Alcohol Withdrawal and Flumazenil: Not for the Faint of Heart

The Toxicologist and Delirium: Flumazenil as a Diagnostic and Therapeutic Tool for Delirium During the Course of Alcohol Withdrawal

“…Regarding AWS, it ordinarily was resolving by the time we gave flumazenil in our cases and was the most common differential diagnosis as the reason to utilize flumazenil. Furthermore, delirium associated with AWS would be unusual to persist beyond 4-5 days of abstinence [6][7][8], which our data supports. Prolonged AWS was ruled out in the majority of our patients by their improvement with flumazenil in the majority of patients (73 % objective improvement).…”

Continuous Intravenous Flumazenil Infusion Used in Iatrogenic Chlordiazepoxide Overdose in the Setting of Alcoholic Withdrawal Syndrome Management

“…Alcohol withdrawal syndrome (AWS) is an umbrella term for the signs and symptoms that patients with alcohol use disorder may experience upon cessation or reduction of alcohol intake [ 2 ]. Symptoms of AWS include hallucinations, seizures, and delirium tremens.…”

“…Patient responsiveness to doses of benzodiazepines varies widely. Some patients display a relative resistance to benzodiazepines, often leading to escalating doses of drug administration [ 2 ]. At the dose required to control AWS symptoms, benzodiazepines can produce sedation, delirium [ 2 ], and acute encephalopathy [ 4 ].…”

“…Benzodiazepines, including chlordiazepoxide, a long-acting benzodiazepine, are the first-line drug class used in alcohol withdrawal syndrome [ 1 ]. A symptom-triggered approach in conjunction with scoring systems, such as the Clinical Institute Withdrawal Assessment (CIWA) of Alcohol Scale, Richmond Agitation-Sedation Scale (RASS), or Riker score, has been adopted in clinical practice; the next dose of benzodiazepine is administered when the patient starts to display recrudescent AWS with the goal to reduce the total dose of benzodiazepine required and the length of hospital stay [ 2 ]. With a symptom-triggered approach, chlordiazepoxide can be given in 50 mg to 100 mg increments, as triggered by symptoms for a maximum of 300 mg per day [ 3 ].…”

Flumazenil, naloxone and the ‘coma cocktail’

“…It can reverse residual depression of diaphragm function more than 24 h after several days of continuous midazolam infusion for mechanical ventilation in the ICU . More provocative is a recent report of its use in expert hands to diagnose and treat delirium several days after hospital admission for severe alcohol withdrawal treated with high dose benzodiazepines (median dose lorazepam 120 mg + diazepam 145 mg) or, paradoxically, for the chronic management of benzodiazepine dependence .…”