Resistant alcohol withdrawal: Does an unexpectedly large sedative requirement identify these patients early?

Abstract

Introduction: While most patients with alcohol withdrawal (AW) respond to standard treatment that includes doses of benzodiazepines, nutrition and good supportive care (non resistant alcohol withdrawal-NRAW), a subgroup may resist therapy (resistant alcohol withdrawal-RAW). This study describes a distinct group of AW patients, their sedative requirements, and hospital courses.Methods: Over a period of 6 months, AW patients requiring 50 mg diazepam IV in the first hour were followed. We recorded admission indices and diazepam doses with vital signs at 1, 2, 3, 6, 12, and 24 hours. Patients were considered to have RAW if they required additional sedatives for control of symptoms and/or were having persistent abnormal vital signs despite the physicians' choices of therapy.Results: Nineteen patients were enrolled; all had similar admission indices. While the 4 NRAW had normal vital signs within 3 hours, all 15 RAW patients had abnormal vital signs; 15 RAW patients required escalating diazepam doses-14 required barbiturates, 7 were intubated, and 5 had hypotension. Comparing groups: interval and total diazepam doses were not different at 1,2, and 3 hours; interval doses at 6 and 12 hours, and total doses at 6, 12, and 24 hours were significantly different.Conclusions: RAW patients require large doses of benzodiazepine administration, additional sedatives, and undergo complicated hospitalizations.

Racial variations in the incidence of severe alcohol withdrawal

“…For the purposes of this investigation, severe alcohol withdrawal is defined to be present in any patient who required either an intensive care unit (ICU) admission for the management of alcohol withdrawal or high benzodiazepine dosing (defined as requiring >200 mg of intravenous diazepam in less than a 24-hour period) [8].…”

In Reply

“…1 Our study, however, provides insufficient data to determine whether inadequate dosing of or inherent resistance to benzodiazepine therapy was factorial in patient outcome. This uncertainty notwithstanding, based on existing knowledge of receptor subunit modulation in a rat model of chronic intermittent ethanol consumption, 2 treatment for those with apparent resistant alcohol withdrawal using agents that exhibit alternative GABA A receptor binding affinity such as barbiturates and propofol appears to be appropriate and may be potentially life-saving.…”

“…1 Whereas previous studies have quoted a mortality rate as high as 35% in DT, the most recent studies suggest that the mortality rate for DT as a sole disease process should approach 0%. 2 This success likely results from improvements in supportive care, appropriate benzodiazepine administration, and identification and treatment of underlying disease processes.…”

A rational approach to the treatment of alcohol withdrawal in the ED

“…Chlordiazepoxide [63,65] Diazepam [ dose of 40 mg lorazepam or 200 mg diazepam in a patient who still does not appear calm or sedated [86]. Simply changing to a different benzodiazepine at that point is not ideal because the mechanism of action is the same no matter which benzodiazepine is used.…”