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MANAGEMENT OF ALCOHOL WITHDRAWAL IN A GENERAL HOSPITAL SETTING- CL PSYCHIATRY PERSPECTIVE

MANAGEMENT OF ALCOHOL WITHDRAWAL IN A GENERAL HOSPITAL SETTING- CL PSYCHIATRY PERSPECTIVE. R.HEWKO MD FRCPC CL PSYCHIATRIST rhewko@telus.net. DISCLOSURE. NOTHING TO DISCLOSE. CL PSYCHIARTY ROLE ?. PRIMARY MANAGMENT ? SECONDARY MANAGEMENT

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MANAGEMENT OF ALCOHOL WITHDRAWAL IN A GENERAL HOSPITAL SETTING- CL PSYCHIATRY PERSPECTIVE

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  1. MANAGEMENT OF ALCOHOL WITHDRAWAL IN A GENERAL HOSPITAL SETTING- CL PSYCHIATRY PERSPECTIVE R.HEWKO MD FRCPC CL PSYCHIATRIST rhewko@telus.net

  2. DISCLOSURE NOTHING TO DISCLOSE

  3. CL PSYCHIARTY ROLE ? • PRIMARY MANAGMENT ? • SECONDARY MANAGEMENT - FAILED PRIMARY SERVICE MANAGEMENT - CLEAN UP - DEPENDANT ON UNDERSTANDING PRIMARY SERVICE MODEL – CIWA PROTOCOL

  4. CIWA MODEL • CIWA MODEL -CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT -ALCOHOL - 9 ITEMS ASSESSED BY NURSING STAFF - LINKED TO A PREPRINTED ORDER SET - PRIMARY AGENTS - BENZODIAZPINES

  5. CIWA PROTOCOL - ADVANTAGES • EVIDENCE BASED PRACTICE • REQUIRE LESS BENZO’S THAN FIXED DOSE MODELS • CONSISTANT TREATMENT • MINIMAL PHYSICIAN INVOVLEMENT • PRIMARILY NURSING BASED CARE • ONE SIZE FITS ALL

  6. MAYO CLINIC ARTICLE • TITLE – Inappropriate use of Symptom-Triggered Therapy for Alcohol Withdrawal in the General Hospital • Authors – KA Hecksel, JM Bostwick, TM Jaeger • Ref. Mayo Clin. Proc. 2008;83(3):2004 274-279

  7. METHODOLOGY • 124 OF 495 PATIENTS RX WITH CIWA PROTOCOL IN TWO MAYO CLINIC AFFILIATED HOSPTIALS • RANDOM SELECTION ACCOUNTING FOR AGE/GENDER • ADMISSION CRITERIA FOR CIWA PROTOCOL MALES - > 4 DRINKS /DAY WK PRIOR TO HOSP. FEMALES - > 2 DRINKS /DAY WK PRIOR TO HOSP. ABLE TO COMMUNICATE MEANINGFULLY

  8. RESULTS • 52 % - 64/124 OF PATIENTS RX DID NOT MEET INCLUSION CRITERIA • 14 % - 9 PTS UNABLE TO COMMUNICATE • 55 % - 35 PTS HAD NO RECENT ALCOHOL HX • 31 % - 20 PTS MET NEITHER CRITERIA

  9. CIWA DEVOPMENT AND VALIDATION • PRIVATE HOSPITAL DETOX • AGE < 60 YRS OLD • PTS MEDICALLY CLEAR • GEN. HOSPTIAL STUDIES EXCLUSION CRITERIA - AGE -SEVERITY OF ILLNESS

  10. PREPRINTED ORDERS • DEVELOPED BY ASAM - 300 PTS. IN A VA DETOX - 3 PTS OVER AGE 60 - PTS MEDICALLY CLEAR

  11. CLINICAL LITERATURE – BENZODIAZEPINESAGENTS OF CHOICE META-ANALYSIS HOSPITAL BASED MANAGEMENT OF AW HOLBROOK,CMAJ,MAR 9,1999. 160(5) 649-655 COMPARITIVE STUDIES – BENZO’S. NEUROLEPTICS, ANTICONVULSANTS, CHLORAL HYDRATE BENZODIAZIPINES SAFE AND EFFECTIVE AGENT OF CHOICE FOR TREATMENT OF AW NO BENZODIAZEPINE SUPERIOR IN EFFICACY / SAFETY

  12. LIMITATIONS • 11 “GOOD” STUDIES • N’s 20-30 PATIENTS PER STUDY • MEAN AGE 35-45 • 5 STUDIES LTD PTS TO MILD ILLNESS • ALL STUDIES EXCLUDED SEVERELY ILL

  13. CIWA PROTOCALADVANTAGES = DISADVANTAGES • EASE AND EFFICIENCY • PHYSICIAN INVOLVEMENT “IDENTIFY” AT RISK PT INITIATE CIWA – TICK BOXES • NURSING STAFF MANAGE THE PATIENT ON “AUTOPILOT” -ASSESS CIWA SCORE -GIVE BENZOS UNTIL SCORE < 10 • MINIMAL ONGOING PHYSICIAN INVOLVEMENT

  14. IMPLICATIONSCIWA PROTOCOL • VALIDATED FOR RELATIVELY YOUNG, HEALTHY PTS • PTS INAPPROPRIATELY STARTED INTO PROTOCOL • MOST PHYSICIANS UNAWARE OF LIMITATIONS • MINIMAL FORMAL TEACHING • LIMITED PHYSICIAN MONITERING • DELAYED RECOGNITION OF COMPLICATIONS • POTENTIAL FOR SIGNIFICANT MORBIDITY/MORTALITY • PSYCHIATRIC REFERRAL - ONGOING AGITATION / CONFUSION - DELIRIUM

  15. DELIRIUM – ALCOHOL HX / SEQUELAE OF CIWA PROTOCOL • DDX - DT’S 1/300 - DELIRIUM “OTHER” ETIOLOGY - BENZODIAZEPINE INTOXICATION - AW AND DELIRIUM OTHER ETIOLOGY - DELIRIUM AND BENZO INTOXICATION

  16. ASSESSMENT/MANAGEMENT • EVIDENCE / ABSENCE OF AUTONOMIC AROUSAL (AA) -AA CONTINUE BENZO’S ADD NEUROLEPTICS REG/PRN -DROWSY / MIN. AA - TAPER BENZO’S - TITRATE REG/PRN NEUROLEPTICS - NORMALIZE SLEEP - QUETIAPINE

  17. AW - MAJOR AUTONOMIC AROUSAL • REFRACTORY AW - AGGRESSIVE BENZO’S - LORAZEPAM 2-4 mg QIH PRN - REG. BENZO’S – LORAZEPAM / DIAZEPAM - HYPOMAGNESEMIA ?

  18. HYPOMAGNESEMIA • COMMON ISSUE IN PATIENTS AT RISK -MAJOR AW • HYPOMAG. - INCR. RISK /SEVERITY OF AW - INCR. RISK SEIZURES / SEIZURE STATUS - REFRACTORY HYPOKALEMIA - REFRACTORY WITHDRAWAL? - BENZO INSENSITIVITY - ANIMAL STUDIES • REPLACEMENT – 5 GMs IV Q12H/Q8H 3-6 DOSES

  19. REFRACTORY DELIRIUM • 42 Y/O MALE – ONGOING DELIRIUM • DAY 4 – DROWSY/ DISORIENTED • AVERAGING 10 mg LORAZEPAM LAST 2 DAYS • CONFUSION/NYSTAGMOUS/ATAXIA • DX ? • RX ?

  20. WERNICKE’S ENCEPHALOPATHY • THIAMINE DEFICIENCY • MEDICAL EMERGENCY • 30 % NEUROLOGIC SEQUELAE EVEN WITH RX • RX - THIAMINE -PARENTERAL IM/IV 100mg - AT LEAST 3 DAYS -RELIABLE UNTIL ORAL INTAKE

  21. SUMMARY • CIWA PROTOCOL NOT VALIDATED IN EDLERLY MEDICALLY COMPRISED • OVERUSED WITH INADEQUATE ASSESSMENT • LOSS OF CLINICAL SKILLS / JUDGEMENT • SIGNIFICANT INCIDENCE RESIDUAL DELIRIUM • A LAW SUIT WAITING TO HAPPEN !

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