1. Dr SumitChandak Asst. Prof, Department of Psychiatry SKNMC
& GH Management of Alcohol Withdrawal
2. Objectives: Identifying an at risk patient. Assessment for
severity of withdrawal in at risk patient. Complications of alcohol
withdrawal and their assessment. Management of alcohol withdrawal
and its complications.
3. Identify at risk individuals:- Need to identify at risk
individuals:- Low detection rates High rates of Mx/Sx complications
when undetected
4. Identifying an at risk patient : Elicit: History of alcohol/
substance use in all patients. Ask Pattern of use Duration of use
Quantity of use Time since last drink May not be possible when
acutely intoxicated acute trauma Then ask : friends family members
Look for:- Smell of alcohol in the breath Features of withdrawal
Tremors Tachycardia -BP Obtain blood alcohol level- if
possible
5. To identify potential problem drinkers: Use screening tool:
CAGE questionnaire. C: Have you ever felt you should cut down on
your drinking? A: Have people annoyed you by criticizing your
drinking ? G: Have you ever felt bad or guilty about your drinking
? E: Have you ever had a drink first thing in the morning to steady
your nerves or get rid of a hangover (eye opener)?
6. Assessment in at risk patient: Primarily for: factors
predisposing to complications severity of withdrawal
7. Assessment for predisposing factors: Metabolic disturbances:
Hypoglycemia Lactic acidosis Ketoacidosis Na, Ca2+,Mg ed / ed K. ed
Triglycerides Cardiac problems : most common Serious post op
problems sec to: Risk of CAD ed cardiovascular stress sec to
withdrawal G.I. problems: PUD Hepatitis Hematological monitoring:
As alcohol suppresses bone marrow Presence of neurological
factors
8. For severity of withdrawal : Clinical monitoring intensively
for first few days. For s/s of alcohol withdrawal Sx population :
can use scales like CIWA-AI
9. CIWA-Ar Clinical Institute withdrawal assessment of Alcohol
scale , revised Observation on 10 parameters. Nausea and vomiting
Tactile disturbances Tremor Auditory disturbance Paroxysmal sweats.
Visual disturbances Anxiety
10. CIWA-Ar Clinical Institute withdrawal assessment of Alcohol
scale , revised Scores max possible: 67 Interpretation 6-7 mild
withdrawal 8-14 : moderate withdrawal >15: severe
withdrawal
11. Complication of withdrawal state: Delirium: can occur
anytime within 7days Seizures: usually around 3 day of last drink
Other : Wernickes encephalopathy Psychosis Depression
12. Delirium Definition: The hallmark symptom of delirium is an
impairment of consciousness, usually accompanied by global
impairments of cognitive functions; generally associated with
emotional labiality, hallucinations or illusions, and
inappropriate, impulsive, irrational, or violent behavior.
Generally considered to be an acute reversible disorder but can
become irreversible.
13. Delirium Diagnostic criteria: A] Disturbance of
consciousness (i.e. reduced clarity of awareness of the
environment) with reduced ability to focus, sustain, or shift
attention. B] A change in cognition (such as memory deficit ,
disorientation, language disturbance) or the development of a
perceptual disturbance that is not better accounted for by a
preexisting, established, or evolving dementia .
14. Delirium: Diagnostic criteria: C] The disturbance develops
over a short period of time (usually hours to days) and tends to
fluctuate during the course of the day. D] There is evidence from
the history, physical examination, or laboratory findings of either
(1) or (2): 1] The symptoms in Criteria A and B developed during
substance intoxication. 2] Medication use is etiologically related
to the disturbance.
15. Delirium Assessment: Points to remember: fluctuating
orientation Sequence of disorientation: T->PL->PE Sequence of
re-orientation: PE->PL->T ASK for TIME:
time/day/date/month/year PLACE: where are you/On what floor PERSON:
Check for recognition of relatives/confabulation Cross check data
with relative/attendant
16. Management of alcohol withdrawal / risk patient: In at risk
patient promote abstinence for at least 4 weeks of an elective
pre-op procedure as it decreases morbidity from 74% -31% Modalities
of Intervention: 1]Pharmacotherapy : Substitute Adjuvant 2]
Counseling
17. Pharmacotherapy: Substituent : Act on GABA receptors &
mimic the action of alcohol: Lorazepam :poimiv Librium : po only
Dosing depends on : severity of withdrawal presence of hepatic
dysfunction altered neurological states 1st 24 hours: fixed dosing
schedule flexible dosing schedule
18. Pharmacotherapy Fixed dosing :Depending on the Quantity,
Quality of alcohol and the time of last drink consumed. For Ex:
Librium (10/25): 1-1-2 0-1-2 0-0-2 Lopez (2) : 2-2-2 1-1-2 Caution:
Monitor Respiratory Rate
19. Pharmacotherapy: Flexible dosing admission monitor fors/s
of withdrawal : IF PRESENT: IF ABSENT: If present Give Librium (10)
2 stat Monitor 2 hourly If increased F/O withdrawal If decreased
Continued monitoring 2 hourly If absent Monitor 4 hourly If
present
20. Pharmacotherapy Dose obtained at end of 24hours is the
total dose required by that individual Continue on the same dose
for 48 hours. Then taper by 20% every day every day, till
eliminated.
21. Pharmacotherapy: Adjuvant :For symptomatic control: 1]
Propranolol 2]CBZ For metabolic parameters : Plenty of oral fluids
Injection Thiamine/MVBC before any I.V. fluids especially
containing sugar Tb Thiamine 75/100mg bid
22. M/M of Delirium : Rule out other causes Lab: Se
Electrolytes, BSL, LFT, RFT SOS: EEG M/M: Pharmacotherapy as above
Restrain the patient Keep the lights on at night Frequently talk to
& reorient the patients Correct electrolyte imbalance and
underlying hepatic d/o if any When protracted - ECT
23. THANK YOU
24. DOS FOR DELIRIUM: Employ environmental interventions to
reduce factors that may exacerbate delirium. These interventions
include changing the lighting to cue day and night, reducing
monotony and overstimulation and understimulation, correcting
visual and auditory impairments (e.g., retrieve glasses, hearing
aids), and rendering the patients environment less alien by having
familiar people and objects present (e.g., family
photographs).
25. DOS FOR DELIRIUM Reorient the patient to person, place,
time, and circumstances. Reorientation should be provided by all
who come into contact with the patient. Provide reassurance to
patients that the deficits they are experiencing are common but
usually temporary and reversible.
26. DONTS FOR DELIRIUM Unnecessarily restrain the patient Avoid
Anticholinergics drugs like Phenergan in delirium especially
alcohol withdrawal