1 Trust Clinical Policy Directorate/Department/Specialist Group Emergency Department, Medical Admissions Unit and All wards and Departments Title Individualised Treatment for Acute Alcohol Withdrawal and Delirium Tremens Reference: 11
2 Document Control Policy Title Author/Contact Document Reference 11 Managing Acute Alcohol Withdrawal and Delirium Tremens Dr. Lynn Owens Nurse Consultant Document File Path EQMS Document impact assessed Yes/No Date: Version Status Approved Publication Date th May 11 Review Date th May 13 Approved by Peter Williams th May 11 Ratified by Clinical & Cost Effectiveness Sub-Committee th May 11 Distribution: Royal Liverpool and Broadgreen University Hospitals NHS Trust-intranet Please note that the Intranet version of this document is the only version that is maintained. Any printed copies must therefore be viewed as uncontrolled and as such, may not necessarily contain the latest updates and amendments. Version Date Comments Author 1 Oct 8 Seen in April 9 amendments requested Lynn Owens 1.1 June 9 Lynn Owens Dec 1 Lynn Owens Review Process Prior to Ratification: Name of Group/Department/Committee Date MMG 17 th April 9 & 1 th Dec 1 Alcohol Multidisciplinary Group 3 th Oct 8 & 17 th Dec 1 Clinical Cost Effectiveness group
3 Main Policy Contents: Section 1. Introduction Page Section 1.1 Equity and Diversity Page Section. Objective Page Section 3. Scope Page Section. Policy Page 5.1 Detection of alcohol misuse/dependence Page 5. Referral to the Alcohol Specialist Nurse Page.3 Acute Alcohol Withdrawal Management Page. Complex Withdrawal & Delirium Tremens Page 8.5 Vitamin Supplements Page 9 Section 5. Roles and Responsibilities Page 9 Section. Associated documentation and references Page 1 Section 7. Training & Resources Page 1 Section 8. Monitoring and Audit Page 1 Annex A Annex A- Adapted Clinical Alcohol Withdrawal Assessment Scale (CIWA- AD) B Information Sheet for Patients Prescribed a Reducing Course of Chlordiazepoxide 1. Introduction 3
4 It is recognised that the management of acute alcohol withdrawal (AAW) and delirium tremens varies according to the expertise available at the point of assessment. This policy aims to provide a robust clinical pathway for the use of symptom triggered medically assisted management (SST) of AAW, which has been shown to be more effective in controlling symptoms, particularly in the early stages. It has also been shown that SST results in fewer complications, reduces progression to delirium, and reduces the course of treatment, thus length of stay in hospital [1, ]. 1.1 Equity and Diversity This policy aims to ensure that all patients receive standardised care of the highest quality in any setting within RLBUHT. Gender, sexual orientation, race, religion, socioeconomic group, language and disability, will be considered in ensuring a individualised approach to treatment delivery and planning.. Objective To ensure safe, timely and effective medically assisted management of acute alcohol withdrawal and delirium tremens. Aims: a) Early identification of AAW b) Prevent unexpected AAW c) Prevent progression of AAW to delirium tremens d) Ensure patient safety and comfort e) Enable accurate assessment and care planning for discharge f) Reduce amount of benzodiazepine used in the course of treatment g) Prevent violence and aggression h) Reduce length of treatment i) Increase staff confidence in dealing with alcohol-related admissions j) Reduce the frequency of inappropriately prescribed parental vitamins (Pabrinex) 3. Scope of Policy This policy applies to all patients who have a history of recent alcohol abuse and are exhibiting symptoms of acute alcohol withdrawal, and those screened as alcohol dependent. Other related policies. PDG no. 1. PDG no. 15.
5 . Policy.1 Detection of alcohol misuse/dependence Alcohol problems can be a sensitive subject to discuss with a patient, however not only is early detection very important, but there are physical complications that will need medical intervention if not dealt with promptly. The Government recommended daily limits for drinking alcohol are -3 units for a woman and 3- units for a man . Patients who misuse alcohol can be divided into two broad categories, dependent drinkers and harmful or hazardous drinkers. Models of Care for Alcohol Misuse (MOCAM) defines harmful drinkers as anyone drinking at levels above those recommended for sensible drinking. When a nurse or doctor suspects that the patient s condition or presentation is associated with alcohol, a referral should be made to the Alcohol Specialist Nurse (ASN) (see section.). The ASN will screen the patient for alcohol misuse using the Alcohol Use Disorders Identification Tool (AUDIT). The aim is to detect hazardous and at-risk drinkers, and is scored on a scale of 1 to, a score of 8 or more indicating the requirement for further intervention, and a score of plus indicating the need to screen for dependence on alcohol. Dependent drinkers are those who are drinking to excess most days, having developed a craving for alcohol including physical withdrawal (DSM IV)[, 7]. They are likely to experience shakes, sweats and anxiety or irritability if they do not drink alcohol. The World Health Organisation (WHO) defines dependence in someone having experienced three or more of the following: A strong desire or compulsion to drink. Difficulty in controlling onset or termination of drinking or levels of alcohol use. A physiological withdrawal state upon cessation of alcohol or the use of alcohol to avoid withdrawal symptoms. An increased tolerance to alcohol. Progressive neglect of other interests. Persisting use of alcohol despite clear evidence and an awareness of the nature and extent of the harm it is causing. On initial assessment in ED triage or MAU if the nurse or doctor suspect that the admission is alcohol-related or observe any sign of AAW they will; 1. Ask the patient how much they drink per drinking day, and how many days per week they drink.. Complete the Clinical Institute Withdrawal Assessment (CIWA-AD) assessment tool. (ANNEX A) Which has been demonstrated to have good inter-rater reliability for general nurses (the K-value for the entire AWS scale was..) 5
6 3. They will then utilise the CIWA-AD score to make a decision as to implementing the Symptom Triggered Guideline for prescribing.. Refer all patients to the Alcohol Specialist Nurse.. Referral to the Alcohol Specialist Nurse Referrals can be made by any member of staff and at any time. Anyone seen in the ED and then admitted to the wards will be followed up, but if in doubt please refer for a review. The ASN will complete the AUDIT screening tool, following an AUDIT score of greater than, the ASN will conduct an assessment using the Severity of Alcohol Dependence Questionnaire (SADQ). Any positive score should initiate an assessment of risk for development symptoms of AAW. The ASN will also perform an assessment using the CIWA-AD. The score from this can be used to guide initiation of the symptom triggered prescribing pathway (see section.3). ASN referrals can be made via extension 383, bleep 59 or ICE. If the patient is being sent home, they should be given an advice leaflet (annex B) and an appointment card with an appointment for the next day s clinic..3. Acute Alcohol Withdrawal Management. It is important to avoid a) inadequate treatment, which may lead to Delirium Tremens or seizures and b) over treatment, which may lead to over sedation and respiratory depression. Early detection and prompt initiation of treatment is crucial as untreated AAW can progress to delirium tremens, which has been shown to be fatal in 15-% of untreated patients. If untreated, death may result from respiratory and cardiovascular collapse or cardiac arrhythmias. Patients most at risk are those with either a high fever (>1 F/39.9 C), tachycardia, or dehydration, and an associated illness (e.g. pneumonia or pancreatitis), general debility or where the diagnosis is delayed. However, appropriate management reduces mortality to around 1%. In most cases this can be achieved with oral benzodiazepines, usually chlordiazepoxide. Because of the psychological impact of detoxification planning and coordination with alcohol follow-up services is essential. Good nursing care in a well lit, cool environment has been shown to reduce the impact of sensory deprivation on the confused patient, and as such is a crucial part of the treatment plan.
7 Benzodiazepines, particularly chlordiazepoxide, are central to the management of alcohol withdrawal and have the following important properties: Sedative, anxiolytic, anticonvulsant, cross-tolerant with alcohol, and do not induce liver enzymes. The Adapted CIWA-AD  will be used by the senior doctors (registrar or above) or ASN to provide guidance for dosage level. Chlordiazepoxide will then be prescribed on the PRN or variable dose section of the patient prescription/drug chart. Figure 1 Oral Chlordiazepoxide Symptom Triggered Regime The presence of jaundice, encephalopathy, ascites, bleeding, prolonged prothrombin time >17 seconds, low serum albumin <3g/l or urea >1mmol/l should alert the clinician to the possibility of significant or de-compensated liver disease. The dose of chlordiazepoxide should be halved in significant liver disease. Benzodiazepines should be avoided if hepatic encephalopathy is present or if decompensation is incipient. The Hepatology team or on-call Gastroenterology registrar on-call should be contacted urgently. CIWA- AD Score Oral Chlordiazepoxide CIWA-AD Score Less than 9 NIL Repeat in 1 hour Score of 1 to 11 15mg Repeat in 1 hour Score of 1 or greater 5mg Repeat in 1 hour Assess hourly for first four hours; when patient symptoms are controlled assessment can be four hourly. Oral Thiamine 1mg three times daily should be commenced. mg in four hours should be considered the norm for patients showing signs of withdrawal, however some patients will OR require up to mgs in hrs. If confusion, ataxia, ophthalmoplegia or BMI less than with If symptoms recent are weight not controlled; loss consider review administration by a senior doctor of Pabrinex must be IV: made. The consultant Give or ASN pairs may of consider Ampoules addition diluted of Haloperidol in 5ml or 1ml as per.9% hospital saline formulary. or 5% glucose. Infuse over 3 minutes. Give TDS for 7hrs and Vitamin supplements should always review be considered alongside this regime. (Section.5) Usually, Note: 1mg Small oral risk thiamine of anaphylaxis. three times daily. However, if confusion, ataxia, ophthalmoplegia or BMI less than with recent weight loss consider administration of Pabrinex IV: Give pairs of Ampoules diluted in 5ml This regime is a guide and can be used to support and augment individualised clinical judgement and must not be used in isolation. The maximum dose of Chlordiazapoxide is mg in hrs or 1ml.9% saline or 5% glucose. Infuse over 3 minutes. Give TDS for 7hrs and review. 7
8 Anyone with an altered level of consciousness, including those who are drunk must have a blood glucose measurement carried out as alcohol can precipitate hypoglycaemia. Discharge Medication Chlordiazepoxide as a discharge medication should only be given by the ASN who will ensure a safe follow-up and monitoring care pathway. Please refer to early discharge protocol for the Lifestyles Team.. Complicated, uncontrolled acute alcohol withdrawal, and Delirium Tremens. The aim of this treatment is to obtain rapid sedation, and prevent seizure. CIWA-AD assessment and close clinical observation is essential. The patient should be nursed in a high dependency area with access to resuscitation equipment. A referral to the Critical Care Outreach Team should be made on commencement of treatment. Benzodiazepines Diazepam by IV injection as indicated in Figure dependant on the clinical condition of the patient, to a maximum dose of 3mg / kg in hours. Patients should ideally be cared for in a High Dependency Unit Repeat hourly to maintain light somnolence. The patient should be sleepy but easily woken. Neuroleptics Can be used only as an adjunct therapy when severe agitation, hallucinations and paranoia are present and not controlled by benzodiazepines. Haloperidol.5mg intravenous or intramuscular every 3 to minutes. If not effective after 3 minutes give a further.5 mg. If not effective increase dose to 5mg, repeat as needed (-8 to hourly) until symptoms are controlled. Maximum daily dose of 18mg IV or IM. Refer patient to mental heath team. 8
9 It is rare for AAW to require intravenous therapy (approximately 5 per year in RLBUHT), however when necessary the following algorithm should be used. Figure Benzodiazepine Intravenous or rectal Diazepam Injection (as Diazamules) Rectal as tubes CIWA- Score 1 or more on initial assessment commence at First Line AD Intravenous Patients must be in a High Dependency Area & be prescribed for and reviewed by a senior medic First Line Treatment 5mg (over minutes) Repeat in 5 to 1 minutes If not effective after two doses GO TO second line Second Line Treatment 1mg (over minutes) Repeat in 5 to 1 minutes If not effective after two doses GO TO third line Repeat CIWA-AD hourly Third Line Treatment mg (over minutes) Maximum dose of 3mg / kg in hours 1 or more Start repeat dose at 1 st Line 9 or less Withhold Repeat CIWA-AD hourly When patient symptoms are stable assessment can be four hourly. Suitability to transfer to oral regime should be considered Administration of Pabrinex IV Should be considered for all patients Give pairs of ampoules diluted in 5ml or 1ml.9% saline or 5% glucose. Infuse over 3 minutes. Give TDS for 7hrs and review Note: Small risk of anaphylaxis. Check blood levels of Sodium Phosphate Magnesium and Potassium.5 Vitamin Supplements All patients with evidence of chronic alcohol misuse and any of the following: acute confusion, decreased conscious level, ataxia, ophthalmoplegia, memory disturbance, hypothermia with hypotension, should be treated with parenteral vitamin B, as they are at risk of developing Wernicke-Korsakoff syndrome (WKS). The primary signs of WKS are confusion, ataxia and ophthalmoplegia, which may be difficult to distinguish from general drunkenness. Therefore any patient with signs of chronic alcohol misuse and signs of ataxia, confusion and 9
10 opthalmoplegia should be given intravenous Pabrinex. This is the only available intravenous treatment which includes thiamine (B1), riboflavin (B), pyridoxine (B), and nicotinamide. Two pairs of ampoules of Pabrinex 1 and diluted in 1ml of normal saline.9% or 5% glucose, should be given intravenous over 3 minutes. If a patient is admitted consider pairs of ampoules three times daily for 7 hours intravenous. This should be followed, if there is improvement, by 1 pair of ampoules per day for 5 days. All hypoglycaemic patients (who are treated with intravenous glucose) with evidence of chronic alcohol ingestion must be given intravenous Pabrinex immediately because of the risk of acutely precipitating WKS. 5. Roles and Responsibilities The Nurse Consultant (NC) and Pharmacy Consultant will be responsible for the dissemination of the policy. Additionally they will monitor and evaluate the effectiveness on clinical care.. Associated documentation and references RLBUHT Formulary & Prescribing Guidelines. Lifestyles Team Early discharge policy 1. Repper-DeLisi, J., et al., Successful implementation of an alcohol-withdrawal pathway in a general hospital. Psychosomatics, 8. 9(): p Daeppen, J.B., et al., Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial. Arch Intern Med,. 1(1): p Department-of-Health, Sensible Drinking. 1995, DOH: London.. Department-of-Health, Models of Care for Alcohol Misuse.. 5. Saunders, J.B., et al., Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption--II. Addiction, (): p Grant, B.F., DSM-IV, DSM-III-R, and ICD-1 alcohol and drug abuse/harmful use and dependence, United States, 199: a nosological comparison. Alcohol Clin Exp Res, 199. (8): p American-Psychiatric-Association, Diagnostic and statistical manual of mental disorders. th ed. Vol. 1., Washington D C: American-Psychiatric- Association. 8. WHO, Alcohol in the European Region - consumption, harm and policies. 1, WHO: Stockholm. 1
11 9. Foy, A., et al., Clinical use of a shortened alcohol withdrawal scale in a general hospital. Intern Med J,. 3(3): p Stockwell, T., D. Murphy, and R. Hodgson, The severity of alcohol dependence questionnaire: its use, reliability and validity. Br J Addict, (): p Mayo-Smith, M.F., et al., Management of alcohol withdrawal delirium. An evidence-based practice guideline. Arch Intern Med,. 1(13): p Training & Resources Dedicated training by the nurse consultant in the use of the CIAW-AD will be given as a rolling programme to all staff identified as appropriate to use the policy. Clinical supervision will be provided by the nurse consultant, or medical consultants as appropriate, to nursing and medical staff. There are no significant resource implications for training or supervision, as this is within the roles and responsibilities of the consultants. 8. Monitoring and Audit a) A prospective audit of prescribing for AAW will be undertaken prior to the introduction of this policy b) A prospective audit of prescribing for AAW will be undertaken within 3 months of the introduction of this policy c) A six month retrospective audit of the use of Pabrinex prior to the implementation of this policy will be conducted. d) After the policy has been in place for seven months the audit will be repeated. e) A retrospective audit of hospital length of stay for patients experiencing AAW will be conducted after six months. 11
12 Annex A- Adapted Clinical Alcohol Withdrawal Assessment Scale (CIWA-AD) Name Unit Number D.O.B Address Alcohol Consumption Number of units per day Number of days per week Ongoing assessment An increase in score indicates need for Benzodiazepine dose as per symptom triggered guideline Temperature C C Greater than 38. C Pulse Greater than 1 Respiratory Rate - Tremor Arms extended fingers spread Sweating Observation Clouding of sensorium What day is this? What is this place? Quality of Contact Agitation observation Visual Disturbances Thought disturbances (flight of ideas, paranoid ideas) NOTE CHANGE IN SCORE Greater than No tremor Not visible can be felt fingertip to fingertip Moderate with arms extended Severe even with arms not extended No sweat visible Barely perceptible, palms moist Beads of sweat visible Drenching sweats Orientated Disorientated for date by no more than two days Disorientated for date by more than two days Disorientated for place /person In contact with examiner Seems in contact, but is oblivious to environment Periodically becomes detached Makes no contact with examiner Normal activity Somewhat more than normal activity Moderately fidgety and restless Pacing, or thrashing about constantly Not present Mild sensitivity (bothered by the lights) Intermittent visual hallucinations (occasionally sees things you cannot) Continuous visual hallucinations (seeing things constantly) No disturbance Does not have much control over nature of own thoughts Constantly troubled by unpleasant thoughts Thoughts come too rapidly and in a disconnected fashion Score Total Score Score hourly for first hours. ORIGINAL ARTICLE: Clinical use of a shortened alcohol withdrawal scale in a general hospital* Foy, S. McKay, S. Ling, M. Bertram and C. Sadler Internal Medicine Journal 3 ()
13 Annex B Information Sheet for Patients Prescribed a Reducing Course of Chlordiazepoxide Patient Name: You have been prescribed a reducing course of chlordiazepoxide (also called Librium) to aid you through your withdrawal from alcohol, which is to be completed at home You will be supplied with 1mg chlordiazepoxide capsules The doses that you need to take will be reduced over the next. days and are described in the table below Your alcohol specialist nurse will review you on. If you find that you feel drowsy whilst you are taking chlordiazepoxide, let your GP know so that your dose may be reviewed. If you feel drowsy, do not drive or operate machinery If you still feel agitated or experience tremor, let your GP know since your dose may need to be reviewed You must not drink alcohol whilst taking chlordiazepoxide Medicines should always be stored safely and well away from children. They should NOT be shared with other people as the prescription is for you only. The lifestyle clinic advice number is (answer phone) Date Dose of Chlordiazepoxide to be taken at Morning Lunchtime Evening Bed time Signatures Prescriber Pharmacist Dispenser Final Check 13