Alcohol Withdrawal

Chapter

Abstract

Alcohol withdrawal is a common problem afflicting patient in many ICUs around the world and across specialties. This is a force of altered cognition that, if left unchecked, can lead to significant challenges in the care of the critically ill and injured. Alcohol withdrawal is a syndrome borne of the sudden cessation of chronic or heavy alcohol ingestion. Its symptoms present on a spectrum and vary in severity. Severe alcohol withdrawal generally involves the manifestation of delirium in combination with symptomatology consistent with alcohol withdrawal. The mainstay of treatment remains benzodiazepines, although many adjuncts have been described in recent years including barbiturates, propofol, and dexmedetomidine.

Keywords

Alcohol withdrawal Ethanol Sedation CIWA Seizures Benzodiazepines 

References

  1. 1.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.CrossRefGoogle Scholar
  2. 2.
    Schuckit MA. Recognition and management of withdrawal delirium (delirium tremens). N Engl J Med. 2014;371(22):2109–13.CrossRefGoogle Scholar
  3. 3.
    Kosten TR, O’Connor PG. Management of drug and alcohol withdrawal. N Engl J Med. 2003;18(348):1786–95.CrossRefGoogle Scholar
  4. 4.
    Schmidt KJ, Doshi MR, Holzhausen JM, Natavio A, Cadiz M, Winegardner JE. Treatment of severe alcohol withdrawal. Ann Pharmacother. 2016;50(5):389–401.CrossRefGoogle Scholar
  5. 5.
    Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict. 1989;84(11):1353–7.CrossRefGoogle Scholar
  6. 6.
    Mainerova B, Prasko J, Latalova K, et al. Alcohol withdrawal delirium - diagnosis, course and treatment. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2015;159(1):44–52.PubMedGoogle Scholar
  7. 7.
    Mayo-Smith MF, Beecher LH, Fischer TL, et al. Management of alcohol withdrawal delirium. An evidence-based practice guideline. Arch Intern Med. 2004;164(13):1405–12.CrossRefGoogle Scholar
  8. 8.
    Khan A, Levy P, DeHorn S, et al. Predictors of mortality in patients with delirium tremens. Acad Emerg Med. 2008;15(8):788–90.CrossRefGoogle Scholar
  9. 9.
    Gold JA, Rimal B, Nolan A, Nelson LS. A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens. Crit Care Med. 2007;35(3):724–30.CrossRefGoogle Scholar
  10. 10.
    Duby JJ, Berry AJ, Ghayyem P, et al. Alcohol withdrawal syndrome in critically ill patients: protocolized versus nonprotocolized management. J Trauma Acute Care Surg. 2014;77(6):938–43.CrossRefGoogle Scholar
  11. 11.
    Carlson RW, Kumar NN, Wong-Mckinstry E, et al. Alcohol withdrawal syndrome. Crit Care Clin. 2012;28(4):549–85.CrossRefGoogle Scholar
  12. 12.
    Schabelman E, Kuo D. Glucose before thiamine for Wernicke encephalopathy: a literature review. J Emerg Med. 2012;42(4):488–94.CrossRefGoogle Scholar
  13. 13.
    Flannery AH, Adkins DA, Cook AM. Unpeeling the evidence for the banana bag: evidence-based recommendations for the management of alcohol-associated vitamin and electrolyte deficiencies in the ICU. Crit Care Med. 2016;44(8):1545–52.CrossRefGoogle Scholar
  14. 14.
    Donnino MW, Vega J, Miller J, Walsh M. Myths and misconceptions of Wernicke’s encephalopathy: what every emergency physician should know. Ann Emerg Med. 2007;50(6):715–21.CrossRefGoogle Scholar
  15. 15.
    Mayo-Smith MF. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA. 1997;9(2):144–51.CrossRefGoogle Scholar
  16. 16.
    Lejoyeux M, Solomon J, Adès J. Benzodiazepine treatment for alcohol-dependent patients. Alcohol Alcohol. 1998;33(6):563–75.CrossRefGoogle Scholar
  17. 17.
    Kleber HD, Weiss RD, Anton Jr. RF, et al. American Psychiatric Association. [Online]; 2006 [cited 2017 Jan. Available from https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines.
  18. 18.
    World Health Organization. [Online]; 2012 [cited 2017 Jan. Available from http://www.who.int/mental_health/mhgap/evidence/alcohol/q2/en/.
  19. 19.
    Weaver MF, Hoffman HJ, Johnson RE, Mauck K. Alcohol withdrawal pharmacotherapy for inpatients with medical comorbidity. J Addict Dis. 2006;25(2):17–24.CrossRefGoogle Scholar
  20. 20.
    Saitz R, Mayo-Smith MF, Roberts MS, et al. Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial. JAMA. 1994;272(7):519–23.CrossRefGoogle Scholar
  21. 21.
    Daeppen JB, Gache P, Landry U, et al. Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial. Arch Intern Med. 2002;162(10):1117–21.CrossRefGoogle Scholar
  22. 22.
    Jaeger TM, Lohr RH, Pankratz VS. Symptom-triggered therapy for alcohol withdrawal syndrome in medical inpatients. Mayo Clin Proc. 2001;76(7):695–701.CrossRefGoogle Scholar
  23. 23.
    Rosenson J, Clements C, Simon B, et al. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo-controlled study. J Emerg Med. 2013;44(3):592–8.CrossRefGoogle Scholar
  24. 24.
    Pandharipande PP, Pun BT, Herr DL, et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA. 2007;298(22):2644–53.CrossRefGoogle Scholar
  25. 25.
    Riker R, Shehabi Y, Bokesch P, et al. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA. 2009;301(5):489–99. Skrupky LP, Drewry AM, Wessman B, et al. Clinical effectiveness of a sedation protocol minimizing benzodiazepine infusions and favoring early dexmedetomidine: a before-after study. Crit Care. 2016;19(136).Google Scholar
  26. 26.
    Crispo AL, Daley MJ, Pepin JL, et al. Comparison of clinical outcomes in nonintubated patients with severe alcohol withdrawal syndrome treated with continuous-infusion sedatives: dexmedetomidine versus benzodiazepines. Pharmacotherapy. 2014;34(9):910–7.CrossRefGoogle Scholar
  27. 27.
    Lizotte RJ, Kappes JA, Bartel BJ, et al. Evaluating the effects of dexmedetomidine compared to propofol as adjunctive therapy in patients with alcohol withdrawal. Clin Pharmacol. 2014;31(6):171–7.Google Scholar
  28. 28.
    Frazee EN, Personett HA, Leung JG, et al. Influence of dexmedetomidine therapy on the management of severe alcohol withdrawal syndrome in critically ill patients. J Crit Care. 2014;29(2):298–302.CrossRefGoogle Scholar
  29. 29.
    Mueller SW, Preslaski CR, Kiser TH, et al. A randomized, double-blind, placebo-controlled dose range study of dexmedetomidine as adjunctive therapy for alcohol withdrawal. Crit Care Med. 2014;42(5):1131–9.CrossRefGoogle Scholar
  30. 30.
    Bielka K, Kuchyn I, Glumcher F. Addition of dexmedetomidine to benzodiazepines for patients with alcohol withdrawal syndrome in the intensive care unit: a randomized controlled study. Ann Intensive Care. 2015;5(33)Google Scholar
  31. 31.
    Liu J, Wang LN. Baclofen for alcohol withdrawal. Cochrane Database Syst Rev. 2013;28(2):1–33, CD008502.Google Scholar
  32. 32.
    Wong A, Benedict NJ, Armahizer MJ, Kane-Gill SL. Evaluation of adjunctive ketamine to benzodiazepines for management of alcohol withdrawal syndrome. Ann Pharmacother. 2015;49(1):14–9.CrossRefGoogle Scholar
  33. 33.
    Eyer F, Schreckenberg M, Hecht D, et al. Carbamazepine and valproate as adjuncts in the treatment of alcohol withdrawal syndrome: a retrospective cohort study. Alcohol Alcohol. 2011;46(2):177–84.CrossRefGoogle Scholar
  34. 34.
    Pani PP, Trogu E, Pacini M, Maremmani I. Anticonvulsants for alcohol dependence. Cochrane Database Syst Rev. 2014;(2):CD008544.Google Scholar
  35. 35.
    Fullwood JE, Mostaghimi Z, Granger CB, et al. Alcohol withdrawal prevention: a randomized evaluation of lorazepam and ethanol--a pilot study. Am J Crit Care. 2013;22(5):398–406.CrossRefGoogle Scholar
  36. 36.
    Gipson G, Tran K, Hoang C, Treggiari M. Comparison of enteral ethanol and benzodiazepines for alcohol withdrawal in neurocritical care patients. J Clin Neurosci. 2016;31:88–91.CrossRefGoogle Scholar
  37. 37.
    Gower WE, Kersten H. Prevention of alcohol withdrawal symptoms in surgical patients. Surg Gynecol Obstet. 1980;151(3):382–4.PubMedGoogle Scholar
  38. 38.
    Hansbrough JF, Zapata-Sirvent RL, Carroll WJ, et al. Administration of intravenous alcohol for prevention of withdrawal in alcoholic burn patients. Am J Surg. 1984;148(2):266–9.CrossRefGoogle Scholar
  39. 39.
    Eggers V, Tio J, Neumann T, et al. Blood alcohol concentration for monitoring ethanol treatment to prevent alcohol withdrawal in the intensive care unit. Intensive Care Med. 2002;28(10):1475–82.CrossRefGoogle Scholar
  40. 40.
    Weinberg JA, Magnotti LJ, Fischer PE, et al. Comparison of intravenous ethanol versus diazepam for alcohol withdrawal prophylaxis in the trauma ICU: results of a randomized trial. J Trauma. 2008;64(1):99–104.CrossRefGoogle Scholar
  41. 41.
    DiPaula B, Tommasello A, Solounias B, McDuff D. An evaluation of intravenous ethanol in hospitalized patients. J Subst Abus Treat. 1998;15(5):437–42.CrossRefGoogle Scholar
  42. 42.
    Nunn J, Erdogan M, Green RS. The prevalence of alcohol-related trauma recidivism: a systematic review. Injury. 2016;47(3):551–8.CrossRefGoogle Scholar
  43. 43.
    Gentilello LM, Duggan P, Drummond D, et al. Major injury as a unique opportunity to initiate treatment in the alcoholic. Am J Surg. 1988;156(6):558–61.CrossRefGoogle Scholar
  44. 44.
    Gentilello LM, Rivara FP, Donovan DM, et al. Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence. Ann Surg. 1999;230(4):473.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Surgery, Division of TraumaAcute Care and Critical Care, Ruby Memorial Hospital, WVU MedicineMorgantownUSA
  2. 2.WVU Critical Care and Trauma Institute, Department of SurgeryRuby Memorial Hospital, WVU MedicineMorgantownUSA

Personalised recommendations