Use of Propofol Plus Dexmedetomidine in Patients Experiencing Severe Alcohol Withdrawal in the Intensive Care Unit

Love, Kaylie; Zimmermann, Anthony E.

doi:10.1002/jcph.1539

Cited by 12 publications

(13 citation statements)

References 12 publications

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“…There is some support for cognitive preservation during dexmedetomidine infusion 61–63. Of note, dexmedetomidine is not an antiepileptic medication and other agents may be necessary for this indication 64. With the appropriate level of monitoring, it has been used in both intubated and non-intubated patients.…”

Section: Discussionmentioning

confidence: 99%

“…This activation inhibits firing, thereby inducing sedation and anxiolysis 1. Of note, propofol binds at a different site of the GABA A receptor than benzodiazepines, and, hence, is often used in benzodiazepine refractory cases 60 64. Propofol also reduces glutamate activity, thereby preventing seizures, inhibits NMDA glutamate receptors, and is thought to inhibit other amino acids that may be upregulated in DTs 1 59 60 69.…”

Section: Discussionmentioning

confidence: 99%

“…Propofol also reduces glutamate activity, thereby preventing seizures, inhibits NMDA glutamate receptors, and is thought to inhibit other amino acids that may be upregulated in DTs 1 59 60 69. Propofol acts within seconds, duration of action is approximately 10 min, and has a short elimination half-life 61 64. Risks of propofol infusion include hypotension, the rare but potentially fatal propofol-related infusion syndrome, metabolic acidosis, and hypertriglyceridemia 61.…”

Section: Discussionmentioning

confidence: 99%

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

Seshadri

Appelbaum

Carmichael

et al. 2022

Trauma Surg Acute Care Open

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Alcohol withdrawal syndrome is a common and challenging clinical entity present in trauma and surgical intensive care unit (ICU) patients. The screening tools, assessment strategies, and pharmacological methods for preventing alcohol withdrawal have significantly changed during the past 20 years. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews the best practices for screening, monitoring, and prophylactic treatment of alcohol withdrawal in the surgical ICU.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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

Seshadri

Appelbaum

Carmichael

et al. 2022

Trauma Surg Acute Care Open

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“…Two trials even suggested a trend to longer LOS if dexmedetomidine was Visc Med 2020;36:160-166 DOI: 10.1159/000507595 added to BZO therapy [42], especially for AWS treatment in medical intensive care unit (ICU) patients [43]. However, in combination with propofol, patients treated in the ICU with severe AWS had a shorter time to extubation and ICU LOS [44].…”

Section: Therapy Of Suspected Aws In the Perioperative Settingmentioning

confidence: 99%

Perioperative Management of Alcohol Withdrawal Syndrome

et al. 2020

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Background: In the perioperative course, alcohol withdrawal syndrome (AWS) can occur in any setting, especially in aero-digestive and acute trauma surgery. Challenging issues are the overlap of other forms of delirium in perioperative and intensive care settings as well as general anesthesia masking the onset of withdrawal symptoms. In contrast to other etiologies of delirium, the pathophysiology and thus treatment strategy of AWS is different: the key point is the tolerance to GABAergic molecules of alcohol-dependent subjects resulting in central nervous hyperactivity once the effect of alcohol or other GABA-stimulating agents is decreased. Summary: Despite limitations due to insufficient accuracy of self-reporting questionnaires and limited feasibility in emergency settings, the AUDIT and the shortened AUDIT-C are the standard tools for detection of alcohol use disorders (AUD), as well as predicting AWS risk and severity in approximately half of these AUD patients. The most important risk factors for AWS are a high blood alcohol concentration at hospital admission, AWS episodes in medical history, and lack of control of alcohol use. Patients considered at risk for severe AWS must be treated with prophylactic medication before the onset of symptoms. Thiamine supplementation is required for all malnourished alcohol-dependent patients. Writing down alcohol-related diagnoses in the medical records requires the patient's presumed consent after shared decision-making. These reports should remain strictly confidential if the patient desires. Psychological support for the perioperative period as well as the following course should be offered to all AUD patients including support in short-and long-term detoxification. Alternative diagnoses must be ruled out with no timely delay, especially if fever and coma are the leading symptoms. The backbone of AWS therapy is the symptom-triggered administration of intravenous benzodiazepines (BZO) in escalating doses until the aimed revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar) or Richmond Agitation-Sedation Scale (RASS) score is achieved. Clonidine, dexmedetomidine, baclofen, ketamine, and neuroleptics may be used as symptom-orientated adjuncts. The therapeutic administration of ethanol or clomethiazole is considered to be harmful in critically ill patients after the onset of AWS. General supportive and intensive care including high-dose thiamine supplementation are mandatory in severe AWS cases. The timely differential diagnosis of delirium is important-and AWS is a diagnosis of exclusion-because BZO are strongly recommended for AWS patients but may not be the treatment of

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“…A systematic review identified the most common approach to management of AWS in critically ill patients was primarily benzodiazepine (BZD)-based. 5 However, phenobarbital, 7,8 dexmedetomidine, 9,10 or propofol 11 may be considered for BZD-sparing effects or for those on mechanical ventilation. Other agents, such as baclofen, 12 valproic acid derivatives, 13 gabapentin, 14 ketamine, 15 clonidine, 16 and antipsychotics 17 have also been evaluated.…”

Section: Introductionmentioning

confidence: 99%

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

Cucci

Palm

Vázquez

et al. 2022

J Am Coll Clin Pharm

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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

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Use of Propofol Plus Dexmedetomidine in Patients Experiencing Severe Alcohol Withdrawal in the Intensive Care Unit

Cited by 12 publications

References 12 publications

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

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

Perioperative Management of Alcohol Withdrawal Syndrome

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

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