Alcohol Withdrawal Resident Rounds July 10, 2007 Maggie Gordon, R2.
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Transcript of Alcohol Withdrawal Resident Rounds July 10, 2007 Maggie Gordon, R2.
Alcohol Withdrawal
Resident Rounds
July 10, 2007
Maggie Gordon, R2
Alcohol Withdrawal
Importance in surgery Definitions Pathophysiology Signs and symptoms Treatment
Importance in Surgery
Importance
~15% primary care and hospitalized patients have problem drinking
23% admitted general surgery patients meet “alcohol abuse” criteria
Early detection and intervention are very effective complications mortality
Importance
Tolerance to anaesthesia, analgesia physiologic reserve stress response morbidity, mortality ICU, hospital stays bleeding infections Tachycardias, cardiac output
Definitions
At-risk drinking
Men: > 16 drinks / week Women: > 10 drinks / week
Alcohol Abuse (DSM IV)
Maladaptive use with work / school / social / interpersonal / legal consequences
At risk of withdrawal
Alcohol Dependence (DSM IV)
Maladaptive use with ≥ 3 of: Tolerance Withdrawal Used in larger quantity than intended Desire to cut down or control use Time is spent obtaining, using, or recovering Social, occupational, or recreational tasks are
sacrificed Use continues despite physical and psychological
problems
At risk ofwithdrawal
Pathophysiology
Pathophysiology
EtOH = CNS depressant serotonin → tolerance, craving Withdrawal
GABA → arousal norepi
Signs and Symptoms
Signs and Symptoms
Spectrum of Presentation Severity Timing
Minor Withdrawal Symptoms
CNS, sympathetic activity: Insomnia Mild anxiety Palpitations Tremors Diaphoresis Headache GI upset Anorexia
Onset: 6 – 48 h post EtOH cessation
Duration: 24 – 48 h
Withdrawal Seizures
Generalized, tonic-clonic Brief post-ictal period Single episode, usually 3% → status epilepticus
Risk Factors Long Hx Chronic alcoholism
Onset: 2 – 48 h post EtOH cessation
Investigate further
Alcoholic Hallucinosis
Usually visual, specific hallucinations Occasionally auditory, tactile
Onset: 12 – 24 h post EtOH cessation
Duration: 24 – 48 h
No “clouding of sensorium”
Delirium Tremens
Hallucinations Disorientation HR BP temperature Diaphoresis Agitation
Onset: 2 – 4 days post EtOH cessation
Duration: 1 – 5 days
Autonomic instability
Delirium Tremens
cardiac output O2 consumption cerebral blood flow
Hyperventilation → Respiratory alkalosis Risk factors
Long binge Significant clouding of sensorium
Delirium Tremens
Risk Factors Sustained drinking Previous DTs > 30 y.o. Concurrent illness Delayed presentation to medical care /
assessment
Delirium Tremens
5% mortality Arrhythmias Complicating illness, e.g. pneumonia Risk factors for death
age Pulmonary disease T > 40°C Liver disease
Withdrawal SyndromesDescription Onset (since last
EtOH)Duration
Comments
MinorWithdrawal
InsomniaMild anxietyPalpitationsTremorsDiaphoresisHeadacheGI upsetAnorexia
< 6 hx 24 – 48 h
Consistent in each patient
Seizures GeneralizedTonic-clonic
2 – 48 h 3% of chronic alcoholics
AlcoholicHallucinosis
Usually visualOccasionally auditory, tactile
12 – 24 hx 24 – 48 h
No clouding of sensorium
DeliriumTremens
HallucinationsDisorientation HR BP temperatureAgitationDiaphoresis
2 – 4 dx 1 – 5 d
5% of patients w/ withdrawal
Treatment
Prevention
Pre-op CAGE questionnaire Have you ever felt the need to Cut down on
drinking? Have you ever felt Annoyed by criticism of your
drinking? Have you ever had Guilty feelings about your
drinking? Do you ever take a morning Eye opener (a drink
first thing in the morning to steady your nerves or get rid of a hangover)?
Prevention
Consider pre-op Collateral from family LET’s
Prevention
Thiamine, folate, multivitamins Abstinence Detox and rehab Referrals Early prophylaxis, i.e., before symptoms
appear
History First
EtOH use Hx of withdrawal syndromes, especially
seizures
Physical Exam
Vitals Tremor
Investigations
Blood work CBC for Hgb, platelets LFT’s
CT LP
Investigations
Rule out and treat Infection Trauma Metabolic derangements Drug overdose Liver failure GI bleeding
Diagnosis of exclusion
Keys to Therapy
Substitute drug of abuse with long-acting medication with similar effects, then taper dose
Keys to Therapy
Reevaluate frequently Avoid complacency Alleviate symptoms
Keys to Therapy
Hydrate (dehydration ← diaphoresis, T, vomiting, HR)
Correct electrolytes K ( K ← vomiting, aldosterone Δs) Mg ( Mg → DT risk) PO4 ( PO4 ← malnutrition)
Therapy
Wernicke’s encephalopathy, Korsakoff’s syndrome prophylaxis Thiamine 100 mg im / iv Folic acid 5 mg po / iv daily x 3 days Multivitamin 1 tablet po daily x indefinite
Therapy
Benzodiazepines Diazepam (Valium) 5 – 10 mg po / iv q 5-10 min Lorazepam (Ativan) 1 – 2 mg po / sl / iv q 5-10 min
liver disease → t½
First dose when CIWA ≥ 8 Titrate until patient “calm, but alert”, i.e. to
CIWA score < 16
May need “massive” doses
CIWA
Therapy
Consider prophylaxis w/out titration Emergency surgery Patient unable to communicate
Diazepam 2.5 – 10 mg po / iv q 6 h Lorazepam 0.5 – 2 mg po / iv q 6 h
Refractory Seizures, DTs
Phenobarbital 130 – 260 mg iv q 15 – 20 min Propofol 1 mg / kg iv push, intubate, then
titrate to sedation
Long-Term Therapy
Evaluation Referral to long-term follow-up
No evidence of effectiveness
References
NEJM
UpToDate
UpToDate
Symptom-Oriented Therapy
ICU patients Flunitrazepam, clonidine, halperidol
Fixed-dose
CIWA-triggered
Withdrawal severity
Worse Better
Total dose Greater Lesser
Days ventilated Greater Fewer
Pneumonia Greater Fewer
ICU stay Longer Shorter
Symptom-Triggered Doses
Fixed-dose
CIWA-triggered
Outcomes Similar
Total dose Greater Lesser
Treatment duration
Greater Lesser
Detox program Oxazepam
For Discussion
Indications for ICU Admission
Age > 40 y.o. Cardiac disease Hemodynamic instability Marked acid-base
disturbances Severe electrolyte
disturbances Respiratory insufficiency Potentially serious
infections
GI pathology Persistent hyperthermia Rhabdomyolysis Renal insufficiency Previous DTs, seizures Need for high doses of
sedatives, iv therapy
UpToDate