Prevention of alcohol withdrawal syndrome in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document

Seshadri, Anupamaa; Appelbaum, Rachel; Carmichael, Samuel P.; Farrell, Michael; Filiberto, Dina M.; Jawa, Randeep S.; Kodadek, Lisa M.; Mandell, Samuel P.; Miles, M Victoria P; Paul, Jasmeet S.; Michetti, Christopher P.

doi:10.1136/tsaco-2022-001010

Cited by 9 publications

(19 citation statements)

References 73 publications

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“…This is not a novel ask of critical care providers, who routinely tailor ionopressors, sedatives, and a myriad of other treatments to the unique circumstances of their patients, relying on available guidelines and evidence, even if incomplete. We direct providers to recent practice guidelines applicable to the management of alcohol withdrawal [69,70 ▪ ,71 ▪ ], opioid withdrawal and agonist treatment [72,73 ▪ ], and pain and delirium [74]. Unfortunately, no guidelines exist for management of stimulant withdrawal [75 ▪ ].…”

Section: Substance Withdrawal Pain Delirium and Preventing Overdosementioning

confidence: 99%

Critical care for patients with substance use disorders

Steel,

Bhatraju,

Hills-Dunlap

2023

Current Opinion in Critical Care

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Purpose of review To examine the impact of substance use disorders (SUDs) on critical illness and the role of critical care providers in treating SUDs. We discuss emerging evidence supporting hospital-based addiction treatment and highlight the clinical and research innovations needed to elevate the standards of care for patients with SUDs in the intensive care unit (ICU) amidst staggering individual and public health consequences. Recent findings Despite the rapid increase of SUDs in recent years, with growing implications for critical care, dedicated studies focused on ICU patients with SUDs remain scant. Available data demonstrate SUDs are major risk factors for the development and severity of critical illness and are associated with poor outcomes. ICU patients with SUDs experience mutually reinforcing effects of substance withdrawal and pain, which amplify risks and consequences of delirium, and complicate management of comorbid conditions. Hospital-based addiction treatment can dramatically improve the health outcomes of hospitalized patients with SUDs and should begin in the ICU. Summary SUDs have a significant impact on critical illness and post-ICU outcomes. High-quality cohort and treatment studies designed specifically for ICU patients with SUDs are needed to define best practices and improve health outcomes in this vulnerable population.

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Section: Substance Withdrawal Pain Delirium and Preventing Overdosementioning

confidence: 99%

Critical care for patients with substance use disorders

Steel,

Bhatraju,

Hills-Dunlap

2023

Current Opinion in Critical Care

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“…The nature of surgical critical illness, injury, and acute pain can produce similar symptoms to the sympathetic stimulation seen in AWS, which can make diagnosis difficult. A clinical consensus document produced by the American Association for the Surgery of Trauma (AAST) recommends use of the Alcohol Use Disorders Identification Test (AUDIT) or Prediction of Alcohol Withdrawal Severity Scale (PAWSS) as screening tools 72 . Clinicians must be mindful that the commonly used alcohol screening tool, CIWA-AR, is unproven in trauma patients and seriously limited in nonverbal patients.…”

Section: Special Topicsmentioning

confidence: 99%

“…Clinicians must be mindful that the commonly used alcohol screening tool, CIWA-AR, is unproven in trauma patients and seriously limited in nonverbal patients. Modified Minnesota Detoxification Scale (mMINDS) does not require participation and is recommended by the Critical Care Committee of the AAST 72 …”

Section: Special Topicsmentioning

confidence: 99%

Optimal strategies for assessing and managing pain, agitation, and delirium in the critically ill surgical patient: What you need to know

Evans,

Olney,

Bernard

et al. 2023

J Trauma Acute Care Surg

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Pain, agitation, and delirium (PAD) are primary drivers of outcome in the ICU, and expertise in managing these entities successfully is crucial to the intensivist’s toolbox. Additionally, there are unique aspects of surgical patients that impact assessment and management of PAD. In this review, we address the continuous spectrum of assessment, and management of critically ill surgical patients, with a focus on limiting PAD, particularly incorporating mobility as an anchor to ICU liberation. Finally, we touch on the impact of PAD in specific populations, including opioid use disorder, traumatic brain injury, pregnancy, obesity, alcohol withdrawal, and geriatric patients. The goal of the review is to provide rapid access to information regarding PAD and tools to assess and manage these important elements of critical care of surgical patients. Study Type Regular Review

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“…Alcohol withdrawal syndrome is a potentially life-threatening illness and is a hospital complication, which is reported in the National Trauma Databank. Given the severity of the complication, efforts should target its prevention 5 …”

mentioning

confidence: 99%

“…Given the severity of the complication, efforts should target its prevention. 5 Alcohol is a central nervous system depressant, and its abrupt cessation leads to generalized hyperexcitability of the brain through multiple pathways. 6 Prolonged alcohol consumption leads to a downregulation of γ-aminobutyric acid (GABA-A) receptors, resulting in a decreased GABA inhibitory activity.…”

mentioning

confidence: 99%

Evaluation of phenobarbital for prevention of alcohol withdrawal in trauma patients

Kip¹,

Forni

Dorfman

et al. 2023

J Trauma Acute Care Surg

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BACKGROUND Up to 30% of trauma patients experience alcohol withdrawal syndrome (AWS) during their hospital admission, which is associated with worse outcomes. While benzodiazepines and phenobarbital are the mainstay of AWS management, there are limited data on the prevention of AWS. The objective was to evaluate the safety and efficacy of phenobarbital for the prevention of AWS. METHODS Adult patients admitted to a level 1 trauma center who received at least one dose of phenobarbital for the prevention of AWS between January 2019 and August 2021 were included. Patients were case matched to a control group managed with symptom-triggered therapy based on risk of AWS. Risk factors included sex, age, history of AWS/delirium tremens or withdrawal seizures, selected laboratory values, and screening questionnaires. The primary endpoint was the need for rescue therapy. Secondary endpoints included the time to rescue therapy, intensive care unit (ICU) length of stay (LOS), and hospital LOS. RESULTS Overall, 110 patients were included with 55 patients in each group. The phenobarbital group had higher baseline Injury Severity Scores (p = 0.03) and were more likely to be admitted to the ICU (44% vs. 24%; p = 0.03). The phenobarbital group required less rescue therapy (16% vs. 62%; p < 0.001) with a longer time to rescue therapy administration (26 vs. 11 hours; p = 0.01). The phenobarbital group had a longer hospital LOS (216 vs. 87 hours; p = 0.0001) but no difference in ICU LOS (p = 0.36). There was no incidence of delirium tremens or seizures and no difference in intubation rates (p = 0.68). There was no incidence of hypotension associated with phenobarbital. CONCLUSION Patients managed with phenobarbital had a lower need for rescue therapy for AWS with no increased adverse effects. Further studies should evaluate a protocol to prevent alcohol withdrawal in the trauma population. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.

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Prevention of alcohol withdrawal syndrome in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document

Cited by 9 publications

References 73 publications

Critical care for patients with substance use disorders

Critical care for patients with substance use disorders

Optimal strategies for assessing and managing pain, agitation, and delirium in the critically ill surgical patient: What you need to know

Evaluation of phenobarbital for prevention of alcohol withdrawal in trauma patients

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