Alcohol Withdrawal Prevention: A Randomized Evaluation of Lorazepam and Ethanol--A Pilot Study

Abstract

Background Alcohol withdrawal syndrome, characterized by a hyperadrenergic state with confusion, agitation and hallucinations, has detrimental effects on patient safety in the context of acute myocardial infarction (MI). Unexpected hospitalization and sudden cessation of alcohol consumption may result in adverse outcomes including in-hospital complications, increased length of stay, and death. Strategies for safe and effective patient management have not been rigorously studied. Purpose We conducted a randomized evaluation of lorazepam and ethanol/lorazepam to evaluate the safety and efficacy of two strategies for the prevention of alcohol withdrawal syndrome in patients with acute coronary syndromes. Methods Patients (n=57) with myocardial infarction were screened for alcohol dependence using the CAGE questionnaire and randomized to lorazepam or to ethanol with lorazepam. Demographic group differences and complication rates were analyzed using chi square (categorical variables) and t-tests (continuous variables). Safety (composite complication rates) of the treatment strategy was evaluated using Fisher’s exact test. Length of stay was analyzed using Wilcoxon rank-sum test. Results Safety-associated complication rates (self-extubation, delirium tremens, re-infarction) were not different between groups (24% lorazepam vs. 18% ethanol; p=0.56). A trend toward fewer complications in the ethanol group was noted. In addition, no difference was detected between the treatment groups for days spent in the CCU (6.9% lorazepam vs. 2.4% ethanol; p = 0.32) or overall hospital stay (6.2% lorazepam vs. 6.4% ethanol; p = 0.72). Conclusions These findings suggest that a randomized evaluation of treatment strategies to prevent complications associated with alcohol withdrawal in acute MI is safe and feasible. A larger study may provide important evidence for improving clinical outcomes for patients experiencing alcohol withdrawal during acute myocardial infarction.

Management of Acute Alcohol Withdrawal Syndrome in Critically Ill Patients

“…One randomized controlled trial evaluating enteral ethanol for AWS met our inclusion criteria . This single‐center study identified 57 patients admitted to the cardiac intensive care unit (CCU) who were at high risk for withdrawal.…”

Alcohol Withdrawal Syndrome in Critically Ill Patients: Identification, Assessment, and Management

“…This practice might halt the progression from mild to severe withdrawal and prevent delirium tremens. 18,20 Use of Serum Biomarkers to Detect an AUD A serum laboratory test that could highlight chronic alcohol use would be helpful, especially when an alcohol history is unobtainable. Laboratory tests such as serum ethanol levels only reveal recent alcohol consumption, not the chronic intake of alcohol that predisposes to withdrawal.…”

Delirium Tremens Is Associated with Increased Mortality in Acute Coronary Syndrome

“…Bartrug et al [10] reported that 24% developed DT, and of these 11% died and an additional 56% had serious complications, which involved patients with a high risk for acute AWS. Additionally, as a result of AWS or DT complications, costs to both the patient and the health care system are a significant factor in providing safe care for these patients [1]. Joy and Kumar [6] reported that the median LOS for patients with ACS was significantly higher for those with AWS (7 days) and DT (11 days) when compared to nonalcoholics (3 days).…”

“…In cases of DT coexisting with ACS that is refractory to appropriate high doses of benzodiazepines, early consideration of mechanical ventilation and the administration of phenobarbital, dexmedetomidine or propofol is recommended [11]. Fullwood et al [1] reported that a randomized evaluation of treatment strategies (using lorazepam alone or a combination of ethanol and lorazepam) to prevent complications associated with alcohol withdrawal in acute myocardial infarction is safe and feasible. No specific treatment guidelines exist for the treatment of ACS with coexisting AWS or DT.…”

“…It is characterized by an altered mental status, confusion, tremors, seizures and delirium [1]. Delirium tremens (DT) is the most feared consequence of acute alcohol withdrawal as it can lead to hallucinations, delirium, seizures, myocardial infarction or death [2,3].…”