A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens*

Abstract

Objective-Patients with severe alcohol withdrawal and delirium tremens are frequently resistant to standard doses of benzodiazepines. Case reports suggest that these patients have a high incidence of requiring intensive care and many require mechanical ventilation. However, few data exist on treatment strategies and outcomes for these subjects in the medical intensive care unit (ICU). Our goal was a) to describe the outcomes of patients admitted to the medical ICU solely for treatment of severe alcohol withdrawal and b) to determine whether a strategy of escalating doses of benzodiazepines in combination with phenobarbital would improve outcomes. Design-Retrospective cohort study.Setting-Inner-city municipal hospital.Patients-Subjects admitted to the medical ICU solely for the treatment of severe alcohol withdrawal. Interventions-Institution of guidelines emphasizing escalating doses of diazepam in combination with phenobarbital.Measurements and Main Results-Preguideline (n = 54) all subjects were treated with intermittent boluses of diazepam with an average total and maximal individual dose of 248 mg and 32 mg, respectively; 17% were treated with phenobarbital. Forty-seven percent required intubation due to inability to achieve adequate sedation and need for constant infusion of sedative-hypnotics. Intubated subjects had longer length of stay (5.6 vs. 3.4 days; p = .09) and higher incidence of nosocomial pneumonia (42 vs. 21% p = .08). Postguideline (n = 41) there were increases in maximum individual dose of diazepam (32 vs. 86 mg; p = .001), total amount of diazepam (248 vs. 562 mg; p = .001), and phenobarbital use (17 vs. 58%; p = .01). This was associated with a reduction in the need for mechanical ventilation (47 vs. 22%; p = .008), with trends toward reductions in ICU length of stay and nosocomial pneumonia.Conclusions-Patients admitted to a medical ICU solely for treatment of severe alcohol withdrawal have a high incidence of requiring mechanical ventilation. Guidelines emphasizing escalating bolus doses of diazepam, and barbiturates if necessary, significantly reduced the need for mechanical ventilation and showed trends toward reductions in ICU length of stay and nosocomial infections.

Racial variations in the incidence of severe alcohol withdrawal

“…These years were selected due to the existence of a concurrent prospective ICU study of alcohol withdrawal care [6]. I Group 2 patients were obtained from a retrospective chart search of all medical toxicology consultations from 1999 to 2003 for patients with severe alcohol withdrawal (as defined above).…”

“…This study was approved by the Institutional Review Board and received exempt status for written consent. Authors from the two prospective studies [6,9] supplied unlinked summary data for analysis.…”

“…The use of surrogate markers for severity of alcohol withdrawal, such as ICU admission and benzodiazepine requirements, may incorporate a bias based on which patients get admitted to the ICU and receive aggressive therapy. It is possible that these results suggest different treatment practices based on race, either intentionally or unintentionally; we believe this is unlikely due to the motivation of enrollment into the prospective study [6] and the large and ethnically diverse clinical staff who treat these patients. However, presumably unintentional racial bias in medical care and referrals appears to exist in other areas of medicine [24,25].…”

Alcohol withdrawal delirium - diagnosis, course and treatment

“…Recently, there were no significant differences found concerning the duration of delirium tremens, length of hospitalization or medical complications between phenobarbital and diazepam. Escalating bolus doses of diazepam and additional barbiturates, if necessary, reduced the need for mechanical ventilation and ICU length of stay and nosocomial infection development 114,115 . There are case reports showing baclofen, a GABA-B agonist, to be effective in alcohol withdrawal delirium 116,117 , but there is not enough evidence for its safe use in uncomplicated withdrawal 118 .…”

Alcohol Withdrawal Syndrome in Critically Ill Patients: Identification, Assessment, and Management

“…48,52 Typically, the use of propofol has been reported in instances in which patients were refractory to massive doses of benzodiazepines. [60][61][62][63] In a retrospective analysis of 64 intubated patients, Sohraby et al 48 compared propofol infusion plus benzodiazepine therapy with benzodiazepine monotherapy.…”