An Ethanol Protocol To Prevent Alcohol Withdrawal Syndrome

doi:10.1016/j.jamcollsurg.2006.04.025

Journal of the American College of Surgeons

Volume 203, Issue 2, August 2006, Pages 186-191

Presented as a poster at The American College of Surgeons 91^st Annual Clinical Congress, San Francisco, CA, October 2005.

https://doi.org/10.1016/j.jamcollsurg.2006.04.025 Get rights and content

Background

Alcohol withdrawal syndrome (AWS) occurs in dependent patients during the initial period of sudden onset abstinence. It is usually manifested by mild symptoms such as disorientation, agitation, and tachycardia, but, if untreated, can lead to severe confusion, seizures, and even cardiovascular collapse. Prevention of AWS has been shown to improve morbidity and mortality and shorten hospital and ICU stays. We examined the efficacy of ethanol as a method of prophylaxis.

Study Design

Our patient population was divided into two groups. Group 1 consisted of surgical patients receiving alcohol prophylaxis for AWS between January 2001 and July 2004 (n = 124), as identified by retrospective chart review. We then developed a protocol for the initiation, dosage, and weaning of intravenous ethanol in patients at risk for AWS, based on blood alcohol levels and clinical assessment of withdrawal symptoms and signs. Group 2 consisted of all patients treated prospectively with this protocol during the subsequent year (n = 76). Patients who did not fit inclusion criteria for the protocol were excluded from analysis, resulting in 92 and 68 patients in group 1 and group 2, respectively. We compared initiation criteria, efficacy, dosage, route, duration, and referral pattern to the substance abuse clinic before and after initiation of the protocol.

Results

Our initial use of intravenous ethanol was very variable in dosage, duration, and indication. The protocol decreased the duration of treatment between the two groups from 7 days to a mean of 3 days. The failure rate dropped from 20% to 7%. Referral to the substance abuse clinic rose from 7.6% to 20%. The only complication was asymptomatic hyponatremia in one patient.

Conclusions

Intravenous ethanol is a viable option for AWS prophylaxis when administered in a systematic protocol.

Section snippets

Methods

After IRB approval, we initially collected data from a 5-year retrospective review (June 1999 to June 2004) of all patients treated with intravenous or oral alcohol for AWS prophylaxis at our Level I trauma center (group 1). Patients were identified using the inpatient pharmacy database. Data were collected on patient demographics, dose, duration, indications for the use of ethanol, and efficacy in preventing symptoms of withdrawal and referral to rehabilitation programs for alcohol dependency

Results

Both groups had similar demographics and consisted primarily of male trauma victims (Table 3).Group 1 consisted of 124 patients who underwent AWS prophylaxis according to varying regimens prescribed by individual physicians. Seventy-four percent (n = 92) had a history of alcohol abuse or earlier AWS. The remainder had no specific history of alcoholism. There were wide variations in dosage and duration, with starting doses ranging from 5 to 60 mL/hour (mean 30 mL/hour) and duration of treatment

Discussion

Alcohol abuse is a serious public health issue in the United States. The risk of being admitted to a hospital increases proportionately with consumption. The incidence of alcohol withdrawal among general hospital patients was found to be 8%, elective surgery patients had an approximate rate of 16%, and trauma patients had a 31% incidence.¹⁰ Alcohol withdrawal has been shown to increase the mortality and morbidity of all patient groups.⁴

Prophylaxis in patients at risk for AWS has been shown to

Author Contributions

Study conception and design: Dissanaike, Griswold

Acquisition of data: Dissanaike

Analysis and interpretation of data: Dissanaike

Drafting of manuscript: Dissanaike

Critical revision: Halldorsson, Frezza, Griswold

Statistical expertise: Halldorsson

Supervision: Griswold

Acknowledgment

We thank Kendra Rumbaugh, PhD, for her assistance with statistical analysis.

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Cited by (38)

Emergency Department Management of Patients With Alcohol Intoxication, Alcohol Withdrawal, and Alcohol Use Disorder: A White Paper Prepared for the American Academy of Emergency Medicine
2023, Journal of Emergency Medicine
Tracking and blind deconvolution of blood alcohol concentration from transdermal alcohol biosensor data: A population model-based LQG approach in Hilbert space
2023, Automatica
Citation Excerpt :
In this brief paper, we consider two applications of this new biosensor technology formulated as linear quadratic Gaussian (LQG) tracking problems. The first is the in-patient management of alcohol withdrawal syndrome (AWS) (Bayard, Mcintyre, Hill, & Woodside, 2004; Dissanaike, Halldorsson, Frezza, & Griswold, 2006; Hansbrough et al., 1984; Hodges & Mazur, 2004) and the related problem of carrying out alcohol clamping studies (ACS) (O’Connor, Morzorati, Christian, & Li, 1998; Ramchandani et al., 2006) in the laboratory. As currently implemented, both of these rely on the manually controlled, open-loop, intravenous, infusion of ethanol.
LQG control in Hilbert space, a novel approach for random abstract parabolic systems, and new transdermal alcohol biosensor technology are combined to yield tracking controllers that can be used to automate inpatient management of alcohol withdrawal syndrome and human subject intravenous alcohol infusion studies, and to blindly deconvolve blood or breath alcohol concentration from biosensor measured transdermal alcohol level. The approach taken is based on a full-body alcohol population model in the form of a random, nonlinear, hybrid system of ordinary and partial differential equations and its abstract formulation in a Gelfand triple of Bochner spaces. The efficacy of the approach is demonstrated through simulation studies based on laboratory collected drinking data.
Predictors of resistant alcohol withdrawal (RAW): A retrospective case-control study
2018, Drug and Alcohol Dependence
Citation Excerpt :
Our findings do suggest that patients with AWS and abnormal liver enzymes on admission may need closer monitoring. Randomized trials and consensus guidelines have reported the strongest predictor for the development of AWS is either a personal or family history of AWS (Dissanaike et al., 2006; Kraemer et al., 2003; Sarff and Gold, 2010). Interestingly, while our results showed a trend towards a personal AWS history predicting RAW (P = 0.062), it was not statistically significant.
Benzodiazepine-resistant alcohol withdrawal (RAW), defined by a requirement of ≥ 40 mg of diazepam in 1 h, represents a severe form of withdrawal without predictive parameters. This study was designed to identify risk factors associated with RAW versus withdrawal without benzodiazepine resistance (nRAW).
A retrospective cohort of adults with severe alcohol withdrawal were screened. Demographic and clinical variables, collected through chart review, underwent logistic regression to select the subset that predicst RAW.
736 patients (515 nRAW, 221 RAW) were analyzed. RAW patients were younger (P < 0.001), male (P = 0.008) Caucasians (P = 0.037) with histories of psychiatric illness (P < 0.001), higher serum ethanol concentrations (P < 0.007), and abnormal liver enzymes (P = 0.01). RAW patients had significantly lower platelets (P < 0.001), chloride (P = 0.02), and potassium (P = 0.01) levels; severity of illness (SAPSII) (P < 0.001) and comorbidity scores (P < 0.001). Caucasian race and male gender were found to be 3.6 and 2.6 times more likely to be RAW. For every 1-unit increase in comorbidity and severity of illness scores, patients were 22% [OR(95% CI) 0.78 (0.66–0.90)] and 4% [0.96 (0.93–0.98)] less likely to be RAW. Patients with a psychiatric history or thrombocytopenia were 2 times more likely [2.02 (1.24–3.30); 2.13 (1.31–3.50), respectively] to be RAW.
These data demonstrate the predictive ability of a history of psychiatric illness, thrombocytopenia, gender, race, baseline severity of illness and comorbidity scores for developing RAW. Considering these characteristics in early withdrawal management may prevent progression to RAW outcomes.
Comparison of enteral ethanol and benzodiazepines for alcohol withdrawal in neurocritical care patients
2016, Journal of Clinical Neuroscience
Citation Excerpt :
Lastly, our sample size totaling 100 patients limited our ability to perform appropriate adjustments for the differences in baseline characteristics and may have affected our ability to find significant differences between the two groups. Using ethanol to prevent and treat AWS is well documented in the literature [3,16,17,20–26]. The administration of ethanol for alcohol withdrawal also poses an ethical dilemma not addressed by this study.
We designed a study to evaluate the use of benzodiazepines and ethanol in patients being assessed for alcohol withdrawal and compare outcomes between the two agents. This is a retrospective chart review of patients admitted to neurocritical care or neurosurgical services who were at risk for ethanol withdrawal between June 2011 and September 2015. Patients were divided into two groups based on the first medication administered for alcohol withdrawal management, either benzodiazepine (n = 50) or enteral ethanol (n = 50). The primary endpoint was the maximum change in Clinical Institute Withdrawal Assessment of Alcohol scale (CIWA) score within the first 24 hours. Secondary endpoints included maximum and minimum CIWA score in 5 days, length of stay, and change in Glasgow Coma Scale. Study groups differed by mortality risk, level of coma at admission, and other clinical characteristics, with the ethanol group appearing less severely ill. There was no significant difference between the two groups in the maximum change in CIWA score at 24 hours (−0.97, 95%CI: −3.21 to 1.27, p = 0.39). Hospital and intensive care unit length of stay was 6.5 days and 1 day shorter for the ethanol group (p = 0.03 and p = 0.02, respectively). In summary, enteral ethanol was preferentially used in patients who are more likely to be capable of tolerating oral intake. We found that the change from baseline in CIWA score or other physiologic variables was not substantially different between the two agents. The overall utility of benzodiazepines and enteral ethanol remains unclear for this population and further study is needed to determine superiority.
The "Prediction of Alcohol Withdrawal Severity Scale" (PAWSS): Systematic literature review and pilot study of a new scale for the prediction of complicated alcohol withdrawal syndrome
2014, Alcohol
To date, no screening tools for alcohol withdrawal syndromes (AWS) have been validated in the medically ill. Although several tools quantify the severity of AWS (e.g., Clinical Institute Withdrawal Assessment for Alcohol [CIWA]), none identify subjects at risk of AWS, thus missing the opportunity for timely prophylaxis. Moreover, there are no validated tools for the prediction of complicated (i.e., moderate to severe) AWS in the medically ill.
Our goals were (1) to conduct a systematic review of the published literature on AWS to identify clinical factors associated with the development of AWS, (2) to use the identified factors to develop a tool for the prediction of alcohol withdrawal among patients at risk, and (3) to conduct a pilot study to assess the validity of the tool.
For the creation of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS), we conducted a systematic literature search using PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines for clinical factors associated with the development of AWS, using PubMed, PsychInfo, MEDLINE, and Cochrane Databases. Eligibility criteria included: (i) manuscripts dealing with human subjects, age 18 years or older, (ii) manuscripts directly addressing descriptions of AWS or its predisposing factors, including case reports, naturalistic case descriptions, and all types of clinical trials (e.g., randomized, single-blind, or open label studies), (iii) manuscripts describing characteristics of alcohol use disorder (AUD), and (iv) manuscripts dealing with animal data (which were considered only if they directly dealt with variables described in humans). Obtained data were used to develop the Prediction of Alcohol Withdrawal Severity Scale, in order to assist in the identification of patients at risk for complicated AWS.
A pilot study was conducted to assess the new tool's psychometric qualities on patients admitted to a general inpatient medicine unit over a 2-week period, who agreed to participate in the study. Blind to PAWSS results, a separate group of researchers retrospectively examined the medical records for evidence of AWS.
The search produced 2802 articles describing factors potentially associated with increased risk for AWS, increased severity of withdrawal symptoms, and potential characteristics differentiating subjects with various forms of AWS. Of these, 446 articles met inclusion criteria and underwent further scrutiny, yielding a total of 233 unique articles describing factors predictive of AWS. A total of 10 items were identified as correlated with complicated AWS (i.e., withdrawal hallucinosis, withdrawal-related seizures, and delirium tremens) and used to construct the PAWSS. During the pilot study, a total of 68 subjects underwent evaluation with PAWSS. In this pilot sample the sensitivity, specificity, and positive and negative predictive values of PAWSS were 100%, using the threshold score of 4.
The results of the literature search identified 10 items which may be correlated with risk for complicated AWS. These items were assembled into a tool to assist in the identification of patients at risk: PAWSS. The results of this pilot study suggest that PAWSS may be useful in identifying risk of complicated AWS in medically ill, hospitalized individuals. PAWSS is the first validated tool for the prediction of severe AWS in the medically ill and its use may aid in the early identification of patients at risk for complicated AWS, allowing for prophylaxis against AWS before severe alcohol withdrawal syndromes develop.
Alcohol Withdrawal Syndrome
2012, Critical Care Clinics
Citation Excerpt :
Specific criteria for identification and severity of AWS were not given, but the investigators concluded that the infusions prevented signs of withdrawal during and subsequent to the ethanol infusions. Predominately in the surgical literature there have been several case reports and series attesting to the efficacy of alcohol therapy.264–267 A retrospective review followed by a prospective study of surgical patients who received alcohol prophylaxis demonstrated significant variation in dosage, duration, and indications for ethanol therapy; although the investigators reported that this approach led to a reduced rate of withdrawal symptoms and shorter duration of treatment, and increased the referral of patients to substance abuse management.267

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Original scientific articleAn Ethanol Protocol To Prevent Alcohol Withdrawal Syndrome

Background

Study Design

Results

Conclusions

Section snippets

Methods

Results

Discussion

Author Contributions

Acknowledgment

Gen Hosp Psychiatry

Am J Surg

Br J Anaesth

J Subst Abuse Treat

Alcohol treatment and health care system reform

Arch Gen Psychiatry

Alcohol intervention in trauma centerscurrent practice and future directions

JAMA

Delirium tremens in surgical patients

Surgery

Perioperative morbidity and mortality in chronic alcoholic patients

Alcohol Clin Exp Res

Blood alcohol concentration for monitoring ethanol treatment to prevent alcohol withdrawal in the intensive care unit

Intensive Care Med

Original scientific article
An Ethanol Protocol To Prevent Alcohol Withdrawal Syndrome