Management of Alcohol Withdrawal Delirium&lt;subtitle&gt;An Evidence-Based Practice Guideline&lt;/subtitle&gt;

Mayo‐Smith, Michael F.

doi:10.1001/archinte.164.13.1405

Cited by 381 publications

(219 citation statements)

References 56 publications

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“…One important component of these guidelines is the use of escalating individual doses of benzodiazepines beyond currently recommended diazepam boluses of 10-30 mg (6). There are many reports of severe AWS and delirium tremens resistant to standard bolus doses of diazepam (9 -12, 20).…”

Section: Discussionmentioning

confidence: 99%

“…Multiple studies suggest that administration of benzodiazepines in a symptom-triggered fashion both reduces the total amount of benzodiazepine administered and shortens the duration of therapy (4,5). In these studies, benzodiazepines are administered in repeated boluses (both intravenous and oral) of 10-20 mg of diazepam (or benzodiazepine equivalent) with current recommendations suggesting a maximal individual bolus of 20-30 mg of diazepam or benzodiazepine equivalent to be given until adequate sedation is achieved (4,6,7). Although widely accepted, these studies focus primarily on patients admitted to detoxification centers or the general hospital wards and exclude subjects admitted to the intensive care unit (ICU) (4,5).…”

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confidence: 99%

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A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens*

Gold

Rimal

Nolan

et al. 2007

Critical Care Medicine

158

164

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Objective-Patients with severe alcohol withdrawal and delirium tremens are frequently resistant to standard doses of benzodiazepines. Case reports suggest that these patients have a high incidence of requiring intensive care and many require mechanical ventilation. However, few data exist on treatment strategies and outcomes for these subjects in the medical intensive care unit (ICU). Our goal was a) to describe the outcomes of patients admitted to the medical ICU solely for treatment of severe alcohol withdrawal and b) to determine whether a strategy of escalating doses of benzodiazepines in combination with phenobarbital would improve outcomes. Design-Retrospective cohort study.Setting-Inner-city municipal hospital.Patients-Subjects admitted to the medical ICU solely for the treatment of severe alcohol withdrawal. Interventions-Institution of guidelines emphasizing escalating doses of diazepam in combination with phenobarbital.Measurements and Main Results-Preguideline (n = 54) all subjects were treated with intermittent boluses of diazepam with an average total and maximal individual dose of 248 mg and 32 mg, respectively; 17% were treated with phenobarbital. Forty-seven percent required intubation due to inability to achieve adequate sedation and need for constant infusion of sedative-hypnotics. Intubated subjects had longer length of stay (5.6 vs. 3.4 days; p = .09) and higher incidence of nosocomial pneumonia (42 vs. 21% p = .08). Postguideline (n = 41) there were increases in maximum individual dose of diazepam (32 vs. 86 mg; p = .001), total amount of diazepam (248 vs. 562 mg; p = .001), and phenobarbital use (17 vs. 58%; p = .01). This was associated with a reduction in the need for mechanical ventilation (47 vs. 22%; p = .008), with trends toward reductions in ICU length of stay and nosocomial pneumonia.Conclusions-Patients admitted to a medical ICU solely for treatment of severe alcohol withdrawal have a high incidence of requiring mechanical ventilation. Guidelines emphasizing escalating bolus doses of diazepam, and barbiturates if necessary, significantly reduced the need for mechanical ventilation and showed trends toward reductions in ICU length of stay and nosocomial infections.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens*

Gold

Rimal

Nolan

et al. 2007

Critical Care Medicine

158

164

View full text Add to dashboard Cite

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“…1,7,9 Clinicians differ in how well they adhere to these criteria, so it is difficult to determine the prevalence of withdrawal delirium, and rates depend on whether persons with this condition were treated as outpatients, as general medical or psychiatric inpatients, or as patients in an intensive care unit (ICU). Most studies estimate that 3 to 5% of patients who are hospitalized for alcohol withdrawal meet the criteria for withdrawal delirium.…”

Section: Withdrawal Delirium (Delirium Tremens)mentioning

confidence: 99%

“…7,9,12 Approximately 1 to 4% of hospitalized patients who have withdrawal delirium die; this rate could be reduced if an appropriate and timely diagnosis were made and symptoms were adequately treated. 7,9,11,13 Death usually results from hyperthermia, cardiac arrhythmias, complications of withdrawal seizures, or concomitant medical disorders.…”

Section: Withdrawal Delirium (Delirium Tremens)mentioning

confidence: 99%

Recognition and Management of Withdrawal Delirium (Delirium Tremens)

2014

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A t some time in their lives, 20% of men and 10% of women in most Western societies will have an alcohol-use disorder, which is defined as repetitive alcohol-related problems in at least 2 of 11 areas of life. 1,2 These conditions can decrease the life span by a decade and are associated with severe impairments in social functioning, as well as high rates of medical problems. Although alcohol-related conditions occur in persons from all social strata and affect more than 20% of patients in most medical settings, 2,3 few physicians have been adequately trained in identifying and treating these serious problems.About 50% of persons with alcohol-use disorders have symptoms of alcohol withdrawal when they reduce or discontinue their alcohol consumption; in 3 to 5% of these persons, grand mal convulsions, severe confusion (a delirium), or both develop. 1 It is essential that clinicians know how to prevent, recognize, and treat these severe withdrawal states to minimize costly hospitalizations and avoidable deaths.

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“…The evidence on how best to treat alcohol withdrawal seizures comes from a 1999 article which demonstrated a benefit of using lorazepam for recurrent seizures. 19,20 21 All of these studies, however, come back to the basic question: Do they apply to the inpatients that hospitalists care for? A key factor to consider: All of the above-mentioned studies, including the derivation and validation of the CIWA scale, were done in outpatient centers or inpatient detoxification centers.…”

mentioning

confidence: 99%

Hospitalists and alcohol withdrawal: Yes, give benzodiazepines but is that the whole story?

Finn

Greenwald

2011

Journal of Hospital Medicine

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Management of Alcohol Withdrawal Delirium<subtitle>An Evidence-Based Practice Guideline</subtitle>

Cited by 381 publications

References 56 publications

A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens*

A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens*

Recognition and Management of Withdrawal Delirium (Delirium Tremens)

Hospitalists and alcohol withdrawal: Yes, give benzodiazepines but is that the whole story?

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