Phenobarbital for Acute Alcohol Withdrawal Management in Surgical Trauma Patients—A Retrospective Comparison Study

Nejad, Shamim H.; Nisavic, Mladen; Larentzakis, Andreas; Dijkink, Suzan; Chang, Yuchiao; Levine, Alexander; Moya, Marc de; Velmahos, George C.

doi:10.1016/j.psym.2020.01.008

Cited by 32 publications

(65 citation statements)

References 23 publications

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“…Studies conducted in emergency department settings suggest that phenobarbital used as a monotherapy improved the control of withdrawal and resulted in an equal or reduced need for inpatient and/or ICU admission compared with use of benzodiazepines ( 54 , 240 , 251 ). In the surgical–trauma ICU setting, phenobarbital-based protocols appear to be effective in preventing withdrawal-related complications, including delirium and clinically significant respiratory depression ( 252 , 253 ). One study in patients with trauma reported statistically significant decreases in the rates of progression to SAWS and medication adverse effects with phenobarbital compared to a fixed-dose benzodiazepine protocol ( 252 ).…”

Section: Section 3: Establishing Best Practices To Improve Clinical Outcomes (T 3 Research)mentioning

confidence: 99%

Research Needs for Inpatient Management of Severe Alcohol Withdrawal Syndrome: An Official American Thoracic Society Research Statement

Steel¹,

Afshar²,

Edwards³

et al. 2021

Am J Respir Crit Care Med

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Background: Severe alcohol withdrawal syndrome (SAWS) is highly morbid, costly, and common among hospitalized patients, yet minimal evidence exists to guide inpatient management. Research needs in this field are broad, spanning the translational science spectrum. Goals: This research statement aims to describe what is known about SAWS, identify knowledge gaps, and offer recommendations for research in each domain of the Institute of Medicine T 0 –T 4 continuum to advance the care of hospitalized patients who experience SAWS. Methods: Clinicians and researchers with unique and complementary expertise in basic, clinical, and implementation research related to unhealthy alcohol consumption and alcohol withdrawal were invited to participate in a workshop at the American Thoracic Society 2019 International Conference. The committee was subdivided into four groups on the basis of interest and expertise: T 0 –T 1 (basic science research with translation to humans), T 2 (research translating to patients), T 3 (research translating to clinical practice), and T 4 (research translating to communities). A medical librarian conducted a pragmatic literature search to facilitate this work, and committee members reviewed and supplemented the resulting evidence, identifying key knowledge gaps. Results: The committee identified several investigative opportunities to advance the care of patients with SAWS in each domain of the translational science spectrum. Major themes included 1 ) the need to investigate non–γ-aminobutyric acid pathways for alcohol withdrawal syndrome treatment; 2 ) harnessing retrospective and electronic health record data to identify risk factors and create objective severity scoring systems, particularly for acutely ill patients with SAWS; 3 ) the need for more robust comparative-effectiveness data to identify optimal SAWS treatment strategies; and 4 ) recommendations to accelerate implementation of effective treatments into practice. Conclusions: The dearth of evidence supporting management decisions for hospitalized patients with SAWS, many of whom require critical care, represents both a call to action and an opportunity for the American Thoracic Society and larger scientific communities to improve care for a vulnerable patient population. This report highlights basic, clinical, and implementation research that diverse experts agree will have the greatest impact on improving care for hospitalized patients with SAWS.

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Section: Section 3: Establishing Best Practices To Improve Clinical Outcomes (T 3 Research)mentioning

confidence: 99%

Research Needs for Inpatient Management of Severe Alcohol Withdrawal Syndrome: An Official American Thoracic Society Research Statement

Steel¹,

Afshar²,

Edwards³

et al. 2021

Am J Respir Crit Care Med

View full text Add to dashboard Cite

show abstract

“…Prior studies comparing phenobarbital to benzodiazepine treatment for inpatient AWS have produced inconclusive results. In two studies from a single hospital ( 17 , 18 ), providers preferentially used phenobarbital in patients with a history of severe or complicated AWS, yet there were no statistically significant differences in rates of AWS-related complications (e.g., mechanical ventilation), mortality, or length of stay among medical and surgical inpatients. A third study compared patients treated with a phenobarbital-based protocol to those treated with a symptom-triggered lorazepam protocol for AWS in an academic medical ICU where providers were free to choose either protocol ( 16 ).…”

mentioning

confidence: 99%

“…Patients with severe AWS often require very high doses of benzodiazepines because of cross-tolerance between alcohol and benzodiazepines at the γ-aminobutyric acid (GABA) A receptor ( 13 , 14 ). Inpatient providers are thus increasingly using benzodiazepine alternatives for AWS, especially phenobarbital ( 15 – 18 ). Phenobarbital enhances GABA and suppresses glutamate activity in the central nervous system ( 19 ).…”

mentioning

confidence: 99%

“…In contrast, benzodiazepines act specifically at the GABA A receptor to augment GABA signaling but do not address the excess glutamate associated with life-threatening AWS ( 13 , 14 , 20 ). Phenobarbital can control AWS at lower drug concentrations (10–20 mg/dL) than typically required for management of epileptic seizures (20–40 mg/dL) ( 18 , 20 , 21 ). Phenobarbital is also easily administered using weight-based dosing by mouth, intramuscular injection, or intravascular infusion.…”

mentioning

confidence: 99%

“…Phenobarbital is also easily administered using weight-based dosing by mouth, intramuscular injection, or intravascular infusion. Based on these perceived advantages, phenobarbital has replaced benzodiazepines as first-line therapy for AWS in some hospital settings ( 15 – 18 ). Unfortunately, similar to practice trends favoring benzodiazepines for AWS in the past, phenobarbital protocols have been implemented for hospitalized patients with AWS in the absence of thorough evaluation.…”

mentioning

confidence: 99%

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Improving Care for Inpatient Alcohol Withdrawal Syndrome: Addressing the Lack of Rigorous Research on a Common Condition

Steel

Bradley

2021

Annals ATS

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Load and go: Assessing safety outcomes of patients discharged from the emergency department after receiving phenobarbital for alcohol withdrawal

Ebeling‐Koning,

Goodman,

Amaducci

et al. 2024

JACEP Open

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ObjectivesPhenobarbital (PB) is a long‐acting GABA A‐agonist with favorable pharmacokinetics (long half‐life and duration of effect) that allows effective treatment of alcohol withdrawal (AW) after administration of a single loading dose. Current evidence suggests that in the setting of AW, PB administration may be associated with decreased hospital admissions and hospital length of stay. The aim of this study was to evaluate the safety outcomes of AW patients who were treated and discharged from the emergency department (ED) after receiving PB for AW.MethodsThis retrospective chart review included a convenience sample of 33 AW patients who presented to four EDs within an 18‐month span. Descriptive statistics (frequencies and percentages) were used to describe demographics, distribution of resources and referrals, and the safety outcomes of PB administration for low‐risk AW patients. Patients were selected for inclusion in consultation with a medical toxicologist, treated with PB, and discharged from the ED. Electronic medical records were utilized to gather information on the patient cohort.ResultsAll patients were treated with at least a single loading dose of 5‒10 mg/kg (ideal body weight) of intravenous or per os PB during their ED stay. Only one patient had an unanticipated event after discharge, which was related to driving against advice. Two additional patients had ED revisits for recurrent alcohol use within 72 h, and 16 patients had recurrent alcohol use within 30 days. All 33 patients were provided with resources for linkage to treatment. None required hospital admission.ConclusionED PB “load and go” may be a safe, effective AW treatment that could help treat AW, facilitate linkage to specific rehabilitation treatments, and decrease hospital admissions.

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Phenobarbital for Acute Alcohol Withdrawal Management in Surgical Trauma Patients—A Retrospective Comparison Study

Cited by 32 publications

References 23 publications

Research Needs for Inpatient Management of Severe Alcohol Withdrawal Syndrome: An Official American Thoracic Society Research Statement

Research Needs for Inpatient Management of Severe Alcohol Withdrawal Syndrome: An Official American Thoracic Society Research Statement

Improving Care for Inpatient Alcohol Withdrawal Syndrome: Addressing the Lack of Rigorous Research on a Common Condition

Load and go: Assessing safety outcomes of patients discharged from the emergency department after receiving phenobarbital for alcohol withdrawal

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