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Prepared by J. Mabbutt & C. Maynard NaMO September 2008

7: Managing Alcohol Withdrawal. Prepared by J. Mabbutt & C. Maynard NaMO September 2008. 7: Managing withdrawal Objectives. 1. During the session nurses & midwives will learn how to identify, assess & manage a patient in alcohol withdrawal

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Prepared by J. Mabbutt & C. Maynard NaMO September 2008

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  1. 7: Managing Alcohol Withdrawal Prepared byJ. Mabbutt & C. MaynardNaMO September 2008

  2. 7: Managing withdrawalObjectives 1. During the session nurses & midwives will learn how to identify, assess & manage a patient in alcohol withdrawal 2. By the end of the session nurses & midwives will have an understanding or use of the AWS/CIWAR-Ar withdrawal scales 3. At the end the session, nurses & midwives will have a basic understanding & knowledge to safely & effectively identify, monitor & manage alcohol withdrawal

  3. 7: Managing withdrawal Effective management of withdrawal in its early stages can reduce or prevent progression to complicated withdrawal Complicated withdrawal may be life-threatening due to: Accidental injury, dehydration, electrolyte imbalance, seizures, delirium tremens, or the negative impact on other concurrent disorders, including acute infection, renal disease or diabetes

  4. 7: Indications and guidelines: Assessing withdrawal • Severe alcohol withdrawal is potentially life threatening • The most important thing is to anticipate when it may occur & to suspect it when an unexplained acute organic brain syndrome is detected • Before continuing to assess alcohol withdrawal, the following information focuses on a form of brain injury called the Wenicke’s-Korsakoff syndrome

  5. 7: Indications and guidelines: Complications of misuse – Wernicke-Korsakoff syndrome (1) • This is a form of brain injury resulting from thiamine deficiency, which complicates alcohol dependence • If not treated early it can lead to permanent brain damage & memory loss – young alcohol-dependent people are at risk • Signs & symptoms of Wernicke’s encephalopathy, which is usually the first stage of the syndrome, are: • Ophthalmoplegia (reduced eye movements or nystagmus) • Ataxia & confusion

  6. 7: Indications and guidelines: Complications of misuse – Wernicke-Korsakoff syndrome (2) • This condition is reversible if recognised and treated with parenteral vitamin B1 • Parenteral thiamine should be administered before any form of glucose • Glucose in the presence of thiamine deficiency risks precipitating Wernicke’s encephalopathy

  7. 7: Indications and guidelines: Assessing withdrawal – Onset & duration of alcohol withdrawal (1) • Onset of alcohol withdrawal is usually 6-24 hours after the last drink • Consumption of benzodiazepines or other sedatives may delay the onset of withdrawal • In some severely dependent drinkers, simply reducing the level of consumption may precipitate withdrawal, even if they have consumed alcohol recently

  8. 7: Indications and guidelines: Assessing withdrawal – Onset & duration of alcohol withdrawal (2) • Usually withdrawal is brief & resolves after 2-3 days without treatment; occasionally, withdrawal may continue for up to 10 days • Withdrawal can occur when the blood alcohol level is decreasing, even if the patient is still intoxicated

  9. Figure 9.1: Progress of alcohol withdrawal syndrome

  10. 7: Indications and guidelines: Assessing withdrawal – Index for Suspicion of Alcohol withdrawal (1) • Severity of alcohol withdrawal ranges from mild to severe • The following questions, known as the Index for Suspicion of Alcohol Withdrawal, will help you determine whether the patient is likely to move into alcohol withdrawal: • A regular intake of 80 grams (8 drinks-Males) or 60 grams (6 drinks-Females) of alcohol or more per day? • Taken even smaller amounts of alcohol in conjunction with other CNS depressants? • Previous episodes of alcohol withdrawal?

  11. 7: Indications and guidelines: Assessing withdrawal – Index for Suspicion of Alcohol withdrawal (2) • Current admission for an alcohol-related reason? • Physical appearance indicate chronic alcohol use: • parotid swelling (swelling in the gland under the ear) • cushingoid face (full/moon looking face) • facial telangiectasia (red spots/blood vessels) • eyes reddened or signs of liver disease • ascites, jaundice, limb muscle wasting

  12. 7: Indications and guidelines: Assessing withdrawal – Index for Suspicion of Alcohol withdrawal (3) • Pathology results show raised serum GGT • Raised mean cell volume (MCV) • Displaying symptoms such as • anxiety, • agitation, • tremor, • sweatiness or early morning retching, which might be due to an alcohol withdrawal syndrome?

  13. 7: Indications and guidelines: Signs & symptoms of alcohol withdrawal (1) • Alcohol withdrawal is a syndrome of central nervous system hyperactivity characterised by symptoms that range from mild to severe • The symptoms and signs of alcohol withdrawal may be grouped into three major classes: See Table 9.4

  14. Table 9.4:Main signs & symptoms of alcohol withdrawal

  15. 7: Indications and guidelines: Signs & symptoms of alcohol withdrawal (2) • Seizures occur in about 5% of patients withdrawing from alcohol • They occur early (usually 7-24 hours after the last drink), are grand mal in type (i.e. generalised, not focal) & usually (though not always) occur as a single episode • Delirium tremens (“the DTs”) is rare & is a diagnosis by exclusion • It is the most severe form of alcohol withdrawal syndrome, & a medical emergency

  16. 7: Indications and guidelines: Signs & symptoms of alcohol withdrawal (3) • DT’s usually develops 2-5 days after stopping or significantly reducing alcohol consumption • The usual course is 3 days, but can be up to 14 days • Its clinical features are: • Confusion & disorientation • Extreme agitation or restlessness – the patient often requires restraining

  17. 7: Indications and guidelines: Signs & symptoms of alcohol withdrawal (4) • Gross tremor • Autonomic instability (e.g. fluctuations in BP & pulse), disturbance of fluid balance & electrolytes, hyperthermia • Paranoid ideation, typically of delusional intensity • Distractibility & accentuated response to external stimuli • Hallucinations affecting any of the senses, but typically visual (highly coloured, animal form)

  18. 7: Indications and guidelines:Alcohol withdrawal scales (1) • The most systematic & useful way to measure the severity of withdrawal is to use a withdrawal scale • These provide a baseline against which changes in withdrawal severity may be measured over time • Research shows that the use of scales minimises both under-dosing & overdosing with benzodiazepines for alcohol withdrawal syndromes

  19. 7: Indications and guidelines:Alcohol withdrawal scales (2) • There has been considerable debate about the application of withdrawal scales • Two different scales, the Alcohol Withdrawal Scale (AWS) and the Clinical Institute Withdrawal Assessment for Alcohol (revised) (CIWA-Ar) are both are recommended for use (see Appendices 2 and 3) • Being familiar with the alcohol withdrawal scale used in your local area is a priority

  20. 7: Indications and guidelines:Alcohol withdrawal scales (3) • Note that withdrawal scales do not diagnose withdrawal, but are merely guides to the severity of an already diagnosed withdrawal syndrome • The nurse or midwife should re-evaluate the patient to ensure that it is alcohol withdrawal & not another condition that is being measured, particularly if the patient does not respond well to treatment

  21. 7: Alcohol withdrawal scalesClinical Institute Withdrawal Assessment for Alcohol Revised Version (CIWA-Ar) (1) • The CIWA-Ar (see Appendix 2)is a 10-item scale that can be administered as part of supportive care • Several studies have shown that the CIWA-Ar scale is a valid, reliable & sensitive instrument for assessing the clinical course of simple alcohol withdrawal

  22. 7: Alcohol withdrawal scalesClinical Institute Withdrawal Assessment for Alcohol Revised Version (CIWA-Ar) – Videos • Video options show either of the following from the CIWA-Ar CD ROM • E5 Using the CIWA-Ar alcohol withdrawal scale (withdrawal symptoms are demonstrated) (10.37 min) • E8 – A Case study

  23. 7: Alcohol withdrawal scalesClinical Institute Withdrawal Assessment for Alcohol Revised Version (CIWA-Ar) (2) • This scale allows a quantitative rating (from 0 to 7 with a maximum possible score of 67) of the following components of withdrawal: • Nausea & vomiting • Tremor • Paroxysmal sweats • Anxiety

  24. 7: Alcohol withdrawal scalesClinical Institute Withdrawal Assessment for Alcohol Revised Version (CIWA-Ar) (3) • Agitation • Tactile disturbances • Auditory disturbances • Visual disturbances • Headache and fullness in head • Orientation & clouding of sensoria

  25. 7: Alcohol withdrawal scalesClinical Institute Withdrawal Assessment for Alcohol Revised Version (CIWA-Ar) (4) Using the CIWA-Ar in presentation to the emergency department: • Monitor the patient hourly for at least 4 hours using the CIWA-Ar • Contact the medical officer or drug & alcohol nurse practitioner for assessment and monitor hourly if: • the alcohol score increases by at least 5 points over this 4-hour period, or • the CIWA-Ar total score reaches 10

  26. 7: Alcohol withdrawal scalesClinical Institute Withdrawal Assessment for Alcohol Revised Version (CIWA-Ar) (5) Using the CIWA-Ar for hospitalised patients: • Monitor the patient 4-hourly, using the CIWA-AR, for at least 3 days • If the total score reaches 10, monitor hourly & notify the medical officer or drug & alcohol nurse practitioner

  27. 7: Alcohol withdrawal scalesAlcohol withdrawal scale (AWS) (1) Alcohol Withdrawal Scale (AWS) • The AWS (see Appendix 3) is a widely used scale in NSW • If a patient’s history or presentation suggests possible withdrawal, the patient’s condition must be monitored & documented

  28. 7: Alcohol withdrawal scalesAlcohol withdrawal scale (AWS) (2) • The AWS (see Appendix 3) is a widely used scale in NSW and is a 7 item scale that allows a quantitative rating (from 0 to 4) of the following components: • Perspiration • Tremor • Anxiety • Agitation • Axilla temperature • Hallucinations • Orientation

  29. 7: Alcohol withdrawal scalesAlcohol withdrawal scale (AWS) (3) Using the AWS in presentation to the emergency department: • Monitor the patient hourly for at least 4 hours using the AWS • Contact the medical officer or drug & alcohol nurse practitioner for assessment & monitor hourly if: • the alcohol score increases by at least 5 points over this 4-hour period, or • the AWS total score reaches 5

  30. 7: Alcohol withdrawal scalesAlcohol withdrawal scale (AWS) (4) Using the AWS for hospitalised patients: • Monitor the patient 4-hourly, using the AWS, for at least 3 days • If the total score reaches 5, monitor hourly & notify the medical officer or drug & alcohol nurse practitioner • Depending on the resources of the local area, these may need review

  31. 7: Indications and guidelines:Pharmacological Treatment (1) From NSW Drug & Alcohol Withdrawal Clinical Practice Guidelines NSW Health 2007 • The most commonly prescribed pharmacological treatment for alcohol withdrawal is diazepam because of its cross-tolerance with alcohol & anti-convulsant properties • Two types of regimes for specialist residential or inpatient setting • Diazepam loading regime • Symptom-triggered sedation

  32. 7: Indications and guidelines:Pharmacological Treatment (2) Diazepam loading regime • On the development of withdrawal symptoms initiate diazepam loading • 20mg initially, increasing to 80mg over 4-6 hours • Or until pt is sedated • Medial review required if dose exceeds 80mg & more diazepam can be ordered depending on withdrawal condition

  33. 7: Indications and guidelines:Pharmacological Treatment (3) Symptom-triggered sedation • Mild withdrawal CIWA-AR <10 & AWS <4 • Supportive care, observations 4 hourly • If sedation necessary; 5-10mg oral diazepam every 6-8 hours for first 48 hrs

  34. 7: Indications and guidelines:Pharmacological Treatment (4) Symptom-triggered sedation • Moderate withdrawal CIWA-AR 10-20 & AWS <5-14 • Medical officer to assess • If alcohol withdrawal confirmed: hourly observations; give 10-20 oral diazepam immediately; repeat 10mg hourly or 10-20mg 2hrly until the pt achieves good symptom control (up to a total dose of 80mg) • Repeat medical review after 80mg of diazepam and if pt is not settling, consider olanzepine (zyprexia) 5-10mg

  35. 7: Indications and guidelines:Pharmacological Treatment (5) Symptom-triggered sedation • Severe withdrawal CIWA-AR 20+ & AWS 14+ • Urgent management. Give a loading dose • Review more frequently until score falls • A rising score indicates a need for more aggressive management

  36. 7: Indications and guidelines:Pharmacological Treatment (6) • Contraindications to diazepam include: • respiratory failure, • significant liver impairment, • possible head injury or cerebrovascular accident – in these situations, specialist consultation is essential From NSW Drug and Alcohol Withdrawal Clinical Practice Guidelines NSW Health 2007 http://www.health.nsw.gov.au/policies/gl/2008/GL2008_011.html

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