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Alcohol Withdrawal

Alcohol Withdrawal. Timeline and treatment. Stats. 8 Million alcoholics in the US 500,000 episodes of withdrawal requiring medication per year Daily drinking for 7-34 days will cause minor withdrawal in most people Daily drinking for 36-84 days will cause major withdrawal symptoms. Why?.

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Alcohol Withdrawal

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  1. Alcohol Withdrawal Timeline and treatment

  2. Stats • 8 Million alcoholics in the US • 500,000 episodes of withdrawal requiring medication per year • Daily drinking for 7-34 days will cause minor withdrawal in most people • Daily drinking for 36-84 days will cause major withdrawal symptoms

  3. Why? • EtOH is a CNS depressant • Abrupt withdrawal causes compensatory over stimulation • GABA: major CNS inhibitor, and receptor is downregulated with EtOH consumption • NE: elevates with EtOH withdrawal due to a decrease in the alpha-2 receptor-mediated inhibition of presynaptic norepinephrine release • Serotonin: implicated in tolerance and craving for alcohol

  4. Minor withdrawal symptoms • Insomnia • Tremulousness • Mild anxiety • Gastrointestinal upset • Headache • Diaphoresis • Palpitations • Anorexia

  5. Minor • Present within 6 hours of last drink • Even if BAL is still elevated • Resolves in 24-48 hours

  6. Withdrawal Seizures • Generalized tonic-clonic convulsions • Occur within 48 hours of last drink, but may occur as soon as 2 hours from last drink • 3 percent of chronic alcoholics have withdrawal-associated seizures • of those, 3 percent develop status epilepticus

  7. Alcoholic Hallucinosis  • Not synonymous with delirium tremens • develop within 12 to 24 hours of abstinence • resolve within 24 to 48 hours (when DT starts) • Usually visual, may be tactile or auditory

  8. DELIRIUM TREMENS  • 5% of alcoholics • hallucinations, disorientation, tachycardia, hypertension, low grade fever, agitation, and diaphoresis • 48-96 hours after last drink, and lasts 1-5 days

  9. DT • Risk Factors • A history of sustained drinking • A history of previous DTs • Age greater than 30 • The presence of a concurrent illness • A greater number of days since the last drink (for example, patients who present more than two days after their last drink for treatment of alcohol withdrawal are more likely to experience DTs than those who present within two days)

  10. DT • Mortality rate of 5% • Mortality associated with • Arrhythmias • Pneumonia

  11. DT • Clinical manifestation • hallucinations, disorientation, tachycardia, hypertension, low-grade fever, agitation, diaphoresis, elevated cardiac indices, oxygen delivery, and oxygen consumption • Respiratory alkalosis • Hypokalemia and hypomagnesemia

  12. Treatment • Bad actor • infection, trauma, metabolic derangements, drug overdose, hepatic failure, or gastrointestinal bleeding • Rule out comorbid conditions • Frequent assessment • Correct metabolic derrangements • Quiet and protective environment • Thiamine first, then glucose infusion for volume deficit

  13. Treatment • Benzos • treat the psychomotor agitation • prevent progression from minor withdrawal symptoms to major ones • Valium and Librium most common • PO route preferred but may give IV prn • Intravenous diazepam, 5 to 10 mg IV every five minutes until the patient is calm

  14. Treatment • Fixed schedule therapy, in which a benzodiazepine is given at fixed intervals even if symptoms are absent, is most useful in patients at high risk of major withdrawal symptoms • Healthy pt’s should be kept lightly sedated • Pt’s with comorbidities, especially cardiac, should be more heavily sedated

  15. Treatment • Symptom-triggered therapy • Clinical Institute Withdrawal Assessment for Alcohol Scale • Given when >8 • Fewer benzos given, shorter course of therapy

  16. Clinical institute withdrawal assessment scale for alcohol, revised (CIWA-Ar)

  17. CIWA-Ar • Total score is a simple sum of each item score (maximum score is 67). • Score:<10: Very mild withdrawal • 10-15: Mild withdrawal • 16-20: Modest withdrawal • >20: Severe withdrawal

  18. Treatment • Refractory DT • Probably d/t low GABA • Barbituates used (phenobarbital) or propofol • Do NOT use anti-psychotics (lowers sz threshold), anticonvulsants, baclofen, clonidine

  19. In summary… • Careful H&P to determine risk of withdrawal and DT • Pt’s with h/o sz, DT or major EtOH withdrawal should be on scheduled dosing of Valium or Librium • Pt’s at risk for withdrawal should be closely monitored and treated if Clinical Institute Withdrawal Assessment for Alcohol Scale is >8 • DT treated with IV valium until stable • Refractory DT treated with phenobarbital or propofol

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