Alcohol Withdrawal

Background Definition

Ethanol is the most common drug of abuse in the world, by far the most costly in lives lost and dollars spent. 5% of Americans are heavy drinkers (≥8 drinks/wk for♀ or ≥15 drinks/wk for♂) and 50% of heavy drinkers experience alcohol withdrawal. Despite the frequency, alcohol withdrawal (or AWS) is frequently misdiagnosed (and under-treated) in the ICU.

Heavy drinking for as little as 15 days is sufficient to precipitate EtOH W/D.

Pathophysiology

Consumption of large quantities of EtOH leads to constitutive GABAergic signaling and compensatory upregulation of NMDA and other excitatory neurotransmitters. Removal of EtOH & its inhibitor effects leads to over-excitation of neurons. This causes a range of syndromes over hours to days.

SCORING ALCOHOL WITHDRAWAL SYNDROME (AWS):

PAWSS:

· Validated 10 item questionnaire divided into 3 parts combines interview, blood EtOH level, Sx

· Screening tool used to identify patients at risk for severe withdrawal (Se = 93% & Sp = 99.5%)

· Requires pt participation, limited by AMS

· Score ≥ 4 = HIGH RISK for moderate to severe withdrawal

MAXIMUM SCORE. = 10 POINTS

score greater than or equal to 4 is consistent with high risk of severe withdrawal

Work up

Labs:

CBC, BMP, Mg, Phos, LFTs, EtOH level, TSH Consider toxic alcohol panel

HEAD CT:

Helps differentiate alternative causes

EEG:

For new onset seizure & status epilepticus

May see ↓ amplitude of theta/delta waves

Thiamine: cofactor in glucose metabolism

· Consider 100 mg IV or IM prophylaxis (avoid giving PO)

· Concern for Wernicke’s Encephalopathy: 500mg IV/IM q8h

· earlier initiation, faster the recovery

Folate: Deficiency causes megaloblastic anemia

· Consider 1 mg q24 hours

Electrolytes: Hypokalemia common & requires repletion

- Hypomagnesemia & Hypophosphatemia may also be seen

- Fluids: Typically high insensible losses; consider replacement

Recommended Treatment

Valium, Diazepam 10-20 mg q5-q10 minutes

PO, PR, IM, IV 1-3 minutes, duration < 1 hours

Chlordiazepoxide 50-100mg librium PO repeated q2-3 hours duration 24 - 48 hours

Symptom triggered therapy is preferable to scheduled (less sedation, shorter treatment duration; however patients with severe AWS may require frequent re-dosing.

Resistant no consistent definition for refractory > 50mg diazepam (valium) or 10mg lorazepam (ativan) in 1 hour

benzodiazepine infusion

DEXMETOMIDINE infusion: Possible BZD adjunctreduces BZD dose, may reduce need for intubation, & may ↑ or ↓ hospital LOS. Monitor for bradycardia.

CLONIDINE 0.1 – 0.2 mg PO: Used to reduce autonomic symptoms of withdrawal. Max 1.2 mg/day.

HALOPERIDOL 2.5 – 5 mg IV/IM q 4 hrs: Used for persistent agitation. Does not replace BZD or PHB. Use with caution as can lower seizure threshold & impair heat dissipation. Check ECG prior and monitor QTc.

BACLOFEN & KETAMINE- theoretic benefits; limited literature to support their use. Avoid.