Wednesday, May 17, 2017

Alcohol withdrawal

Yesterday we discussed alcohol withdrawal.

Alcohol use can have effects on the body from head to toe. Complications of alcohol use can include:

-          Thiamine deficiency
o   Causing Wernicke encephalopathy characterized by the triad of encephalopathy, oculomotor dysfunction, and ataxia, or Korsakoff syndrome, the chronic consequence of Wernicke encephalopathy
-          Malnutrition and refeeding syndrome
-          Alcoholic ketoacidosis
-          Hypertension and cardiovascular disease
-          Cardiomyopathy
-          Liver disease including cirrhosis and hepatitis
-          Pancreatitis
-          Gastritis and esophagitis
-          Peripheral neuropathy
-          Bone marrow suppression
-          Injury/trauma
-          Malignancies, including GI, liver, and breast cancer
-          Psychiatric disorders

Another complication of alcohol use is alcohol withdrawal. There are several different phases of alcohol withdrawal. As such, the timing of symptoms compared to the last drink is helpful piece of information on history.

Manifestations of alcohol withdrawal:
-          Early alcohol withdrawal (onset 1-48 hours after last drink) can include symptoms such as insomnia, tremulousness, anxiety, GI upset, anorexia, headache, diaphoresis and palpitations.
-          Alcohol withdrawal seizures (onset 6-48 hours after last drink) are usually generalized, tonic-clonic seizures. Don’t forget basic principles such as accuchecks to ensure it is not a hypoglycemic seizures and reporting to the Ministry of Transportation for seizures. First line treatment of alcohol withdrawal seizures is benzodiazepines
-          Alcoholic hallucinosis (onset 12-48 hours after last drink) usually involves visual, auditory or tactile hallucinations. Importantly, orientation and vital signs are normal and that is what distinguishes alcoholic hallucinosis from delirium tremens.
-          Delirium tremens (onset 24-96 hours after last drink) is a serious manifestation of alcohol withdrawal characterized by delirium, agitation, tachycardia, hypertension, fever and diaphoresis. It is a medical emergency.

Principles of the management of alcohol withdrawal include:
1.       Rule out other causes of symptoms. Depending on the clinical presentation, for example confusion or change in level of consciousness, don’t forget to investigate for other causes of the presentation such as infection, co-ingestions, metabolic derangement, liver failure, GI bleeds, pancreatitis, and injuries (such as subdural hematoma) to name a few.
2.       Supportive care.
a.       Initial resuscitation including ABCs. Treat volume depletion.
b.      Treat any identified triggers or other causes of symptoms. There can be something else going on, such as pancreatitis or an infection, that led to reduced alcohol intake and then alcohol withdrawal.
c.       GIVE THIAMINE (before giving glucose) and a multivitamin  
d.      Nutritional support (may need to be NPO depending on level of consciousness to prevent aspiration) à consider other methods of nutritional support, get SLP and dietitian involved, and don’t forget to monitor for refeeding syndrome.
e.      Monitor severity of alcohol withdrawal with CIWA-Ar and clinical assessments.
                                                               i.      Items on the CIWA-Ar (Clinical Institute Withdrawal Assessment Scale for Alcohol, revised) include: nausea and vomiting, tremor, paroxysmal sweats, anxiety, agitation, tactile auditory and visual disturbances, headache, and orientation.  
f.        Treat alcohol withdrawal with benzodiazepines.
                                                               i.      Often diazepam or lorazepam are the benzodiazepines of choice and they are used in a symptom-triggered approach (administration and dose triggered by CIWA-Ar score)
                                                             ii.      Diazepam has a longer half-life so is usually the first choice to avoid recurrent withdrawal or seizures.
                                                            iii.      However, with cirrhosis or acute hepatitis, a benzodiazepine with a shorter halt-life such as lorazepam, may be preferred to avoid over-sedation.
                                                           iv.      Take a look and become familiar with the CIWA-Ar protocols at your institution.
                                                             v.      For refractory delirium tremens, barbiturates such as phenobarbital and/or propofol may be necessary.

1.       Up-to-date “Management of moderate and severe alcohol withdrawal syndromes”. Hoffman et al. Last updated Jan 17, 2017.

2.       Schuckit M. Recognition and Management of Withdrawal Delirium. NEJM. 2014;371:2109-13.