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

7. 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

8. 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

9. 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

10. 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

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

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

13. CLINICAL LITERATURE – BENZODIAZEPINES AGENTS 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

14. 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

15. CIWA PROTOCAL ADVANTAGES = 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

16. IMPLICATIONS CIWA 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

17. 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

18. 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

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

20. 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

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

22. 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

23. 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 !