Alcohol withdrawal severity is decreased by symptom-orientated adjusted bolus therapy in the ICU

Spies, Claudia; Otter, Hilke; Hüske, Bernd; Sinha, Pranav; Neumann, Tim; Rettig, Jordan S.; Lenzenhuber, Erika; Kox, Wolfgang J.; Sellers, Edward M.

doi:10.1007/s00134-003-2033-3

Cited by 118 publications

(72 citation statements)

References 29 publications

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“…Although the incidence of mechanical ventilation was high (47%), it is in agreement with small case series of subjects with benzodiazepine-resistant AWS and in postoperative surgical patients treated with bolusdose therapy of benzodiazepines (9,14). In concert with these studies, the use of mechanical ventilation was associated with a higher ICU LOS and development of nosocomial infections, suggesting that a strategy aimed at reducing the need for mechanical ventilation may improve overall clinical outcomes (14).…”

Section: Discussionsupporting

confidence: 77%

“…Another limitation is the lack of objective withdrawal categorization such as attained with use of the clinical institute withdrawal assessment for alcohol scale. CIWA scores have been used by numerous investigators for triggering bolus therapy for symptom-triggered therapy of alcohol withdrawal both in a detoxification setting and in the ICU in postsurgical/trauma patients (4,5,14). Consequently, we cannot fully exclude that differences were not due to subtle differences in the severity of withdrawal in the pre-and postguideline cohorts.…”

Section: Discussionmentioning

confidence: 97%

“…Spies et al (14) demonstrated that in surgical/trauma patients who developed AWS in the ICU, symptom-triggered therapy with boluses of benzodiazepines was associated with less need for mechanical ventilation and a reduction in nosocomial infections. However, the main indication for ICU admission in those studies was their underlying surgical diagnosis, making it difficult to extrapolate these data to medical patients whose sole reason for ICU admission is severe AWS.…”

Section: Discussionmentioning

confidence: 99%

“…In one study, five of six subjects with benzodiazepine resistance, as defined previously, required intubation (9). Once patients are admitted to the ICU, numerous studies document the course and treatment of surgical patients who develop AWS postoperatively and/or posttrauma (3,13,14). In these subjects, symptom-triggered therapy results in lower rates of complications and improved outcomes, although nearly 65% required reinstitution of mechanical ventilation (14).…”

mentioning

confidence: 97%

“…Once patients are admitted to the ICU, numerous studies document the course and treatment of surgical patients who develop AWS postoperatively and/or posttrauma (3,13,14). In these subjects, symptom-triggered therapy results in lower rates of complications and improved outcomes, although nearly 65% required reinstitution of mechanical ventilation (14). However, the preexisting surgical diagnosis makes it difficult to generalize these results to medical patients admitted to the ICU solely for treatment of AWS.…”

mentioning

confidence: 99%

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

Gold

Rimal

Nolan

et al. 2007

Critical Care Medicine

154

164

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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.

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Section: Discussionsupporting

confidence: 77%

Section: Discussionmentioning

confidence: 97%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 97%

mentioning

confidence: 99%

See 3 more Smart Citations

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

Gold

Rimal

Nolan

et al. 2007

Critical Care Medicine

154

164

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Baclofen to Prevent Agitation Caused by Alcohol Withdrawal in the ICU

Reade

2021

JAMA

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Alcohol use and abuse is common in many societies and is associated with adverse effects on health. According to the US National Institute on Alcohol Abuse and Alcoholism, in 2019, an estimated 14.1 million adults aged 18 years and older had alcohol use disorder, defined as "chronic relapsing brain disease characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences." 1 Among the numerous alcohol-related diseases and harms, including liver cirrhosis, obesity, some cancers, injury, and suicide, only some directly contribute to acute critical illness. However, among patients with alcohol use or abuse who require intensive care unit (ICU) or hospital admission, alcohol withdrawal is an important factor that may complicate treatment and increase the risk of adverse outcomes.Alcohol activates γ-aminobutyric acid type A (GABA A ) receptors, initially suppressing inhibitory neurotransmitter systems (relaxing social inhibitions) and, at higher levels, reducing consciousness. Chronic use induces tolerance by downregulating GABA A receptors. Abrupt abstinence induces a hyperexcitable state within 6 to 24 hours, characterized by anxiety, agitation, sympathetic activity, and hallucinations and seizures in severe cases. Alcohol withdrawal, rather than alcohol use per se, is the more common reason for alcoholrelated issues among patients admitted to the ICU. A systematic review from 2013 found that the prevalence of alcohol withdrawal syndrome (AWS) in general ICU populations ranged from 0.5% to 8%, but was up to 52% among patients with alcohol-related admissions. 2 However, the same review also found "little high quality data for how best to prevent, diagnose and treat AWS in the ICU." 2 The first challenge is to identify patients at greatest risk for AWS. No validated tool exists for patients admitted to the ICU, but scoring tools for hospitalized patients in non-ICU settings (eg, the Prediction of Alcohol Withdrawal Severity Scale) 3 highlight the importance of previous withdrawal episodes, seizures, hallucinations, alcohol rehabilitation treatment, and other substance abuse. Various risk thresholds for the reported habitual quantity of alcohol consumed have been proposed, but no consensus has been reached. 2 Several preventive strategies have been studied in critically ill patients considered at high risk of AWS, including ethanol, flunitrazepam, clonidine, clomethiazole, haloperidol, and diazepam, with disappointing or inconclusive results due to poor study design. 2 Most guidelines 4 for care in the ICU and elsewhere emphasize treatment over prophylaxis and require the development of specific symptoms and signs of alcohol withdrawal before medication administra-

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Benzodiazepines for alcohol withdrawal

Ntais

Pakos

Kyzas

et al. 2005

Cochrane Database of Systematic Reviews

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Alcohol withdrawal severity is decreased by symptom-orientated adjusted bolus therapy in the ICU

Abstract: We conclude that symptom-orientated bolus-titrated therapy decreases the severity and duration of AWS and of medication requirements, with clinically relevant benefits such as fewer days of ventilation, lower incidence of pneumonia, and shorter ICU stay.

Cited by 118 publications

References 29 publications

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

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

Baclofen to Prevent Agitation Caused by Alcohol Withdrawal in the ICU

Benzodiazepines for alcohol withdrawal

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