Acute Alcohol Withdrawal:Guidelines For Evaluation and Treatment

1. Acute Alcohol Withdrawal:Guidelines For Evaluation and Treatment By: David Bridgers, M.D.

2. NCBH 1:00 A.M. Nurse: “We have Mr. Johnson here in 709, and you know, I think he’s going into the DTs.” Intern: “What’s he doing?” Nurse: “ I don’t know. He’s a little shaky, and I think he’s hallucinating.” Intern: “ Well, how bad is he?” Nurse: “ I don’t know…..not too bad. Can I give him something?” Intern: “ Yeah…..just give him some ativan. 2 mg IV will be fine.”

3. NCBH 1:30 A.M. Intern: “ Hey, I got a guy from the ED. I think he’s an alcoholic. I just gave him some Ativan.” Upper Level: “ (Yawn) That’s fine. Just put him on….I don’t know…..a couple of milligrams q 2 hours, or something. You know, for DT prophylaxis. He’ll be fine, and you can get some sleep……and so can I.” Intern: “Will that be too much?” Upper Level: “ Nah….a sleeping drunk is a good drunk. Call me if you need me. I’m going back to bed.”

4. NCBH: Four Days Later Attending (Grabarczyk): “Why is Mr. Johnson so out of it?” Intern: “ I’m not sure. He should be up and around by now. We’ve treated his pneumonia, and he hasn’t had any fever for two days.” Attending: “ Is he getting anything to make him sleepy?” Intern: “ Not really. He’s just been getting a little Ativan for DT prophylaxis.” Attending: “Well how much?”

5. NCBH: Four Days Later Intern: “Just 2 mg. He was getting it q 2 hours IV until yesterday when I made it p.o. and PRN.” Attending: “Well how much has he gotten since then?” Intern: (Flipping through MAR)“Uh…….It looks like he’s still gotten it every 2 hours.” Attending: “So now tell me…..Why is he still so out of it!?”

6. A Little Bit o’ Background Information • In 1990 there were an estimated 11-18 million in the U.S. reporting heavy alcohol abuse and dependence • Lifetime prevalence of 14% and 8% respectively • 15-20% of hospitalized and primary care patients (400,000 at any time) have alcoholism or withdrawal as their primary or supporting diagnosis • This lead to 1 million discharges from acute care facilities with alcohol related diagnoses

7. But what do the statistics mean?WE AS PHYSICIANS MUST BE ABLE TO IDENTIFY AND TREAT THIS COMMON CONDITION!

8. How do we go about this?Knowledge is Power! • Understand the effects of alcohol on the patient • Know how to identify the symptoms of alcohol withdrawal • Know how to adequately assess the severity of withdrawal, and the tools used in doing so • Know how to treat withdrawal and prevent complications

9. How Alcohol Effects the Brain Low Level Ingestion • Euphoria • Anesthesia • Amnesia

10. How Alcohol Effects the Brain High Level Ingestion • Severe Intoxication • Respiratory Depression • Coma

11. Physiological Changes Caused By Alcohol

12. Metabolic Abnormalities Hypokalemia: due to: • alterations in aldosterone level • renal and extra-renal losses • changes in the distribution of potassium levels across the cell membrane Hypomagnesemia: may predispose the patient to withdrawal seizures

13. Metabolic Abnormalities Hypophosphatemia: • common due to malnutrition • frequently symptomatic • predisposing the patient to fatal cardiac failure and rhabdomyolysis Volume Depletetion: • resulting from hyperthermia, diaphoresis, vomiting, and tachypnea

14. Signs and Symptoms of Alcohol Withdrawal

15. Due to increased central nervous system and sympathetic activity usually resolve w/i 24-48 hrs vary from episode to episode Headache Anorexia Agitation Increased sweating Tachycardia Increased hand tremor GI upset Insomnia Palpitaions Mild Withdrawal Symptoms

16. Alcoholic Hallucinosis • transient tactile visual or auditory hallucinations • usually visual • NOT synonymous with DTs *other signs may or may not be present * not usually associated with clouding of the sensorium

17. Withdrawal Seizures • w/i 48 hours of last drink • generalized tonic-clonic • 3% of chronic alcoholics develop this • 3% of those who seize develop Status Epilepticus • Seizures can be attributed to alcohol withdrawal if the patient has: • a normal EEG • history of documented seizure activity in withdrawal • no other cause for their seizures can be determined

18. Delirium Tremens • 5% of patients who withdraw develop DTs • Early figures of associated mortality were as high as 37% • earlier diagnosis, improved pharmacological, and non-pharmacological management, and improved treatment of co-morbidities has lead to mortality now being apx. 1% • Death is usually due to arrhythmia or secondary complications. (pneumonia,liver failure)

19. Risk Factors For Developing DTs • History of sustained drinking • Previous DTs • Age >30 • Greater number of days since last drink • Presence of other illnesses

20. Hallmarks of DTs • Hallucinations • Disorientation • Tachycardia • Hypertension • Low Grade Fever • Agitation • Diaphoresis • Sensorium Clouding

21. Hallmarks of DTs Physiologic Changes: • Elevated cardiac indices, oxygen delivery and oxygen consumption • Hyperventilation and Respiratory alkalosis which result in reduced cerebral blood flow

22. Early Studies on the Natural History of Alcohol Withdrawal • Victor and Adams 1953 • described four different “states” (tremulous, hallucinatory, epileptic, and delirious) seen either separately from one another, or in combination • Course described was ambiguous • Found mortality to be 15%

23. Natural History of the Alcohol Withdrawal Process: Foy et al 1997 • Describe a more accurate view of the natural history of alcohol withdrawal • Timing of major events • Incidences of seizures, hallucinations, delirium • Risk factors for these events

24. Foy et al 1997:Timing of Withdrawal Onset and Resolution Onset: • Overall median time of onset of withdrawal was 5 hours and 90% were withdrawing by 24 hours • Longer for those with complications (7 hours versus 4 hours) • Measured BAL of 0: On admission (75% were in withdrawal within 1 hour) Resolution: • Resolution shorter for those without complications (22 hours versus 33 hours)

25. Foy et al 1997: Incidences of Complications • Of the 426 patients in the study, 113 experienced complications with a few experiencing more than one complication • Seizures: 10 • Delirium: 45 • Hallucinations: 90

26. Foy et al 1997: Timing of Complications • Seizures occurred the earliest with 50% occurring on admission and 90% by 9 hours • Hallucinations were next with 50% occurring by 20.5 hours and 90% by 64 hours *They were mostly short-lived with a median duration of 6 hours and 90th percentile of 46 hours • Delirium had the latest onset. 50% occurred within 46 hours and 90% by 85 hours *The duration of delirium was wider and more variable with a median duration of 23 hours and 90th percentile of 100 hours

27. Foy et al 1997: Risk Factors For Complications • Age greater than 70 • Need for assisted ventilation • Pathology of the CNS, hypoxia, and femur fractured conveyed a greater risk of delirium • Delaying initial assessment and subsequent diagnosis for more than 24 hours

28. Assessment of Alcohol Withdrawal Uh..uh.. I don’t know Is that dude withdrawing?

29. Severity Assessment Scoring Systems • Objective way to quantify the severity of alcohol withdrawal by interacting with the patient and giving them a total severity assessment score • Ideal scale should: 1. Be able to not only asses the patient initially for signs of alcohol withdrawal, but also follow their course of withdrawal 2. Be administered rapidly by nursing staff 3. Help guide Physicians in administering appropriate treatment

30. Early Severity Assessment Scales • Formulated by Gross et al in 1973 • Total Severity Assessment Scale (TSA) and Selective Severity Assessment Scale (ASA) • Faulted in the fact that some of the characteristics were only applicable daily and did not follow the course of withdrawal on a hour to hour basis • Difficult to administer

31. CIWA-A • Clinical Institute Withdrawal Assessment for Alcohol Withdrawal • 15 item scale developed by Shaw 1981 • Designed to follow the course of withdrawal by being able to be administered several times a day • Administration time apx. 6 minutes

32. Tremor Sweating Clouding of the sensorium Quality of contact Agitation Seizures Nausea and vomiting Tactile disturbances visual disturbances auditory disturbances Headache Flushing of face Convulsions Thought disturbances General Hallucinations CIWA-A Assessment Categories

33. CIWA-A Scoring • Scoring was based on a seven point scale • Points were given according to severity of category • The total score was tallied to determine severity of withdrawal as defined in their study results as: ·        Mild-20.4 (+/-2.6) ·        Moderate 24.2 (+/- 5.4) ·        Severe 29 (+/- 7.6)

34. Shaw et al 1981 • The premise of their study was that patients admitted with alcohol withdrawal could, if objectively assessed with the CIWA-A, be treated by a program of “supportive care” without using medications • The supportive care program consisted of minimizing environmental stimuli, and administering comfort measures such as fluids, blankets and smoking when desired every 30 minutes

35. Study DEsShaw et al 1981: Study Protocolign

36. Shaw et al 1981:Results • The group defined supportive care as a success when the CIWA-A score after 8 hours was reduced to <10 and there was no rebound during the 72 hours of admission • 38 patients were admitted to the study • 28 patients were declared a success by the above • 10 had no response to the supportive care program, but were managed well using diazepam as described without complication 

37. Shaw et al 1981:Conclusions • The systematic evaluation of patients using the CIWA-A scale to score the severity of their withdrawal coupled with “supportive” nursing care was effective in the treatment of patients suffering from alcohol withdrawal • 75% of the patients in their study required no medication • Nurses could be trained to administer the scale in a timely fashion without direct physician supervision

38. Shaw et al 1981:Conclusions • The scale was valid when compared to physician assessments • Using the scale was also important because frequent nursing intervention was beneficial to the patient. The interaction reoriented the patient and helped calm them, thus preventing the need for medication in many circumstances

39. Shaw et al 1981 Weaknesses of study: • Small size of patients • Patient population was selected to minimize co-morbidities • Study was in a alcohol treatment facility and did not incorporate the same population seen in a general medical facility, thus leading one to question its applicability there

40. Determine that CIWA testing was valid in this population Prospective study Royal Newcastle Hospital in Australia 203 adult general medical and surgical patients age 20-75 various other common co-morbidities and met criteria for alcohol withdrawal Outcomes assessed : Occurrence of severe withdrawal (confusion, hallucination, or seizures after admission) highest score prior to developing complications, or discharge use of benzodiazepines for symptoms Foy et al 1988

41. Foy et al 1988: Treatment Protocol

42. Foy et al 1988:Results

43. Mean CIWA-A Scores

44. Foy et al 1988: Conclusions • Patients who developed severe alcohol withdrawal had higher scores than other patients even before the development of complications; therefore, a severity scale used in a general hospital does predict who is at greater risk for severe withdrawal. • The higher the score the greater the risk that an untreated patient would develop severe withdrawal. • The scale can be used as a guide to treatment in a general medical facility.

45. Foy et al 1988: Conclusions • Benzodiazepines do appear to prevent complications when given early as determined by a high CIWA-A score. • The only limitations to using the CIWA-A in a general hospital were in dealing with patients who were critically ill (hypoxia, shock or septicemia) or had femur fractures, and thus require special attention.

46. CIWA Evolution: CIWA-Ar • In 1987 Sullivan et al identified that the original CIWA-A had several items that were redundant and by eliminating these, it could be more efficient to administer without losing accuracy of assessing the withdrawal severity • convulsions, quality of contact, general hallucinations, flushing, and thought disturbances were eliminated • His scale consists of vomiting, sweats, tremor, anxiety, agitation, tactile disturbances, auditory hallucinations, visual hallucinations, headache, and clouding of the sensorium

47. CIWA-Ar

48. Sullivan 1991 • He put his CIWA-Ar to test to see if it not only be valid in the assessment of alcohol withdrawal, but also serve as a guide in the treatment of the condition • He identified that patients receiving fixed-dosing of benzodiazepines may be over-medicated and thus would benefit from using the CIWA-Ar to help titrate the medication administered in a more appropriate fashion

49. Sullivan 1991: Study Design • Retrospective reviewed the medical record of 117 patients treated for alcohol withdrawal in the previous 24 months prior to CIWA-AR initiation (S- control group) • they were treated with fixed-dosing of benzodiazepines without criteria for drug administration • The S+ group consisted of 133 patients followed prospectively after the initiation of the CIWA-Ar scale over the next 24 months

50. Sullivan 1991: Protocol • Patients were evaluated hourly during the initial phases of the withdrawal period, and then as needed with the CIWA-Ar • If they had a score>10 they received Diazepam 20 mg, or Librium 100 mg orally