Therapy of alcohol withdrawal syndrome in intensive care unit patients following trauma

Abstract

JUSTIFICATIVA E OBJETIVOS: A sedação de dependentes de álcool e drogas em Unidades de Terapia Intensiva (UTI) é um desafio pela elevada incidência de tolerância às drogas sedativas e da elevada freqüência de síndromes de abstinência. O objetivo deste relato é mostrar um caso de paciente jovem admitido na UTI que desenvolveu síndrome de abstinência alcoólica e tolerância às drogas sedativas, solucionadas somente após o uso de clonidina. RELATO DO CASO: Paciente do sexo masculino, 18 anos, dependente de álcool, tabaco, cocaína e maconha, vítima de acidente por arma de fogo, foi admitido na UTI no 1º dia de pós-operatório de enterectomia, após aspiração de conteúdo gástrico durante reintubação traqueal. Evolução clínica: d r o g a s v a s o a t i v a s a t é o 4 º d i a d e i n t e r n a ç ã o e b r o n c o p n e u m o n i a b i l a t e r a l c o m d e r r a m e p l e u r a l e necessidade de ventilação artificial até o 15º dia. O esquema de sedação inicial utilizado foi a associação de midazolam e fentanil. A partir do 4º dia, o paciente apresentou vários episódios de agitação psicomotora, mesmo com a associação de lorazepam no 6° dia. No 9° dia, o paciente recebeu as maiores doses dos fármacos, mas permanecia agitado. Optou-se pela associação de dexmedetomidina, que reduziu as doses das outras drogas em 35% e diminuiu a agitação. No 12° dia, o midazolam e a dexmedetomidina foram substituídos pela infusão de propofol, com piora do quadro. No 13° dia, foi associada clonidina ao esquema de sedação, com resolução do quadro de agitação. No 14° dia, o propofol foi suspenso, sendo mantida a infusão de fentanil e reintroduzida a infusão de midazolam, com doses respectivamente 75% e 65% menores em relação ao pico de uso destas drogas. No 15° dia, o paciente foi extubado e teve alta da UTI. CONCLUSÕES: A droga de escolha para o tratamento da síndrome de abstinência alcoólica é o benzodiazepínico. Entretanto, no presente relato, somente o uso adjuvante de clonidina conseguiu proporcionar tratamento adequado ao paciente. Unitermos: DOENÇAS: síndrome de abstinência alcoólica; DROGAS: a 2-agonista: clonidina SUMMARY Braz LG, Navarro LHC, Braz JRC, Silva UT, Yamaguti FA, Cris-tovan JC-Clonidine as Adjuvant Therapy for Alcohol Withdrawal Syndrome in Intensive Care Unit. Case Report BACKGROUND AND OBJECTIVES: Sedation of patients with past history of alcohol and drug abuse in Intensive Care Units (ICU) is a challenge due to the high incidence of sedative drugs tolerance and withdrawal syndromes. This report aimed at describing a case of a young patient admitted to the ICU who developed alcohol withdrawal syndrome and tolerance to sedatives, resolved only after clonidine administration. CASE REPORT: Male patient, 18 years old, alcohol, tobacco, cocaine and marijuana abuser, victim of firearm accident, who was admitted to the ICU in the first post-enterectomy day, after gastric content aspiration during tracheal re-intubation. Clinical evolution was: vasoactive drugs up to the 4 th day; bilateral bron-chopneumonia with pleural effu...

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

“…In one study, 8% of all general hospital admissions, 16% of all postsurgical patients, and 31% of all trauma patients developed AWS (2). The higher incidence in trauma patients has been confirmed in other studies (3) and probably reflects the high association of alcohol use with numerous types of dangerous behaviors…”

“…First, although antiadrenergic agents (β-blockers and clonidine) have been used in combination with benzodiazepines for treatment of AWS in surgical patients, randomized placebo-controlled trials document that the greatest benefit to these agents is modulation of autonomic signs of AWS (heart rate and blood pressure), with only modest effects for these agents on treatment of delirium with some reports documenting an increase in delirium with β-blocker treatment (3,(26)(27)(28)(29). In similar fashion, a randomized controlled study of the α 2 -adrenergic agonist, lofexidine, documented an increase in delirium in subjects being treated for AWS with similar trends observed in postsurgical ICU subjects randomized to the combination of flunitrazepam/clonidine for treatment of AWS (3,30,31). We chose not to incorporate haloperidol based on both the lack of placebo-controlled data documenting benefit and the ability of neuroleptics to lower the seizure threshold and induce seizure in humans and animals with AWS (19,32).…”

“…In one study, five of six subjects with benzodiazepine resistance, as defined previously, required intubation (9). Once patients are admitted to the ICU, numerous studies document the course and treatment of surgical patients who develop AWS postoperatively and/or posttrauma (3,13,14). In these subjects, symptom-triggered therapy results in lower rates of complications and improved outcomes, although nearly 65% required reinstitution of mechanical ventilation (14).…”

Alcohol withdrawal delirium - diagnosis, course and treatment

“…Additionally, in patients who are still alcohol intoxicated, unpredictable interactions with benzodiazepines (somnolence, respiratory depression or arrest and death) may emerge. That is why in such cases, continuous and careful monitoring of their condition is necessary 89 . Potential risk of abuse and addiction must be taken into consideration anytime benzodiazepines are used in withdrawal management in outpatient settings 90 .…”

Alcohol Withdrawal Syndrome in Critically Ill Patients: Identification, Assessment, and Management

“…39 Typically, drug therapy is started in patients who have a score greater than 8. Despite widespread use of the CIWA-ar scale in the ICU, only 4 randomized clinical studies [44][45][46][47] and 1 retrospective cohort study 48 that included use of the scale in patients with AWS have been published. In one of the early studies, Spies et al 44 used the CIWA-ar scale to assess and guide therapy.…”