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) 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 At risk of withdrawal

10. Pathophysiology

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

12. Signs and Symptoms

13. 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. 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 Investigate further

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 Onset: 2 – 4 days post EtOH cessation Duration: 1 – 5 days Autonomic instability

18. Delirium Tremens  cardiac output  O 2 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 DescriptionOnset (since last EtOH) Duration Comments Minor Withdrawal Insomnia Mild anxiety Palpitations Tremors Diaphoresis Headache GI upset Anorexia < 6 h x 24 – 48 h Consistent in each patient SeizuresGeneralized Tonic-clonic 2 – 48 h3% of chronic alcoholics Alcoholic Hallucinosis Usually visual Occasionally auditory, tactile 12 – 24 h x 24 – 48 h No clouding of sensorium Delirium Tremens Hallucinations Disorientation  HR  BP  temperature Agitation Diaphoresis 2 – 4 d x 1 – 5 d 5% of patients w/ withdrawal

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) PO 4 (  PO 4 ← 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 →  t ½ 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

46. Symptom-Oriented Therapy ICU patients Flunitrazepam, clonidine, halperidol Fixed-doseCIWA-triggered Withdrawal severityWorseBetter Total doseGreaterLesser Days ventilatedGreaterFewer PneumoniaGreaterFewer ICU stayLongerShorter

48. Symptom-Triggered Doses Fixed-doseCIWA-triggered OutcomesSimilar Total doseGreaterLesser Treatment durationGreaterLesser Detox program Oxazepam

49. For Discussion

50. Indications for ICU Admission 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 UpToDate