Ethanol withdrawal: Difference between revisions

Revision as of 16:04, 11 June 2015

Withdrawal symptoms due to reduced GABA and increased glutamate
Benzos useful due to cross tolerance at ethanol GABA receptor
Symptom triggered therapy
- As effective as fixed dose therapy, but w/ more rapid detox

Reduction in alcohol use that has been heavy and prolonged
At least 2 of the following
- Autonomic hyperactivity (e.g., diaphoresis, HR>100)
- Increased hand tremor
- Insomnia
- Nausea/vomiting
- Transient visual, tactile, or auditory hallucinations
- Psychomotor agitation
- Anxiety
- Grand mal seizures
CIWA score
- http://www.mdcalc.com/ciwa-ar-for-alcohol-withdrawal/#about-calculator
- Start benzo therapy at score of 8. Consider ICU admission with score >20.

Benzodiazepines
- Diazepam (Valium) 5-10mg IV (depending on severity)
  - May repeat q5-10min for severe withdrawal (double dose until desired effect achieved)
- Lorazepam (Ativan) 1-4mg IV (depending on severity)
  - May repeat q15-20min for severe withdrawal (titrated to effect)
  - Rarely causes hepatitis, as opposed to diazepam which may cause a cholestatic hepatitis[ref]National Institute of Diabetes and Digestive and Kidney Diseases. Lorazepam Drug Record. http://livertox.nih.gov/Lorazepam.htm[/ref]
- Chlordiazepoxide
  - Generally for outpt tx of mild cases
Beta blockers
- Improve VS, reduces craving
Alpha-2 agonists (clonidine)
- Decrease severity of sxs, but only supplemental to GABA-ergic first-lines
- Dexmedetomidine gtt, start 0.2 mcg/kg/min, likely needing no more than 0.7 mcg/kg/min
Barbituates (Phenobarbital)
- Used when refractory to benzodiazepines
- Phenobarbital 130-260 mg IV q 15-20 minutes
Banana bag
- Thiamine 100mg IV
- Folate 1mg IV (cheaper PO)
- MVI 1 tab IV (cheaper PO)
- Magnesium sulfate 2mg IV
- NS 1L IV

Onset after last drink: 12-24hr
Visual hallucinations are most common
Different from delirium tremens
- Resolves within 24-48 from last drink (before onset of DTs)
- No delirium
- Normal vital signs

Goal = sleepy, but arousable w/ HR <110
Diazepam
- Long duration of action, max effect within 5min
- Start 10mg IV
  - Redose q5min after observing effect
  - Can double subsequent doses until achieve goal
Propfol
- Consider intubation + propofol drip if benzo-nonresponsive
Thiamine 100mg

The propylene glycol diluent in lorazepam, phenobarbital and diazepam, may induce a hyperosmolar anion gap metabolic acidosis if given as a drip in high doses ≥ 48hrs.^[1] Consider alternatives such as propofol or dexmedetomidine if patients need long term sedation for Delirum Tremens

↑ Arroliga AC, Shehab N, McCarthy K, Gonzales JP. Relationship of continuous infusion lorazepam to serum propylene glycol concentration in critically ill adults*. Critical Care Medicine. 2004;32(8):1709–1714. doi:10.1097/01.CCM.0000134831.40466.39.

@@ Line 27: / Line 27: @@
 **[[Lorazepam]] (Ativan) 1-4mg IV (depending on severity)
 ***May repeat q15-20min for severe withdrawal (titrated to effect)
+***Rarely causes hepatitis, as opposed to diazepam which may cause a cholestatic hepatitis[ref]National Institute of Diabetes and Digestive and Kidney Diseases. Lorazepam Drug Record. http://livertox.nih.gov/Lorazepam.htm[/ref]
 **[[Chlordiazepoxide]]
 ***Generally for outpt tx of mild cases