Implementation of a Phenobarbital-based Pathway for Severe Alcohol Withdrawal: A Mixed-Method Study

Bosch, Nicholas A; Crable, Erika L.; Ackerbauer, Kimberly; Clark, Kristopher; Drainoni, Mari-Lynn; Grim, Valerie; Ieong, Michael H.; Walkey, Allan J.; Murphy, Jaime

doi:10.1513/annalsats.202102-121oc

Cited by 9 publications

(9 citation statements)

References 34 publications

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“…Our study shows that PB is not associated with any increase in the risk of oversedation and the need for mechanical ventilation when used in AWS. Similar findings have been shown in other studies in the ICU ( 17 , 24 ) and by randomized controlled trials in ED ( 25 , 26 ). We only had one patient in the PB arm who required intubation to protect the airway because of vomiting with seizure.…”

Section: Discussionsupporting

confidence: 92%

“…Our study shows an excellent safety profile for PB when used in escalating doses over a short time targeting symptomatic control. The significant decrease in the need for physical restraints and mechanical ventilation compared with BZD has been reported by Bosch et al (24) and Gold et al (17) in previous publications. Our study shows that PB is not associated with any increase in the risk of oversedation and the need for mechanical ventilation when used in AWS.…”

Section: Discussionmentioning

confidence: 57%

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Phenobarbital-Based Protocol for Alcohol Withdrawal Syndrome in a Medical ICU: Pre-Post Implementation Study

Alwakeel

Alayan

Saleem

et al. 2023

Critical Care Explorations

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We assessed the efficacy and safety of PB compared with benzodiazepine (BZD)-based protocols in treating AWS in MICU.DESIGN: Single-center, pre-post protocol implementation study. SETTING:The setting is a forty-bed MICU in a tertiary-level academic medical center. PATIENTS:We included all patients admitted to the MICU with a primary diagnosis of AWS. INTERVENTIONS:Intravenous PB 260 mg followed by 130-mg doses every 15-30 minutes as needed up to 15 mg/kg of ideal body weight versus escalating doses of BZD, to achieve a Clinical Institute Withdrawal Assessment Alcohol Scale-Revised score less than 10. MEASUREMENTS AND MAIN RESULTS:ICU and hospital length of stay (LOS), in addition to safety measures were the main outcomes of the study. A total of 102 patients were included, 51 in the PB arm and 51 in the BZD arm. There were no differences in baseline clinical characteristics. Half the patients in each group were admitted with delirium tremens. The use of PB-based protocol was associated with 35% reduction in median ICU LOS (1.5 d [interquartile range,; p = 0.009) and 50% reduction in hospital LOS (3 d [2.7-4 d] vs 6 d [4-10 d]; p < 0.001). After adjustment for comorbidities and clinical factors, PB protocol decreased ICU LOS days by 40% (95% CI; 25.8-53.5%). PB group required fewer adjunctive medications to control symptoms (0.7 [0.5-1] vs 2.5 [2-3]; p < 0.001), less need for intubation (1/51 [2%] vs 10/10 [19.6%]; p = 0.023) and less need for physical restraint (19/51 [37.3%] vs 29/51 [56.9%]; p = 0.047), compared with the BZD group. CONCLUSIONS:A protocol utilizing rapidly escalating doses of PB over a short period is an effective and safe alternative to BZD in treating AWS in MICU.

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Section: Discussionsupporting

confidence: 92%

Section: Discussionmentioning

confidence: 57%

Phenobarbital-Based Protocol for Alcohol Withdrawal Syndrome in a Medical ICU: Pre-Post Implementation Study

Alwakeel

Alayan

Saleem

et al. 2023

Critical Care Explorations

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“…Several large before-andafter ICU-based studies suggest that increased use of phenobarbital in the treatment of AWS may be associated with a reduction in the utilization of intubation and mechanical ventilation, although these results are limited by the inclusion of other changes in AWS care in addition to a shift in phenobarbital utilization. [77][78][79] Nonrandomized observational and retrospective studies in the ward and ICU settings also suggest that phenobarbital treatment is associated with a decrease in ICU and hospital LOS, [79][80][81] decreased utilization of continuous sedative infusions, [77][78][79] and lower rates of delirium. 82…”

Section: Summary Of the Evidencementioning

confidence: 99%

“…The duration of hospitalization can also be a marker of AWS severity but may also be affected by the success of treatment. Multiple retrospective studies demonstrate an association between phenobarbital use and decreased hospital LOS or increased rate of hospital discharge within 3 days 72,79–81 . Tidwell and colleagues 79 reported a shorter hospital LOS (mean ± SD 4.3 ± 3.4 days vs. 6.9 ± 6.6 days, p = 0.004) in those treated with adjunctive phenobarbital.…”

Section: Pico Question 368mentioning

confidence: 99%

“…72,[79][80][81] Tidwell and colleagues79 reported a shorter hospital LOS (mean ± SD 4.3 ± 3.4 days vs.6.9 ± 6.6 days, p = 0.004) in those treated with adjunctive phenobarbital. Hawa and colleagues,81 in a retrospective cohort study, showed that phenobarbital monotherapy was associated with decreased LOS compared to benzodiazepine-alone therapy (2.8 days vs. 3.6 days, p < 0.001).…”

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confidence: 97%

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Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE‐4): Alcohol use disorder and cannabinoid hyperemesis syndrome management in the emergency department

Borgundvaag,

Bellolio,

Miles

et al. 2024

Academic Emergency Medicine

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The fourth Society for Academic Emergency Medicine (SAEM) Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE‐4) is on the topic of the emergency department (ED) management of nonopioid use disorders and focuses on alcohol withdrawal syndrome (AWS), alcohol use disorder (AUD), and cannabinoid hyperemesis syndrome (CHS). The SAEM GRACE‐4 Writing Team, composed of emergency physicians and experts in addiction medicine and patients with lived experience, applied the Grading of Recommendations Assessment Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding six priority questions for adult ED patients with AWS, AUD, and CHS. The SAEM GRACE‐4 Writing Team reached the following recommendations: (1) in adult ED patients (over the age of 18) with moderate to severe AWS who are being admitted to hospital, we suggest using phenobarbital in addition to benzodiazepines compared to using benzodiazepines alone [low to very low certainty of evidence]; (2) in adult ED patients (over the age of 18) with AUD who desire alcohol cessation, we suggest a prescription for one anticraving medication [very low certainty of evidence]; (2a) in adult ED patients (over the age of 18) with AUD, we suggest naltrexone (compared to no prescription) to prevent return to heavy drinking [low certainty of evidence]; (2b) in adult ED patients (over the age of 18) with AUD and contraindications to naltrexone, we suggest acamprosate (compared to no prescription) to prevent return to heavy drinking and/or to reduce heavy drinking [low certainty of evidence]; (2c) in adult ED patients (over the age of 18) with AUD, we suggest gabapentin (compared to no prescription) for the management of AUD to reduce heavy drinking days and improve alcohol withdrawal symptoms [very low certainty of evidence]; (3a) in adult ED patients (over the age of 18) presenting to the ED with CHS we suggest the use of haloperidol or droperidol (in addition to usual care/serotonin antagonists, e.g., ondansetron) to help with symptom management [very low certainty of evidence]; and (3b) in adult ED patients (over the age of 18) presenting to the ED with CHS, we also suggest offering the use of topical capsaicin (in addition to usual care/serotonin antagonists, e.g., ondansetron) to help with symptom management [very low certainty of evidence].

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Load and go: Assessing safety outcomes of patients discharged from the emergency department after receiving phenobarbital for alcohol withdrawal

Ebeling‐Koning,

Goodman,

Amaducci

et al. 2024

JACEP Open

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ObjectivesPhenobarbital (PB) is a long‐acting GABA A‐agonist with favorable pharmacokinetics (long half‐life and duration of effect) that allows effective treatment of alcohol withdrawal (AW) after administration of a single loading dose. Current evidence suggests that in the setting of AW, PB administration may be associated with decreased hospital admissions and hospital length of stay. The aim of this study was to evaluate the safety outcomes of AW patients who were treated and discharged from the emergency department (ED) after receiving PB for AW.MethodsThis retrospective chart review included a convenience sample of 33 AW patients who presented to four EDs within an 18‐month span. Descriptive statistics (frequencies and percentages) were used to describe demographics, distribution of resources and referrals, and the safety outcomes of PB administration for low‐risk AW patients. Patients were selected for inclusion in consultation with a medical toxicologist, treated with PB, and discharged from the ED. Electronic medical records were utilized to gather information on the patient cohort.ResultsAll patients were treated with at least a single loading dose of 5‒10 mg/kg (ideal body weight) of intravenous or per os PB during their ED stay. Only one patient had an unanticipated event after discharge, which was related to driving against advice. Two additional patients had ED revisits for recurrent alcohol use within 72 h, and 16 patients had recurrent alcohol use within 30 days. All 33 patients were provided with resources for linkage to treatment. None required hospital admission.ConclusionED PB “load and go” may be a safe, effective AW treatment that could help treat AW, facilitate linkage to specific rehabilitation treatments, and decrease hospital admissions.

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Implementation of a Phenobarbital-based Pathway for Severe Alcohol Withdrawal: A Mixed-Method Study

Cited by 9 publications

References 34 publications

Phenobarbital-Based Protocol for Alcohol Withdrawal Syndrome in a Medical ICU: Pre-Post Implementation Study

Phenobarbital-Based Protocol for Alcohol Withdrawal Syndrome in a Medical ICU: Pre-Post Implementation Study

Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE‐4): Alcohol use disorder and cannabinoid hyperemesis syndrome management in the emergency department

Load and go: Assessing safety outcomes of patients discharged from the emergency department after receiving phenobarbital for alcohol withdrawal

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