min for severe sxs
    • 130 mg q 30 min for moderate sxs

Evidence/References

Phenobarbital for Acute Alcohol Withdrawal: A Prospective, Double Blind Placebo Controlled Study

  • Small RCT from Highland where pts randomized to phenobarb followed by CIWA guided lorazepam vs placebo followed by CIWA guided lorazepam
  • 51 pts in each arm
  • Less ICU admissions in the phenobarb arm
  • No differences in LOS or adverse events
  • Difference likely accounted for by less requirement for lorazepam gtt in the phenobarb group therefore not meeting criteria for ICU admission

 

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