Alcohol Withdrawal Resident Rounds July 10, 2007 Maggie Gordon, R2

Alcohol Withdrawal

Resident Rounds

July 10, 2007

Maggie Gordon, R2

Alcohol Withdrawal

Importance in surgery Definitions Pathophysiology Signs and symptoms Treatment

Importance in Surgery

Importance

~15% primary care and hospitalized patients have problem drinking

23% admitted general surgery patients meet “alcohol abuse” criteria

Early detection and intervention are very effective complications mortality

Importance

Tolerance to anaesthesia, analgesia physiologic reserve stress response morbidity, mortality ICU, hospital stays bleeding infections Tachycardias, cardiac output

Definitions

At-risk drinking

Men: > 16 drinks / week Women: > 10 drinks / week

Alcohol Abuse (DSM IV)

Maladaptive use with work / school / social / interpersonal / legal consequences

At risk of withdrawal

Alcohol Dependence (DSM IV)

Maladaptive use with ≥ 3 of: Tolerance Withdrawal Used in larger quantity than intended Desire to cut down or control use Time is spent obtaining, using, or recovering Social, occupational, or recreational tasks are

sacrificed Use continues despite physical and psychological

problems

At risk ofwithdrawal

Pathophysiology

Pathophysiology

EtOH = CNS depressant serotonin → tolerance, craving Withdrawal

GABA → arousal norepi

Signs and Symptoms

Signs and Symptoms

Spectrum of Presentation Severity Timing

Minor Withdrawal Symptoms

CNS, sympathetic activity: Insomnia Mild anxiety Palpitations Tremors Diaphoresis Headache GI upset Anorexia

Onset: 6 – 48 h post EtOH cessation

Duration: 24 – 48 h

Withdrawal Seizures

Generalized, tonic-clonic Brief post-ictal period Single episode, usually 3% → status epilepticus

Risk Factors Long Hx Chronic alcoholism

Onset: 2 – 48 h post EtOH cessation

Investigate further

Alcoholic Hallucinosis

Usually visual, specific hallucinations Occasionally auditory, tactile

Onset: 12 – 24 h post EtOH cessation

Duration: 24 – 48 h

No “clouding of sensorium”

Delirium Tremens

Hallucinations Disorientation HR BP temperature Diaphoresis Agitation

Onset: 2 – 4 days post EtOH cessation

Duration: 1 – 5 days

Autonomic instability

Delirium Tremens

cardiac output O2 consumption cerebral blood flow

Hyperventilation → Respiratory alkalosis Risk factors

Long binge Significant clouding of sensorium

Delirium Tremens

Risk Factors Sustained drinking Previous DTs > 30 y.o. Concurrent illness Delayed presentation to medical care /

assessment

Delirium Tremens

5% mortality Arrhythmias Complicating illness, e.g. pneumonia Risk factors for death

age Pulmonary disease T > 40°C Liver disease

Withdrawal SyndromesDescription Onset (since last

EtOH)Duration

Comments

MinorWithdrawal

InsomniaMild anxietyPalpitationsTremorsDiaphoresisHeadacheGI upsetAnorexia

< 6 hx 24 – 48 h

Consistent in each patient

Seizures GeneralizedTonic-clonic

2 – 48 h 3% of chronic alcoholics

AlcoholicHallucinosis

Usually visualOccasionally auditory, tactile

12 – 24 hx 24 – 48 h

No clouding of sensorium

DeliriumTremens

HallucinationsDisorientation HR BP temperatureAgitationDiaphoresis

2 – 4 dx 1 – 5 d

5% of patients w/ withdrawal

Treatment

Prevention

Pre-op CAGE questionnaire Have you ever felt the need to Cut down on

drinking? Have you ever felt Annoyed by criticism of your

drinking? Have you ever had Guilty feelings about your

drinking? Do you ever take a morning Eye opener (a drink

first thing in the morning to steady your nerves or get rid of a hangover)?

Prevention

Consider pre-op Collateral from family LET’s

Prevention

Thiamine, folate, multivitamins Abstinence Detox and rehab Referrals Early prophylaxis, i.e., before symptoms

appear

History First

EtOH use Hx of withdrawal syndromes, especially

seizures

Physical Exam

Vitals Tremor

Investigations

Blood work CBC for Hgb, platelets LFT’s

CT LP

Investigations

Rule out and treat Infection Trauma Metabolic derangements Drug overdose Liver failure GI bleeding

Diagnosis of exclusion

Keys to Therapy

Substitute drug of abuse with long-acting medication with similar effects, then taper dose

Keys to Therapy

Reevaluate frequently Avoid complacency Alleviate symptoms

Keys to Therapy

Hydrate (dehydration ← diaphoresis, T, vomiting, HR)

Correct electrolytes K ( K ← vomiting, aldosterone Δs) Mg ( Mg → DT risk) PO4 ( PO4 ← malnutrition)

Therapy

Wernicke’s encephalopathy, Korsakoff’s syndrome prophylaxis Thiamine 100 mg im / iv Folic acid 5 mg po / iv daily x 3 days Multivitamin 1 tablet po daily x indefinite

Therapy

Benzodiazepines Diazepam (Valium) 5 – 10 mg po / iv q 5-10 min Lorazepam (Ativan) 1 – 2 mg po / sl / iv q 5-10 min

liver disease → t½

First dose when CIWA ≥ 8 Titrate until patient “calm, but alert”, i.e. to

CIWA score < 16

May need “massive” doses

CIWA

Therapy

Consider prophylaxis w/out titration Emergency surgery Patient unable to communicate

Diazepam 2.5 – 10 mg po / iv q 6 h Lorazepam 0.5 – 2 mg po / iv q 6 h

Refractory Seizures, DTs

Phenobarbital 130 – 260 mg iv q 15 – 20 min Propofol 1 mg / kg iv push, intubate, then

titrate to sedation

Long-Term Therapy

Evaluation Referral to long-term follow-up

No evidence of effectiveness

References

NEJM

UpToDate

UpToDate

Symptom-Oriented Therapy

ICU patients Flunitrazepam, clonidine, halperidol

Fixed-dose

CIWA-triggered

Withdrawal severity

Worse Better

Total dose Greater Lesser

Days ventilated Greater Fewer

Pneumonia Greater Fewer

ICU stay Longer Shorter

Symptom-Triggered Doses

Fixed-dose

CIWA-triggered

Outcomes Similar

Total dose Greater Lesser

Treatment duration

Greater Lesser

Detox program Oxazepam

For Discussion

Indications for ICU Admission

Age > 40 y.o. Cardiac disease Hemodynamic instability Marked acid-base

disturbances Severe electrolyte

disturbances Respiratory insufficiency Potentially serious

infections

GI pathology Persistent hyperthermia Rhabdomyolysis Renal insufficiency Previous DTs, seizures Need for high doses of

sedatives, iv therapy

UpToDate