1288: Evaluation of Phenobarbital for Prevention of Alcohol Withdrawal in Trauma Patients

Kip, Lindsey; Forni, Allison; Dorfman, Jon D.; Li, Irene

doi:10.1097/01.ccm.0000910888.02046.98

Cited by 3 publications

(7 citation statements)

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“…Our findings are consistent with a recent publication by Kip et al that demonstrated a lower need for rescue therapy without increased AEs with the use of prophylactic phenobarbital in trauma patients. 22 In their study, 44% of patients were admitted to the ICU for phenobarbital initiation, phenobarbital use was not protocolized with only 13% received a phenobarbital loading dose, and HLOS was 5 days longer in the phenobarbital group. In contrast, our study provides a protocolized approach in which none of our patients were admitted to the ICU for phenobarbital initiation and HLOS was similar between PRE and POST groups.…”

Section: Discussionmentioning

confidence: 99%

“Should We Phenobarb-it-All?” A Phenobarbital-Based Protocol for Non-Intensive Care Unit Trauma Patients at High Risk of or Experiencing Alcohol Withdrawal

Wang,

Falank,

Simboli

et al. 2024

The American Surgeon™

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Background Alcohol use is frequent in trauma patients and alcohol withdrawal syndrome (AWS) is associated with significant morbidity. Benzodiazepines are commonly used for AWS, but may cause neurologic and respiratory adverse events (AEs). The objective was to evaluate the effectiveness and safety of a phenobarbital-based protocol for the treatment of AWS in non-intensive care unit (ICU) trauma patients. Methods Adult non-ICU trauma patients at high risk of or experiencing AWS PRE and POST implementation of a phenobarbital-based protocol were included. Outcomes were AWS-related complications (AWS-RC), benzodiazepine use, adjunctive medication use, hospital length of stay (HLOS), and medication-related AEs. Subgroup analyses were performed on patients with traumatic brain injury (TBI), rib fractures, and at high risk of severe AWS. Results Overall, 110 patients were included (51 PRE, 59 POST). AWS-RC developed in 17 PRE patients compared to 10 POST patients (33% vs 17%; P = .05). PRE patients were more likely to receive benzodiazepines (88% vs 42%, P < .0001) and higher total dose (11 vs 4 mg lorazepam equivalent; P = .001). No difference noted in HLOS (8 vs 8 days, P = .27), adjunctive medication use (49% vs 54%, P = .60), or AEs (57% vs 39%, P = .06). There was no difference in AWS-RC in the TBI subgroup ( P = .19), less AEs in the rib fracture POST subgroup ( P = .04), and less AWS-RC in the high risk of severe AWS POST subgroup ( P = .03). Discussion A phenobarbital-based protocol in trauma patients is effective in preventing AWS-RC and decreasing benzodiazepine use without increasing AEs.

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Section: Discussionmentioning

confidence: 99%

“Should We Phenobarb-it-All?” A Phenobarbital-Based Protocol for Non-Intensive Care Unit Trauma Patients at High Risk of or Experiencing Alcohol Withdrawal

Wang,

Falank,

Simboli

et al. 2024

The American Surgeon™

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“…There has been significant recent interest in using phenobarbital for treating AWS, but our protocol differs in that it does not use barbiturates. [8][9][10]21,22 While phenobarbital appears to be safe and effective, it requires intense monitoring, most often in an ICU setting. In addition, it is primarily administered for active withdrawal, although there are some data that suggest that it is feasible in the prevention of AWS.…”

Section: Discussionmentioning

confidence: 99%

“…7 Benzodiazepine-sparing protocols for both AWS prophylaxis and treatment exist within the medical literature, but the data to support their use in the trauma population are limited and primarily use phenobarbital. [8][9][10] Our group reviewed the AWS risk screening questionnaire published by Maldonado et al 11,12 in 2014 and their group's subsequent benzodiazepine-sparing protocol and modified the pharmacologic algorithm for use on our trauma service. Our aim was to create a protocol for management of AWS within the trauma population that incorporated risk stratification, prophylaxis, and treatment while also considering the physiologic effects of injury.…”

mentioning

confidence: 99%

Eliminating the benzos: A benzodiazepine-sparing approach to preventing and treating alcohol withdrawal syndrome

McCullough,

Miller,

Martin

et al. 2023

J Trauma Acute Care Surg

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Background Alcohol withdrawal syndrome (AWS) represents significant cost to the hospitalized trauma population from a clinical and financial perspective. Historically, AWS has been managed with benzodiazepines. Despite their efficacy, benzodiazepines carry a heavy side effect profile. Recently, benzodiazepine sparing protocols for the prophylaxis and treatment of AWS have been used in medical patient populations. Most existing benzodiazepine-sparing protocols utilize phenobarbital while ours primarily utilizes gabapentin and clonidine, and no such protocol has been developed and examined for safety and efficacy specifically within a trauma population. Methods In December of 2019, we implemented our benzodiazepine-sparing protocol for trauma patients identified at risk for alcohol withdrawal on admission. Trauma patients at risk for AWS admitted to an academic Level 1 trauma center before (CONV) and after (BS) protocol implementation were compared. Outcomes examined include morphine milligram equivalent (MME) dosing rates, lorazepam equivalent dosing rates as well as the Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) scores, hospital length of stay (LOS), ICU (Intensive Care Unit) LOS, and ventilator days. Results 387 conventional (CONV) and 134 benzodiazepine sparing (BS) patients were compared. ISS (13 vs 16, p = 0.10) and admission alcohol levels (99 vs 149, p = 0.06) were similar. Patients in the BS pathway had a lower maximum daily CIWA-Ar (2.7 vs 1.5, p = 0.04). While mean MME/day was not different between groups (31.5 vs 33.6, p = 0.49), mean lorazepam equivalents per day was significantly lower in the BS group (1.1 vs 0.2, p < 0.01). LOS and vent days were not different between the groups. Conclusions Implementation of a benzodiazepine-sparing pathway that utilizes primarily clonidine and gabapentin to prevent and treat alcohol withdrawal syndrome in trauma patients is safe, reduces the daily maximum CIWA-Ar, and significantly decreases the need for benzodiazepines. Future studies will focus on outcomes affected by avoiding AWS and benzodiazepines in the trauma population. Level of Evidence IV, Therapeutic/care management

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“…3 Much focus has been placed on avoiding benzodiazepines in the treatment of AWS, with a recent emphasis on the successful use of other medications including phenobarbital. 4,5 Gabapentin, a drug frequently utilized in our pathway, has recently been shown to be efficacious in treating alcohol use disorder in patients with a history of AWS. 6 The authors cited Leung et al in the evaluation of gabapentin for AWS.…”

mentioning

confidence: 99%

“…An excellent review of the literature regarding clonidine and other medications utilized in our protocol was cited in our original article, but we have cited it again here for the authors’ convenience 3 . Much focus has been placed on avoiding benzodiazepines in the treatment of AWS, with a recent emphasis on the successful use of other medications including phenobarbital 4,5 . Gabapentin, a drug frequently utilized in our pathway, has recently been shown to be efficacious in treating alcohol use disorder in patients with a history of AWS 6 .…”

mentioning

confidence: 99%

Reply to letter to the editor: Eliminating the benzos: A benzodiazepine-sparing approach to preventing and treating alcohol withdrawal syndrome

Martin,

Rebo,

Stettler

et al. 2024

J Trauma Acute Care Surg

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achieved rapid symptom triggered tapering (in as little as nine hours 2 ). The inclusion of BS "prophylaxis" patients similarly conflated patients who required therapy with those who did not, or those who could similarly have achieved rapid tapering.The appropriateness of the assessment tools requires further explication, and the study appears underpowered and ill designed for adequate assessment of adverse events. Clonidine and dexmedetomidine predictably blunt adrenergic components of the CIWA-Ar and modified Minnesota Detoxification Scale assessment toolstremor, diaphoresis, pulse, diastolic pressure, etc.-making them appear "therapeutic" and improve AW, without addressing central pathophysiology. The trivial reported differences in daily CIWA-Ar (2.7 vs. 1.5), is likely explained by decreased scoring of assessment elements affected by clonidine. Analogously, beta-adrenergic antagonists demonstrably improved CIWA-Ar scores, but were abandoned as inappropriate AW therapy. Prediction of Alcohol Withdrawal Severity Scale score validation in trauma patients, who would be expected to have altered autonomic activity, should be referenced. The authors report clonidine discontinuation due "to relative hypotension," while setting the high bar for sequelae of acute kidney injury and vasopressors. Blood pressure and pulse decreases and orthostatics at the patient and population level (medians, range, maximums), need for volume resuscitation, additional pharmacological agents, and induced fall risk (so assiduously being avoided by BS) are omitted. In addition, AW measures that matter such as total days of required therapy; need for AW rescue medications; incidence of disorientation, agitation, seizures, hallucinations, and delirium tremens; restraint use; intubation for AW; and mortality in severe AW are unreported.The BS protocol is not a "major advancement in the care of AWS." 1 It presents a methodologically confounded abandonment of efficacious, patient-triggered therapies, administration of multiple potentially unneeded, inferior, or demonstrably harmful agents, and a regression to a "q shift," provider-centered mentality, which the authors ultimately demonstrated was harmful, at a minimum, to ICUAW patients. We urge institutions to adopt a patient-centered approach with proven symptom-triggered agents with appropriate adjuvants. AUTHORSHIPAll authors contributed to the study conception and design. All authors read and approved the final article as submitted. DISCLOSUREJTACS Disclosure forms have been supplied and are provided as supplemental digital content (http://links. lww.com/TA/D540).

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1288: Evaluation of Phenobarbital for Prevention of Alcohol Withdrawal in Trauma Patients

Cited by 3 publications

References 0 publications

“Should We Phenobarb-it-All?” A Phenobarbital-Based Protocol for Non-Intensive Care Unit Trauma Patients at High Risk of or Experiencing Alcohol Withdrawal

“Should We Phenobarb-it-All?” A Phenobarbital-Based Protocol for Non-Intensive Care Unit Trauma Patients at High Risk of or Experiencing Alcohol Withdrawal

Eliminating the benzos: A benzodiazepine-sparing approach to preventing and treating alcohol withdrawal syndrome

Reply to letter to the editor: Eliminating the benzos: A benzodiazepine-sparing approach to preventing and treating alcohol withdrawal syndrome

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