Survey of critical care practices for alcohol withdrawal syndrome in the intensive care unit

Abstract

Introduction: Alcohol use disorder affects up to 60% of intensive care unit (ICU) patients. Alcohol withdrawal syndrome (AWS) is associated with increased length of stay, mechanical ventilation, and mortality. The lack of clinical practice guidelines specific to ICU patients leads to ambiguity about the standard management of AWS in this population. Objectives: The aim of this study was to describe current practice patterns employed for AWS management in ICU settings across the United States. Methods: This was a cross-sectional survey of practicing critical care pharmacists identified via a pharmacy professional organization critical care listserv. Emails were sent four times to the recipient list from May 14, 2021 to June 25, 2021. Retired pharmacists and trainees on the listserv were excluded. The survey was conducted by REDCap and descriptive statistics were performed.Results: There were a total of 144/1534 (9.4%) responses. Predominant characteristics included university hospital settings (n = 71/143, 49.7%) with greater than 75 ICU beds (n = 54/144, 37.5%), and medical (n = 53/144, 36.8%) or mixed (n = 52/144, 36.1%) ICU populations. The majority reported having an institutional AWS guideline (n = 96/140, 68.6%). A total of 139/143 (97.2%) preferred benzodiazepines, with lorazepam (n = 136/143, 97.8%) as the primary benzodiazepine agent.Most preferred lorazepam as needed, rather than preemptively (n = 137/138, 99.3%). Phenobarbital use was reported by 82.6% (n = 119/144) of respondents, primarily for treatment of benzodiazepine-refractory withdrawal (n = 96/117, 82.1%).Similarly, dexmedetomidine use was reported by 86.1% (n = 124/144) of respondents, primarily for refractory withdrawal (n = 48/121, 39.7%). Propofol was primarily preferred for patients on mechanical ventilation (n = 56/98, 57.1%) or refractory withdrawal (n = 51/98, 52.0%). Clonidine was preferred by 45.8% (n = 66/144) and atypical antipsychotics by 33.6% (n = 48/143) of respondents.Conclusions: Most ICU pharmacists prefer symptom-triggered benzodiazepines first line, followed by propofol in intubated patients and dexmedetomidine and/or