-Rule out other possible dx: CNS infection, CNS bleed, metabolic d/o, drug overdose, liver failure, and GI bleed that can mimic or coexist with alcohol withdrawal. Consider CT head and lumbar puncture.
-Evaluate patient for complications of alcohol abuse and alcohol withdrawal.
–CIWA-Ar Protocol.
-CBC, CMP, Urine Drug Screen, Urinalysis.
-Supportive care: IV Fluids, nutritional supplementation, and frequent clinical checks and vital signs.
-Correct metabolic derangements: Check and replace K+, Mg2+, Phos, and Glucose.
-Place the patient in a quiet and safe environment
-Fall, aspiration, and seizure precaution.
-Mechanical restraint as needed (temporarily) until chemical sedation achieved.
-IV Fluids till euvolemic.
–Banana bag. (Thiamine + Folate + Multivitamins)
-Thiamine 500 mg IV piggyback daily for 3 days. Give thiamine first and then glucose to prevent or treat Wernicke’s encephalopathy. May give together.
-D/c Beta-blockers. They mask symptoms.
-Keep NPO to avoid aspiration. Will give treatments IV for the first 1-2 days as GI absorption is often poor in chronic alcoholics.
-Will, then, do swallow evaluation and transition patient to PO.
-Monitoring: Continual assessment of vital signs, pulse oximetry, fluid status, and neurological function.
–Treatment with benzos for CIWA-Ar ≥ 8. Treat psychomotor agitation with benzos (1st-line). Prevents seizures. All benzos okay but long-acting ones are preferred.
-If refractory to aggressive tx with high-dose PRN benzos, transfer to the ICU and tx with benzo drip, phenobarbital, or propofol.
–Prophylaxis.
-Criteria for admitting alcohol withdrawal patients to the ICU reviewed.
Important Links
- Alcohol Withdrawal Prophylaxis.
- Treatment vs. Prophylaxis of Alcohol Withdrawal.
- Alcohol Withdrawal Treatment in the Hospital.
- Alcohol Withdrawal Treatment in the Outpatient.
- CIWA-Ar.
- Complications of Alcohol Abuse and Alcohol Withdrawal.
- Pathophysiology of Alcohol Withdrawal: Chronic use of alcohol (a CNS depressant) leads to insensitivity to GABA, an inhibitory neurotransmitter. Abrupt cessation of alcohol use produces CNS hyperactivity.
“Based on the published literature, for patients with a chronic alcohol use disorder admitted to the ICU with symptoms that may mimic or mask Wernicke’s encephalopathy, we suggest abandoning the banana bag and utilizing the following formula for routine supplementation during the first day of admission: 200-500 mg IV thiamine every 8 hours, 64 mg/kg magnesium sulfate (approximately 4-5 g for most adult patients), and 400-1,000 μg IV folate. If alcoholic ketoacidosis is suspected, dextrose-containing fluids are recommended over normal saline.” Crit Care Med. 2016
References / Further Reading
Crit Care Med. 2016 Aug;44(8):1545-52. Unpeeling the Evidence for the Banana Bag: Evidence-Based Recommendations for the Management of Alcohol-Associated Vitamin and Electrolyte Deficiencies in the ICU. https://www.ncbi.nlm.nih.gov/pubmed/27002274
N Engl J Med. 2014 Nov 27;371(22):2109-13. Recognition and Management of Withdrawal Delirium (Delirium Tremens). https://www.ncbi.nlm.nih.gov/pubmed/25427113
Kattimani S, Bharadwaj B. Clinical management of alcohol withdrawal: A systematic review. Industrial Psychiatry Journal. 2013;22(2):100-108. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4085800/
Sachdeva A, Choudhary M, Chandra M. Alcohol Withdrawal Syndrome: Benzodiazepines and Beyond. Journal of Clinical and Diagnostic Research : JCDR. 2015;9(9):VE01-VE07. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4606320/
Mirijello A, D’Angelo C, Ferrulli A, et al. Identification and Management of Alcohol Withdrawal Syndrome. Drugs. 2015;75(4):353-365. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4978420/
https://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes