Phenobarbital Monotherapy for the Management of Alcohol Withdrawal Syndrome in Surgical-Trauma Patients

Abstract

Background Benzodiazepine is first-line therapy for alcohol withdrawal syndrome (AWS), and phenobarbital is an alternative therapy. However, its use has not been well validated in the surgical-trauma patient population. Objective To describe the use of fixed-dose phenobarbital monotherapy for the management of patients at risk for AWS in the surgical-trauma intensive care unit. Methods Surgical-trauma critically ill patients who received phenobarbital monotherapy, loading dose followed by a taper regimen, for the management of AWS were included in this evaluation. The effectiveness of phenobarbital monotherapy to treat AWS and prevent development of AWS-related complications were evaluated. Safety end points assessed included significant hypotension, bradycardia, respiratory depression, and need for invasive mechanical ventilation. Results A total of 31 patients received phenobarbital monotherapy; the majority of patients were at moderate risk for developing AWS (n = 20; 65%) versus high risk (n = 11; 35%). None of the patients developed AWS-related complications; all patients were successfully managed for their AWS. Nine patients (29%) received nonbenzodiazepine adjunct therapy for agitation post–phenobarbital initiation. Three patients (10%) experienced hypotension, and 3 (10%) were intubated. None of the patients had clinically significant bradycardia or respiratory depression. Conclusion and Relevance Fixed-dose phenobarbital monotherapy appears to be well tolerated and effective in the management of AWS. Further evaluation is needed to determine the extent of benefit with the use of phenobarbital monotherapy for management of AWS.

Phenobarbital and Alcohol Withdrawal Syndrome: A Systematic Review and Meta-Analysis

“…The baseline characteristics of the included studies are summarized in Table 1. A total of nine studies were included: one retrospective case series with more than 11 participants and including original data [10], seven retrospective studies [11][12][13][14][15][16][17], and one abstract with data relevant to the study design [18]. The sample sizes of the included studies ranged from 31 to 135 individuals.…”

Prevention of alcohol withdrawal syndrome in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document

“… 18 Those patients with recent alcohol use (within 2 weeks of admission) with either a BAL of 0.1 g/dL or higher, elevated MCV (>90 fL), or elevated ALT to AST ratio greater than or equal to 1.5:1 are considered high risk as well. 22 23 Screening tools as described in previous sections can be used to identify patients who can benefit from empiric alcohol withdrawal prophylaxis as well. Current best practice is for patients deemed high risk to receive empiric prophylaxis.…”

“… 22 Patients who may be at higher risk for hemodynamic changes include those with hepatic dysfunction, liver cirrhosis, traumatic brain injury, and recent opioid, sedative, or benzodiazepine administration. 22 25 …”

“…The authors found that no patients developed severe AWS-related complications including seizure, alcoholic hallucinations, and alcoholic withdrawal delirium, and only 13% (4/31) of patients developed phenobarbital-related adverse events, which were hypotension and need for intubation. 22 Using a fixed-dose regimen is recommended rather than a symptom-based approach due to the long half-life and pharmacokinetics of phenobarbital. Phenobarbital has a narrow margin of safety and a symptom-based approach has not been validated.…”

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

“…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 ).…”