Prealbumin Levels and Delirium Tremens Marcey Furlow, RN, CCRN, SRNA Hamot Medical Center School of...
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Transcript of Prealbumin Levels and Delirium Tremens Marcey Furlow, RN, CCRN, SRNA Hamot Medical Center School of...
Prealbumin Levels and Delirium Tremens
Marcey Furlow, RN, CCRN, SRNA
Hamot Medical Center School of Anesthesia/Gannon University
• 63 year old male• 85 kg 70 inches• Planned Surgery: Bilateral Total Knee
Replacement
• PMH: HTN, hyperlipidemia, bruises easily, hypothyroidism, peripheral neuropathy, GERD, depression, consume alcohol almost every day “but not a lot”, denies smoking
• PSH: Right knee arthroscopy, cystoscopy x 2, TURP, left shoulder SLAP repair, No history of problems with anesthesia
Clinical Scenario
Clinical Scenario
• EKG- NSR with possible LVH and atrial enlargement
Clinical Scenario
CXR- no acute pulmonary disease, moderate pulmonary hyperinflation, moderate cardiomegaly
Clinical Scenario
• Bilateral femoral catheters placed for post-op pain control
• Operation was uneventful • Post-op course:
• Day 1: pt slightly agitated, family states that his disposition is normal
• Day 2: pt still agitated, slightly tachycardic, HR 100’s, complaining of headache. Given Ativan, Norco, and Lopressor restarted from home med list. Still agitated when awake but very drowsy, HR decreased to 70’s
Clinical Scenario
• Post-op course: (cont.)– Day 3: Hallucinating, physical therapy notices a decline
in patient’s coordination. Patient falls during physical therapy is taken back to his room and has a seizure.
Clinical Scenario
• What happened?
Presentation Objectives
• Describe effects of chronic alcohol consumption on the brain
• Learn about alcohol withdrawal syndrome and delirium tremens
• Recognize a link between nutrient deficits and neurologic disorders
• Review research comparing prealbumin levels and incidence of delirium tremens
• Understand relevance to a CRNA’s practice
Statistics
• Nearly 27% of adults (age 18-64) meet the criteria for alcohol dependency (2005, McKinley)
• Medical costs related to alcohol abuse, both acute and chronic, are estimated to be 100 billion dollars a year (2004, Baynard)
DSM-IV Criteria for alcohol dependence
• At least three out of seven of the following criteria must be manifest during a 12 month period:– Tolerance– Withdrawal symptoms or clinically defined Alcohol Withdrawal
Syndrome– Use in larger amounts or for longer periods than intended– Persistent desire or unsuccessful efforts to cut down on alcohol use– Time is spent obtaining alcohol or recovering from effects– Social, occupational and recreational pursuits are given up or
reduced because of alcohol use– Use is continued despite knowledge of alcohol-related harm
(physical or psychological)
Possible Long-Term Effects of Alcohol
Areas of the Brain Affected by Alcohol
Comparative PET scan (PET=positron emission tomography)
NMDA Receptors(N-methyl-d-aspartate receptor)
• Excitatory • Neurotransmitter- Glutamate• Blocked by acute ingestion of ETOH• Up-regulated due to chronic consumption of
ETOH
GABA Receptors (γ-aminobutyric acid receptor)
• Inhibitory• ETOH binds to receptor and increases Cl-
influx• Down- Regulated by chronic ETOH
consumption
• GABA remodeling
Alcohol Withdrawal Syndrome
• Symptoms develop approximately 48-72 hours following last drink
• Prophylaxis- multivitamins, folic acid, thiamine and low to moderate dose benzodiazepines
• Treatment- high dose benzodiazepines• CIWA- Assessment
Signs and Symptoms of Alcohol Withdrawal Syndrome
• Agitation/Anxiety• Confusion• Depression• Diaphoresis• Fear• Panic Attacks• Headache• Hyperthermia
• Tachycardia
• Palpitations• Tremors • Weakness• Hypertension• Gastrointestinal Upset
Delirium Tremens Latin for “shaking frenzy”
• First described in literature approximately 200 years ago
• Most severe form of alcohol withdrawal syndrome
• Exact etiology still unknown• Hypothesized that the sudden decrease in
alcohol unmasks remodeled receptors resulting in an extreme hyper-excitable state
• Progression from alcoholic withdrawal syndrome
• Severe autonomic instability and hyperactivity• Intense visual disturbances and hallucinations• Severe uncontrolled tremors• Seizures• Mortality is approximately 5% when treated
and 35% untreated
Delirium Tremens
Isolated Risk Factors for Developing Delirium Tremens
• Presence of infectious disease• Severe tachycardia • Over activity of the nervous
system while patient is still intoxicated
• Previous history of delirium tremens
• Concurrent epileptic disorders and multiple co-morbidities
Wenicke-Korsakoff Syndrome
• Combination of Wernicke’s encephalopathy and Korsakoff’s psychosis
• Results from a Vitamin B1 (Thiamine) deficiency causing damage in the thalamus and hypothalamus
• Signs and Symptoms:– Ataxia -- Leg tremors– Confusion -- Double vision– Memory loss -- Nystagmus – Hallucinations
Conceptual Framework
• Evidence based application• Lutz and Przyulski (2006)- Identified the role of
pyridoxine (vitamin B6)• Co-enzyme in the synthesis and catabolism of
amino acids including neurotransmitters • Involved in the metabolism and synthesis of over
100 enzymes• Pyridoxine must be ingested, deficiency is rare in
the general population but common in people with chronic alcohol ingestion
Nutrition Deficits Associated with Chronic Alcohol Consumption
• Vitamin B– B1 (Thiamine)– B2 (Riboflavin)– B3 (Niacin)– B6 (Pyridoxine) – B12 (Cobalamin)
• Vitamin C• Vitamin D
• Folic Acid• Vitamin K• Vitamin A• Phosphate • Magnesium• Amino Acid/Protein
Prealbumin (transthyretin)
• Carrier protein esp. (thyroxine and retinol)• Found in blood and CSF• Routinely used to determine nutrition status• Lab value reflects current nutrition status due
to sensitivity of 2-4 days
Half Life (days)
Normal Levels (mg/dL)
Malnutrition (mg/dL)
Mild Moderate Severe
2-4 15.7-29.6 12-15 8-12 < 8
Statement and Significance of the Problem
• Delirium tremens is an acute—sometimes fatal—psychotic reaction caused by cessation of alcoholic beverages
• Patients who develop delirium tremens have prolonged and complicated hospital stays
• Medical treatments are mostly reactionary, not proactive or preventative
• Quantitative, descriptive research study
• Retrospective chart review
• Setting 375 bed urban medical center in northwestern Pennsylvania
Research Design
Sample Demographics
• Out of 464 charts reviewed 24 met the inclusion criteria
• 12 patients who experienced delirium tremors and 12 patients who did not were included
• Each sub-group was comprised of 11 men and 1 woman
Prealbumin results
Group Range (mg/dL) Mean (mg/dL) Median (mg/dL)
Delirium Tremens 3.9-42.5 17.8 16.1
Non Delirium Tremens
13.3-42.3 27.9 28.2
Overall sample 3.9-42.5 22.5 24.4
Prealbumin levels for the delirium tremens group were on average 10.1 mg/dL lower
Statistical Analysis
• Analysis using a paired t test found the difference significant at the .001 level
• These findings suggest there is a 99.9% chance that the levels are significantly different
Limitations
• The sample size was small• Lack of a set diagnosis criteria for Delirium
Tremens• Inability to control extraneous variables • Prealbumin is not a routine lab for patients
with chronic alcohol abuse• Patients with liver disease were not excluded
Recommendations for Future Research
• Larger Sample size• Prospective study so that variables can be
controlled • Increased exclusion criteria
Relevance to CRNA Practice
• Identifying risk factors may aide in early identification and proactive treatment
• Elective procedures with subsequent hospital admission could be discouraged d/t increased patient risk
• To assist in differential diagnosis
• To add to a CRNA’s body of knowledge
Special Thanks:
Dr. Sharon J. Thompson, PhD, RN, MPH Chairperson of Thesis Committee
Krista L.Yoder, MSN, CRNA Program Director/Thesis Committee
Tara Morrison, MSN, CRNA Thesis Committee
Carin Shollenberger, BSN, RN, SRNA co-researcher
Greg McMichael, MSN, SRNAco-researcher
References
Al-Sanouri, I., Dikin, M., & Soubani, A. O. (2005). Critical care aspects of alcohol abuse.
Southern Medical Journal, 98, 372-381.
Anderson, D. M., Keith, J., Novak, P. D. & Elliot, M. A. (Eds.). (2002). Mosby’s
medical, surgical, and allied health dictionary (6th ed.). St. Louis, MO: Harcourt Health Sciences.
Baynard, M., McIntyre, J., Hill, K., & Woodside, J. (2004). Alcohol withdrawal
syndrome. American Family Physician, 69, 1443-1540.
Burnham, E. L., & Moss, M. (2006). Alcohol abuse in the critically ill patient. The
Lancet, 368, 2231-2242.
Chertow, G. M., Goldstein-Fuchs, D. J., Lazarus, J. M., & Kaysen, G. A. (2005).
Prealbumin, mortality, and cause-specific hospitalization in hemodialysis patients.
Kidney International, 68, 2794-2800.
References
Devoto, G., Gallo, F., Marchello, C., Racchi, O., Garbarini, R., Bonassi, G., et al. (2006).
Prealbumin serum concentrations as a useful tool in the assessment of malnutrition in hospitalized patients. Clinical Chemistry, 52, 2281-2285.
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Fiellin, D. A., O’Connor, P. G., Holmboe, E. S., & Horwitz, R. I. (2002). Risk for
delirium tremens in patients with alcohol withdrawal syndrome. Substance Abuse.
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Florim, C., Kobza, R., Ehmann, T., & Erne, P. (2006). ECG changes amongst patients
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References
Kruger, T. H., Brink, P., Goebel, M. U., Schiffer, B., Schedlowski, M., Hartmann, U.,
et al. (2006). Endocrine alternations during a detoxification treatment with
carbamazepine in male alcoholics. Addiction Biology, 11, 175-183.
Lee, J. H., Jang, M. K., Lee, J. Y., Kim, S. M., Kim, K., Park, J., Y., et al. (2005).
Clinical predicators for delirium tremens in alcohol dependence. Journal of Gastroenterology and Hepatology, 20, 1833-1837.
Lutz, C., & Przyulski, M. (2006). Nutrition and diet therapy: Evidence based
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McKinley, M. G. (2005). Alcohol withdrawal syndrome: Overlooked and mismanaged.
Critical Care Nurse, 25, 40-49.
Nagelhout, J., & Zaglaniczny, K. (2005). Nurse anesthesia (3rd ed.). St. Louis, MO:
Elsevier Saunders.
References
Palmstierna, T. (2001). A model for predicting alcohol withdrawal delirium. Psychiatric
Services, 52, 820-823.
Robinson, M. K., Trujillo, E. B., Mogensen, K. M., Rounds, J., McManus, K., & Jacobs,
D. O. (2003). Improving nutritional screening of hospitalized patients: The role of prealbumin. Journal of Parenteral and Enteral Nutrition, 27, 389-396.
Rogawski, M. A. (2005). Update on the neurobiology of alcohol withdrawal seizures.
Epilepsy Currents, 5, 225-230.
Wright, T., Myrick, H., Henderson, S., Peters, H., & Malcolm, R. (2006). Risk factors for
delirium tremens: A retrospective chart review. The American Journal of Addictions, 15, 213-219.