Severe alcohol withdrawal syndrome: Evolution of care and impact of adjunctive therapy on course and complications of 171 intensive care unit patients

Abstract

This single site retrospective observational study assessed the evolution of sedation therapy for severe alcohol withdrawal syndrome in the intensive care unit. Patient records for 2 intervals were reviewed: Interval 1, which included 87 intensive care unit patients admitted January 2005 through September 2007, for whom benzodiazedpine monotherapy was utilized; and Interval 2, January 2010 through December 2010, for whom 54 of 84 (64.3%) intensive care unit patients, including all those intubated, received adjunctive agents, including dexmedetomidine or propofol. Clinical management was similar for both intervals, as well as prevalence of alcohol withdrawal syndrome versus total adult hospital admissions and comorbid conditions. Overall, respiratory failure (53 versus 39%), seizures (36 versus 18%), and pneumonia (51 versus 38%) were less frequent during Interval 2 (all p < .05), with lower benzodiazedpine basal dose requirements for those given adjunctive therapy. However, if instances of pneumonia or respiratory failure related to seizures prior to intensive care unit admission are excluded, the prevalence of these complications was similar (p = ns) for Interval 1 and Interval 2. Intensive care unit and hospital length of stay were not altered by adjunctive therapy, which was typically employed for more severely affected patients. High intensity sedation with adjunctive drugs led to few cardiovascular adverse events and may have facilitated management, but did not alter intensive care unit course of severe alcohol withdrawal syndrome.

Use of Propofol Plus Dexmedetomidine in Patients Experiencing Severe Alcohol Withdrawal in the Intensive Care Unit

“…In this study dexmedetomidine was associated with a higher incidence of bradycardia, with about 17.6% of patients experiencing it compared with no patients who received propofol; however, this finding was not statistically significant. Other studies have reported patients experiencing bradycardia with both dexmedetomidine and propofol, and this change resulted in the discontinuation of dexmedetomidine but not propofol in both studies . In 1 study propofol was associated with a higher rate of intubation when compared with dexmedetomidine, with 100% of patients receiving propofol requiring intubation, whereas 14.7% of patients receiving dexmedetomidine required intubation .…”

“…In previous studies the use of either propofol or dexmedetomidine as adjunctive therapy to benzodiazepines has been associated with a significant decrease in benzodiazepine use . Both propofol and dexmedetomidine have been associated with hypotension, with 1 study reporting about 28.5% of patients in the propofol group experiencing it and 17.6% of patients in the dexmedetomidine group experiencing it .…”

“…Other studies have reported patients experiencing bradycardia with both dexmedetomidine and propofol, and this change resulted in the discontinuation of dexmedetomidine but not propofol in both studies. 13,14 In 1 study propofol was associated with a higher rate of intubation when compared with dexmedetomidine, with 100% of patients receiving propofol requiring intubation, whereas 14.7% of patients receiving dexmedetomidine required intubation. 8 Patients receiving dexmedetomidine were able to be extubated after about 0.8 days versus about 4 days for patients receiving propofol.…”

“…In previous studies the use of either propofol or dexmedetomidine as adjunctive therapy to benzodiazepines has been associated with a significant decrease in benzodiazepine use. [5][6][7][8][9]13,14 Both propofol and dexmedetomidine have been associated with hypotension, with 1 study reporting about 28.5% of patients in the propofol group experiencing it and 17.6% of patients in the dexmedetomidine group experiencing it. 8 In this study dexmedetomidine was associated with a higher incidence of bradycardia, with about 17.6% of patients experiencing it compared with no patients who received propofol; however, this finding was not statistically significant.…”

“…Benzodiazepines are considered first‐line drugs in the treatment of AWS; however, patients receiving higher doses tend to be more delirious and require a longer period of intubation . Both propofol and dexmedetomidine have been studied and compared as adjunctive therapy to benzodiazepines, but there are limited data on their use together. To our knowledge this is the first retrospective analysis of the use of propofol plus dexmedetomidine as adjunctive therapy to benzodiazepines in the treatment of AWS, and there have also been no prospective studies.…”