1. UNMH Alcohol Withdrawal Protocol Based on and adapted from alcohol withdrawal protocol at Bayfront Medical Center CriticalCareNurse Vol 30, No. 3, June 2010

2. CIWA is replacing CAGE Clinical Institute Withdrawal Assessment of Alcohol Validated in many other centers Multidisciplinary team developed the current protocol – Pharmacy, Neuro, Critical Care, Nursing – Trialed in MICU with good results – Modified from the current VA protocol as well Low intensity vs. High intensity

3. How to order Adult Alcohol Withdrawal Protocol-CIWA Pick dosing and pre-check all meds under the category Dose adjustment: >65 yo, Child’s B/C cirrhosis, severe neuro injury, pregnancy – Uses ativan only OR NO dose adjustment – Uses librium (or ativan if not taking po) Nurses do the rest with scoring and dosing of the meds

4. Total score is a simple sum of each item score (maximum score is 67). Score: <10: Very mild withdrawal 10-15: Mild withdrawal 16-20: Modest withdrawal >20: Severe withdrawal CIWA Scoring

5. Benzodiazepines Comparison Medication (action)Onset of action Dose Equivalent (mg) Average Half Life (Hr) in Healthy patient Active Metabolite and Metabolism Chlordiazepoxide (long) Oral 1-2 hrs256.6-25Yes (Desmethyldiaz epam) CYP3A4 Diazepam (long) Oral, IV, rectal Almost immediate 520-50Yes (Desmethyldiaz epam) CYP3A4 Lorazapam (short) Oral, IV, IM 5-20 minutes0.75-110.5No Glucuronide conjugation Oxazepam (short) Oral 1-2 hrs152.8-8.6No Glucuronide conjugation