Alcohol Withdrawal

1. Alcohol Withdrawal Resident Rounds July 10, 2007 Maggie Gordon, R2

2. Alcohol Withdrawal • Importance in surgery • Definitions • Pathophysiology • Signs and symptoms • Treatment

3. Importance in Surgery

4. 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

5. Importance • Tolerance to anaesthesia, analgesia •  physiologic reserve •  stress response •  morbidity, mortality •  ICU, hospital stays •  bleeding •  infections • Tachycardias,  cardiac output

6. Definitions

7. At-risk drinking • Men: > 16 drinks / week • Women: > 10 drinks / week

8. Alcohol Abuse (DSM IV) • Maladaptive use with work / school / social / interpersonal / legal consequences At risk of withdrawal

9. Alcohol Dependence (DSM IV) At risk of withdrawal • 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

10. Pathophysiology

11. Pathophysiology • EtOH = CNS depressant •  serotonin → tolerance, craving • Withdrawal •  GABA →  arousal •  norepi

12. Signs and Symptoms

13. Signs and Symptoms • Spectrum of • Presentation • Severity • Timing

14. 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

15. Investigate further 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

16. Alcoholic Hallucinosis • Usually visual, specific hallucinations • Occasionally auditory, tactile Onset: 12 – 24 h post EtOH cessation Duration: 24 – 48 h No “clouding of sensorium”

17. Delirium Tremens • Hallucinations • Disorientation •  HR •  BP •  temperature • Diaphoresis • Agitation Autonomic instability Onset: 2 – 4 days post EtOH cessation Duration: 1 – 5 days

18. Delirium Tremens •  cardiac output •  O2 consumption •  cerebral blood flow • Hyperventilation → • Respiratory alkalosis • Risk factors • Long binge • Significant clouding of sensorium

19. Delirium Tremens • Risk Factors • Sustained drinking • Previous DTs • > 30 y.o. • Concurrent illness • Delayed presentation to medical care / assessment

20. Delirium Tremens • 5% mortality • Arrhythmias • Complicating illness, e.g. pneumonia • Risk factors for death •  age • Pulmonary disease • T > 40°C • Liver disease

22. Withdrawal Syndromes

23. Treatment

24. 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)?

25. Prevention • Consider pre-op • Collateral from family • LET’s

26. Prevention • Thiamine, folate, multivitamins • Abstinence • Detox and rehab • Referrals • Early prophylaxis, i.e., before symptoms appear

27. History First • EtOH use • Hx of withdrawal syndromes, especially seizures

28. Physical Exam • Vitals • Tremor

29. Investigations • Blood work • CBC for Hgb, platelets • LFT’s • CT • LP

30. Investigations • Rule out and treat • Infection • Trauma • Metabolic derangements • Drug overdose • Liver failure • GI bleeding Diagnosis of exclusion

31. Keys to Therapy • Substitute drug of abuse with long-acting medication with similar effects, then taper dose

32. Keys to Therapy • Reevaluate frequently • Avoid complacency • Alleviate symptoms

33. Keys to Therapy • Hydrate (dehydration ← diaphoresis,  T, vomiting,  HR) • Correct electrolytes • K ( K ← vomiting, aldosterone Δs) • Mg ( Mg → DT risk) • PO4 ( PO4← malnutrition)

34. 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

35. 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

36. CIWA

37. 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

38. Refractory Seizures, DTs • Phenobarbital 130 – 260 mg iv q 15 – 20 min • Propofol 1 mg / kg iv push, intubate, then titrate to sedation

39. Long-Term Therapy • Evaluation • Referral to long-term follow-up No evidence of effectiveness

40. References

41. NEJM

42. UpToDate

44. UpToDate

46. Symptom-Oriented Therapy • ICU patients • Flunitrazepam, clonidine, halperidol

48. Symptom-Triggered Doses • Detox program • Oxazepam

49. For Discussion

50. 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 Indications for ICU Admission UpToDate