Guideline for the Management of Acute Alcohol Withdrawal Syndrome (AWS)

Transcription

1 Derby Hospitals NHS Foundation Trust Guideline for the Management of Acute Alcohol Withdrawal Syndrome (AWS) Background Reference No: CG-T/2007/063 Alcohol Withdrawal Syndrome (AWS) occurs with sudden cessation after longterm use of ethanol, varies in severity and may represent a medical emergency Improved detection of alcohol misuse is essential for better outcomes (Consider using FAST questionnaires see page 2) Violent incidents fall by nearly 50% with increased awareness of alcohol withdrawal and its management Wernicke s Encephalopathy (WE) is a nutritional disorder (thiamine depletion) that Is exacerbated by alcohol and poor diet and is a medical emergency in its own right. It may be undetectable or be almost impossible to diagnose whilst the patient is still intoxicated. Presentations may be subclinical without classic triad of symptoms. Untreated patients with WE have a 10-20% mortality rate and of those surviving WE without treatment, 80% have Korsakoff psychosis and are permanently disabled. Delirium tremens (DTs) occurs in about 5% of patients during withdrawal, usually 2 to 5 days after cessation or rapidly decreased intake. DTs are fatal in 15-20% of inappropriately managed patients. Good prophylactic management will reduce incidence of DTs significantly (see algorithm) % of patients with Alcohol withdrawal fits will progress to DT s without adequate treatment. DT s are the most severe form of AWS with severe autonomic derangement. Hallucinations are often extreme. Electrolyte disturbances are common in malnutrition and excessive alcohol use and should be sought and treated combinations of low potassium, magnesium and phosphate usually occur. Aims and Scope This is a Trust wide guideline aiming to minimise morbidity and mortality, and maximise patient comfort and reduce agitation through: Better recognition of alcohol misusers Identification of groups with or at risk of potentially life threatening complications. Prompt initiation of adequate and timely medical management. Consistency of Detoxification prescribing between clinical settings Avoiding starting treatment too late, with sub-optimal doses resulting in under-sedation, increased agitation and cumulative risks. Patients identified by this algorithm as suffering from severe alcohol withdrawal, delirium tremens and/or associated severe electrolyte imbalance should be managed on Ward 30 at the City Hospital in an HDU/ITU setting where staff are experienced in the management of this condition. CG-T/2007/ 063 Page 1 of 8 Review Date: 2009

2 In order to recognise a potential problem, First take an adequate Alcohol History Use these simple questions and the table of beverages or use the FAST screening tool then apply this information to the two algorithms outlining appropriate treatment for alcohol withdrawal and Wernicke s encephalopathy. Do you drink alcohol? What do you drink? illicit the strength ABV of the beverage if known or brand name. How often in a week would you drink and how much? average out in units per week. If you are under stress do you drink more than this? Re-evaluate answer above How long have you been drinking this much (if higher than recommended levels but under 10u / day woman, 15u day men consider value of Brief Intervention) if over 10 / 15u /day levels regular pattern over two weeks or more or if has a binge drinking pattern that extends over 4 days at a time with withdrawal features in between look to protocol. Any history of alcohol related fits or seizures? Any history of shaking, sweating, fear on cessation. Recent Diet / appetite & Sleep pattern. Are any antidepressant or benzodiazepines being used? Review rationale for prescribing Repeated self harming, suicidal ideology / intent Reported and observed physiological symptoms CG-T/2007/ 063 Page 2 of 8 Review Date: 2009

3 Fast Screening Alcohol Harm Reduction (Screening tool used to identify hazardous drinkers and refer harmful drinkers to Alcohol Misuse Treatment Services) For the following questions, please circle the answer, which best applies; 1 Drink = ½ pint of beer (3.5% abv) or 1 standard glass of wine (125 ml at 9% abv) or 1 single measure of spirits (25ml at 40% abv) 1. Males; how often do you have 8 or more drinks (e.g. 4 pints) on one occasion? Females; How often do you have 6 or more drinks on one occasion? 0. Never.1. Less than monthly 2. Monthly 3. Weekly 5. Daily/almost daily 2. Males; How often do you have 50 or more drinks (e.g. 25 pints) in a week? Females; How often do you have 36 or more drinks in a week? 0. Never. 1. Less than monthly 2. Monthly 4. Most weeks 6. Every week 3. How often during the last year have you been unable to remember what happened the night before, because you were drinking? 0. Never. 1. Less than monthly 2. Monthly 4. Weekly 6. Daily/almost daily 4. How often in the last year have you failed to do what was normally expected, because of your drinking? 0. Never. 1. Less than monthly 2. Monthly 4. Weekly 6. Daily/almost daily 5. In the last year has a relative or friend, or a doctor or health care worker ever been concerned about your drinking and suggested you cut down? 0. No 1. Yes, on one occasion 4. Yes, on at least 3 occasions 6. Yes, on more than 5 occasions Advice: A score of 3 or more indicates probable hazardous drinking and appropriate advice should be given. Referral: A score of 12 or more indicates possible harmful drinking and referral to appropriate service(s) should be made. CG-T/2007/ 063 Page 3 of 8 Review Date: 2009

4 Take an Adequate Alcohol History & Establish current intake. Uncontrolled when printed There is no need to treat individuals who have only abused for a few days and do not have objective signs of AWS unless known clinical history suggests otherwise ie AWS seizures. For periodic drinkers with heavy bouts for week or less inform patient they may feel nervous / anxious and have trouble sleeping for a few nights. All Patients must have the following investigations and followed up as a matter of urgency U & E s K, Mg & PO 4 LFT s + GGT FBC Clotting Screen Blood Glucose Folate / B12 Ethanol or Breath Alcohol Content if monitor is accessible Are there any features Alcohol Withdrawal? Anxiety / agitation / irritability Sweating Tremor in hands / tongue / eyelids Tachycardia Insomnia Anorexia Visual / tactile hallucinations that can be challenged Fever Mild systolic hypertension Nausea / vomit / retch YES prescribe Atenolol 50 mg od for 5 days unless contraindicated Are the any risk factors for progression to severe withdrawal? (Any one of the following) High Regular Established Alcohol intake (>15 u / day men > 10 u / day women) High levels of anxiety Sweating History of severe withdrawal History of seizures / DT s Respiratory alkalosis High regular daily intake with low blood alcohol level Poor physical health Insomnia YES No treatment necessary but continue to monitor. AWS usually begin 4-12 hours after cessation but may take up to a day or two, -usually peaking in intensity by day2 Are there any symptoms of Autonomic over activity? Paranoid ideas Severe Hallucinosis Severe confusion Profuse sweating Severe agitation Tachypnoea YES Presume Severe AWS or DT s MEDICAL EMERGENCY 1) Give IV Lorazepam 1-2mg (repeat every 10 mins as required) (use monitoring sheet - see intranet) and initiate Chlordiazepoxide 50mg po qds 2) Administer I.V Pabrinex High Potency (HP) (see over) Chlordiazepoxide regime prescribed on variable dose section and vitamin supplementation should always be considered alongside see over Discharge medication Chlordiazepoxide as a TTO should not be considered unless: A suitable supportive home environment exists. Patient is safely established on detox regime And that; Continued commitment to ongoing abstinence has been established as a goal. Time Very Severe symptoms only mg 30mg 20mg 20mg 20mg 10mg 10mg S mg 30mg 20mg 10mg 10mg 10mg T mg 30mg 20mg 10mg 10mg 10mg 10mg O mg 30mg 20mg 20mg 20mg 10mg 10mg 10mg P Initial dose should be titrated up to meet clinical signs. Initial 30mg QDS is sufficient for almost all cases but may need up to 50mg QDS to control very severe symptoms, therefore an extra day of detoxification may be required as indicated above. Mild presenting symptoms consider starting detox as per 2 and observe. Regular recorded T & BP and observe for breakthrough AWS. Severity of withdrawals do not correlate simply with consumption levels. Caution care in liver disease, respiratory depression, renal impairment or >70years CG-T/2007/ 063 Page 4 of 8 Review Date: 2009

5 Management Algorithm for Electrolyte and Vitamin Supplementation & Prevention and / or Treatment of Wernicke s Encephalopathy Every patient prescribed Chlordiazepoxide- reducing regime should have One dose of 1 ampoule pair Pabrinex High Potency (HP) Vitamins I.V (To initialise treatment, prophylaxis or to counter sub-clinical presentations) Check haematology and K/Mg/PO 4 results (see refeeding/phosphate guidelines on intranet) Mg is essential for the conversion of thiamine into its active form (thiamine pyrophosphate) and levels may be reduced when higher doses of IV Pabrinex are used. Serum levels <0.50 mmol should be corrected intravenously Are any one of the following list present? Acute confusion Decreased Consciousness Memory disturbance Unexplained hypotension with hypothermia Ophthalmoplegia Nystagmus Ataxia YES Presume Wernicke s encephalopathy 2 pairs ampoules Pabrinex HP IV TDS for 2 days. Are there any further Risk Factors that suggest Wernicke s encephalopathy? Intercurrent illness Symmetrical Peripheral Neuropathy Drinking >20u daily Recent protracted vomiting / diarrhoea Signs of malnutrition DT s or Treatment for DT s Alcohol related seizures Poor diet YES Enduring dietary intolerance, ataxia, poly neuritis or memory disturbance continue 1 Pair Pabrinex IVHP OD for 5 days or as long as improvement continues then oral dosing Risk of W.E 1 Pair ampoules Pabrinex HP IV O.D for 3 days then oral dosing Commence oral dosing Bibliography: Oral dosing and discharge medication: Thiamine oral 50mg QDS ) Vitamin B Co Strong 2 tabs OD ) to complete 28 days including inpatient treatment Folic Acid 5mg daily Continue for three months in peripheral neuropathy and add pyridoxine 20mg OD CG-T/2007/ 063 Page 5 of 8 Review Date: 2009

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7 Ambrose ML, Bowden SC Whelan G. Thiamin treatment and working memory function of alcohol-dependent people: preliminary findings. Alcohol Clin Exp Res 2001;25(1) Ashol J (2004) Withdrawal Syndromes Available online Chataway J (1995) Letters to the Editor, Thiamine in Wernicke s syndrome- how much and how long? Postgraduate Medical Journal. Vol Cook CCH, Hallwood PM, Thomson A (1998) invited review B vitamin deficiency and neuropsychiatric syndromes in alcohol misuse. Alcohol & Alcoholism vol Dancy M, Evans G, Gaitonde MK, Maxwell JD (1984) Blood thiamine and thiamine phosphate ester concentrations in alcoholic and non alcoholic liver diseases British Medical Journal Vol E, Bentham P, Callaghan R, Kuruvilla T, George S (2003) Thiamine for Wernicke-Korsakoff Syndrome in people at risk from over-consumption of alcohol (Protocol for a Cochrane Review). In: The Cochrane Library, Issue 3, Oxford De Angelo A, Halliday A (2002). Wernicke-Korsakoff Syndrome Online Accessed 27/11/03 US Derby Hospitald NHS Foundation Trust (Twine P) (2005 ) Guidelines for Phosphate Replacement in Refeeding Syndrome and Malnourished Patients CG-T/2005 V2.0 DHNHST Harper C, Giles m and Finlay-Jones R (1986) Clinical signs in the Wernicke- Korsakoff Complex: a retrospective analysis of 131 cases diagnosed at necropsy. Journal of neurology, neurosurgery and psychiatry vol Mayo-Smith MF Pharmacetical management of alcohol withdrawal (1997) A meta analysis and evidence based guideline. American society of Addiction Medicine Working Group on Pharmacetical Management of Alcohol Withdrawal. Jama 1997; 278(2) Pirmohamed M (2001), ALCOHOL - can the NHS afford it? Royal College of Physicians RCP London Scottish Intercollegiate Guidelines Network (2003) The management of harmful drinking and alcohol dependence in primary care a national clinical guideline. RCP Edinburgh. Victor M, Adams RD, and Collins GH. (1989) The Wernicke-Korsakoff Syndrome and Related Neurological Disorders due to Alcoholism and Malnutrition.. F.A. Davis Company, Philadelphia Wood B, Currie J (1995) Presentation of Acute Wernicke s Encephalopathy and Treatment with Thiamine Metabolic Brain Disease, Vol Documentation Controls Development of Guideline: Consultation with: Approved by: Hepatology Consultant A&E and ICU Consultants Clinical Guidelines Group Signature: Print Name and Position: Dr. Nick Chesshire, Chair of Clinical Guidelines Group Approval Date: January 2007 Review Date: January 2009 Distribution and location : Key Contact: All wards and Departments Consultant Hepatologist CG-T/2007/ 063 Page 7 of 8 Review Date: 2009

8 Appendix 1 Alcohol Content of Some Beverages Beer / Lager ABV % Measure Units Lynx ml 4.25 Carlsberg Special ml 4.5 Brew / Tennants Super / Amsterdam ml 5.8 Maximator Labatts/ Carling 4.0 Pint 568ml 2.3 Cider Strongbow 4.5 Litre 4.5 Old English 5.5 Pint 3.1 Frosty Jack/ litre 22.5 Zeppelin / white lightening Spirit Vodka / Rum ml 26.3 Absinthe 75 30ml 2.3 Wines ml Useful Contacts: Locally: Mary Johnson, Alcohol Liaison Specialist Nurse City Hospital via switchboard. Web sites: Alcohol Concern, The Portman Group, APAS Nottingham Alternatively, visit your G.P CG-T/2007/ 063 Page 8 of 8 Review Date: 2009