Alcohol withdrawal syndromes in the critically ill
|
|
- Dana Rich
- 8 years ago
- Views:
Transcription
1 Page 1 of 5 Biomedical JP DeMuro 1 * Alcohol withdrawal syndromes in the critically ill Abstract Introduction Alcohol abuse continues to be a global problem. Here the four stages and pathogenesis of alcohol withdrawal syndrome are reviewed. The pharmacotherapy of the patient includes benzodiazepines, propofol, barbiturates, dexmedetomidine, betablockers and phenothiazines. The author s pharmacological protocol for alcohol withdrawal syndrome is included. Conclusion The pharmacological strategy needs to match the severity the patient is experiencing. Introduction Alcohol abuse is a common problem globally, and it is estimated to result in 2.5 million deaths annually 1. Of the drugs of abuse, alcohol is the most common 2, with an estimated 18.3 million individuals dependent on it in the United States 3. Alcohol abuse has a prevalence of 22.4% in a hospitalised general medical population 4. In one analysis, alcohol-related admissions accounted for 9% of admissions to a population of mixed medical intensive care unit (ICU) and surgical ICU patients; in addition these patients accounted for 13% of total ICU costs 5. One population with a particularly high rate of alcohol abuse are trauma patients, with estimates of prevalence ranging from 31% to 70% across centres 6,7. Alcohol-related complications in the ICU affect nearly every organ system (Table 1). Alcohol abuse in * Corresponding author jdemuro@winthrop.org 1 Winthrop University Hospital, Department of Surgery, Division of Trauma & Critical Care, Mineola, New York patients is associated with increased length of stay 8, outpatient pneumonia 9,10 and an almost three times higher incidence of healthcare-associated infections 11. The aim of this critical review is to discuss alcohol withdrawal syndromes in the critically ill. Discussion The author has referenced some of its own studies in this review. These referenced studies have been conducted in accordance with the Declaration of Helsinki (1964) and the protocols of these studies have been approved by the relevant ethics committees related to the institution in which they were performed. All human subjects, in these referenced studies, gave informed consent to participate in these studies. Diagnosis The gold standard for the diagnosis of alcohol withdrawal syndrome (AWS) is the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition 12. It requires that a patient s alcohol usage is heavy and prolonged, there is a cessation in alcohol intake and also that there is no other general condition that better accounts for the diagnosis. There should also be a manifestation of symptoms with two or more of the following: autonomic hyperactivity, increase in hand tremors, insomnia, nausea or vomiting, transient hallucinations, psychomotor agitation, anxiety or grand mal seizures. Finally, the symptoms should cause significant distress and interfere with important areas of functioning. AWS has four clinical stages: (1) autonomic hyperactivity, (2) hallucinations, (3) neuronal excitation and (4) delirium tremens (Table 2) 13. Patients generally start the withdrawal process at 5 h, with hallucinations at 24 h, and delirium at 48 h; it is rare for this to persist for more than 120 h 14. While some patients may linearly progress through these stages, others may progress more rapidly. The author has seen patients in the postoperative period immediately after general anaesthesia for surgery present in delirium tremens with no manifestation of progression through the lower stages. Pathophysiology AWS is the result of a disruption of the delicate neurochemical balance that is controlled via inhibitory and excitatory neurotransmitters. The principal inhibitory neurotransmitter is gamma aminobutyric acid (GABA), which exerts its effect on the GABA-A neuroreceptor 15. A principal excitatory transmitter is glutamate, which affects the N-methyl-D-aspartate neuroreceptor. With chronic alcohol exposure, the brain has a tolerance to the effects of the alcohol due to down-regulation of the GABA-A receptor over time 16. This down-regulation may occur by modification of the GABA-A receptor in the alpha 1 subunit to make the receptor less susceptible to the effects of alcohol exposure 17. Pharmacological treatment The severity of the symptoms of AWS should direct the appropriate pharmacotherapeutic interventions. The patient s comorbidities, other active diagnoses as well as exposure to any other drug of abuse should also be factored into the development of their treatment plan. Benzodiazepines Benzodiazepines have historically been the mainstay pharmacologic intervention of AWS 18 ; they are generally considered to be the gold standard treatment 19. It has
2 Page 2 of 5 Table 1. Complica ons of chronic alcohol consump on. Systemic Shortened life span Immunosupression Increased risk of malignancy: gastric, oesophageal, pancreatic, breast Cardiovascular Alcoholic cardiomyopathy Gastrointestinal Hepatic cirrhosis Peptic ulcer disease Pancreatitis Genita Male: erectile dysfunction, gynaecomastia Female: infertility, abnormal uterine bleeding Haematologic Impaired iron metabolism Megaloblastic anaemia Bone marrow suppression Musculoskeletal Osteoporosis Neurological Intracranial haemorrhage Wernicke Korsakoff syndrome Peripheral neuropathy Renal Beer Drinker s hyponatremia Hypophosphatemia Hypomagnesemia Hypocalcaemia Nephromegaly been shown that sedative-hypnotic agents such as benzodiazepines, in comparison with other agents, reduce mortality and control the symptoms of AWS 20,21. All benzodiazepines have the same mechanism of action on the GABA receptor. Several agents have been used for AWS including chlordiazepoxide, lorazepam, valium, oxazepam and midazolam. Lorazepam is suggested as the benzodiazepine of choice for AWS due to its intermediate half-life, which balances a smooth withdrawal, with the potential for delayed metabolism in those with impaired hepatic function such as geriatric or cirrhotic patients 22. In less severe cases of AWS, benzodiazepine can be administered via the oral route. However, for alcohol withdrawal severe enough to require admission to the critical care setting, the parenteral route is chosen. In some cases, it can be intermittently given as a bolus, although some patients may require a continuous infusion of the medication. With a prolonged infusion of the sedative, mechanical ventilation is necessary, which prolongs the length of stay in the ICU, and has the known complication of ventilator-associated pneumonia (VAP) and prolonged coma even with cessation of benzodiazepine 23. When the duration of benzodiazepine infusion in the critical care setting exceeds seven days, a benzodiazepine withdrawal syndrome has also been described 24. Benzodiazepines were traditionally administered to AWS patients in a fixed dose regimen. There has now been over two decades of experience accumulated with the use of on demand or symptom-triggered dosing of benzodiazepines for AWS treatment 25. This method of symptom-triggered dosing relies on the Clinical Institute Withdrawal Assessment for Alcohol [CIWA-A or CIWA-Ar (revised)]. In studies, the symptom-triggered dosing method results in both a decrease in the amount of benzodiazepines administered and a shortened duration of withdrawal symptoms 26. While the symptom-triggered approach has these advantages, there is quite limited experience of the use of this approach in critical care settings 27,and it has not shown the same benefit across all studies 28. Benzodiazepine resistance There are sporadic reports of AWS patients being benzodiazepine resistant and requiring extremely high doses of these agents for a prolonged time to control their symptoms While these patients can be managed using benzodiazepine as monotherapy, it can only be done at supratherapeutic doses, which have a propensity to accumulate, and then require a significantly prolonged wean. This often precipitates unnecessary neurologic workup, including brain imaging and prolonged mechanical ventilation. Clinicians often turn to additional agents to avoid supratherapeutic benzodiazepines and the predictable sequelae. Intravenous ethanol, while still used in some centres, is not currently favoured by many clinicians and Compe ng interests: none declared. Conflict of interests: none declared.
3 Page 3 of 5 Table 2. Stages of alcohol withdrawal 45. (1) Autonomic hyperactivity Increased sympathetic outflow with an increase in circulating catecholamines with symptoms including diaphoresis, nausea, vomiting, anxiety, tremor and agitation. (2) Hallucinations Visual and tactile are common and auditory is unusual. The hallucination of ants crawling on skin is classically described. (3) Neuronal excitation Alcohol withdrawal seizures. (4) Delirium tremens Delirium that is in combination with autonomic hyperactivity and alcohol hallucinosis. offers no advantages over benzodiazepine 33. It is generally reserved for use in overdoses of methanol, isopropanol or ethylene glycol 34. Barbiturates can be a reasonable agent in the setting of a severe AWS. Advantages include low cost and long half-life which can provide longer term saturation of the GABA receptors, resulting in less symptoms including agitation. A disadvantage of barbiturates is the lack of a reversal agent in case of an overdose. Phenobarbital has been used in emergency department settings as a sole agent for mild to moderate cases of alcohol withdrawal 35. In ICUs, barbiturates often get added to benzodiazepine in resistant cases. In a study by Gold et al., with a protocol of escalating doses of phenobarbital and diazepam, there was a trend towards less days of mechanical ventilation, less nosocomial pneumonia and a reduced ICU length of stay 36. Another agent used in case of benzodiazepine-resistant patients with AWS is propofol. It is an intravenous sedative commonly used in critical care settings for sedation via continuous infusion. Its mechanism of action is also on the GABA receptor. Propofol has the advantage of a shorter half-life and rapid wakeup when stopped; the disadvantage is propofol infusion syndrome, particularly with longer usage at higher doses. It is hypothesised that the propofol is synergistic with benzodiazepine, thereby avoiding the toxic effects of monotherapy with a high-dose benzodiazepine approach. There is limited experience to this approach 37,38, although the most resistant AWS do respond to this strategy in the author s experience. The major drawback of propofol for AWS is that it requires mechanical ventilation, so its use should be reserved for the more severe end of the spectrum. Adjunctive agents The alpha-2-agonist, clonidine, has traditionally been used to blunt the sympathomimetic effects of AWS 39. This has been done outside critical care settings. While intravenous clonidine is available in Europe, it is not currently available for use in the United States. This has resulted in intensivists to turn to dexmedetomidine, a drug derived from clonidine. Dexmedetomidine is not FDA-approved for AWS, but rather for procedural conscious sedation and sedation for mechanical ventilation <24 h. While there have been isolated case reports of dexmedetomidine being used for AWS with good results, retrospective data has recently been published Dexmedetomidine may be used as an adjunctive agent in conjunction with benzodiazepine for AWS, and it may shorten the ICU length of stay and avoid intubation. The maximum approved infusion dose of dexmedetomidine is 0.7 mcg/kg/h, although some patients may benefit from higher doses (up to 1.4 mcg/kg/h). The patients who respond well to dexmedetomidine can be transitioned to a clonidine patch as their symptoms stabilise. Beta-blockers Beta-blockers have been used as an adjunctive agent in AWS. Given the sympathetic outflow associated with autonomic hyperactivity, betablockers are a direct antagonist. This medication can be administered either orally or intravenously, and it serves to normalise tachycardia and hypertension in non-agitated patients that are otherwise comfortable. In a randomised trial by Gottlieb, atenolol in patients with AWS served to make a more rapid resolution of their vital sign abnormalities and clinical signs such as tremor 43. Beta-blockers serve an important role as part of a multimodal pharmacological plan, but they should never be used without a GABA agent. Haloperidol Haloperidol is a phenothiazine that is commonly prescribed in ICUs for acute agitation. It has the benefit of haemodynamic neutrality, and the possible complications of an elevation in the QTc interval and tardive dyskinesia. While haloperidol is an adjunctive agent in AWS setting, it is particularly useful for the symptoms related to delirium 44. Conclusion AWS continues to challenge clinicians in critical care settings. Keys to good outcomes in this area include early recognition of the disorder and rapid implementation of appropriate pharmacologic treatment. The range of symptoms represents a spectrum; the pharmacologic strategy needs to match the severity that the patient is experiencing. While some patients have a good therapeutic response to a single benzodiazepine agent, more severe cases may require a multimodality therapy. The current
4 Page 4 of 5 Table 3. Cri cal care treatment of alcohol withdrawal syndrome. Lorazepam 2 mg intravenously every 6 h Dexmedetomidine up to 1.4 mcg/kg/h intravenously titrated to RASS* = 0 (tolerate -1 to +1) (apply clonidine patch 0.1 to 0.2 mg/day before stopping infusion) Intubate patient and mechanical ventilation Lorazepam at 0.5 to 2 mg/h continuous intravenous infusion Propofol continuous infusion Phenobarbital in escalating intravenous bolus doses (65 mg, 130 mg, 260 mg) Adjunctive agents: Lopressor 2.5 mg to 5 mg every 6 h intravenously for hypertension or sinus tachycardia >120 beats/min Haloperidol 2.5 mg to 10 mg every 6 h intravenously, and as needed for control of agitation *RASS, Richmond Agitation Sedation Scale. protocol used at our institution is presented in Table 3. With a stepwise protocol-driven plan, intubation and mechanical ventilation can be avoided except in the more severe cases, contributing to better outcomes in terms of length of stay and VAP. Abbreviations list AWS, alcohol withdrawal syndrome; CIWA-A, Clinical Institute Withdrawal Assessment for Alcohol; GABA, gamma aminobutyric acid; ICU, intensive care unit; VAP, ventilator-associated pneumonia. References 1. Management of substance abuse: alcohol. World Health Organization (WHO). Available from: int/substance_abuse/facts/alcohol/en/ index.html#, accessed Dec 26, Lieber CS. Medical disorders of alcoholism. New Engl J Med Oct;333(16): Substance Abuse and Mental Health Services Administration. Results from the 2008 National Survey on Drug Use and Health: National Findings. Rockville MD: Office of Applied Studies; NSDUH series H-36, HHS publication SMA Umbricht-Schneiter A, Santora P, Moore RD. Alcohol abuse: comparison of two methods for assessing its prevalence and associated morbidity in hospitalized patients. Am J Med Aug;91(2): Baldwin WA, Rosenfeld BA, Breslow MJ, Buchman TG, Deutschman CS, Moore RD. Substance abuse-related admissions to adult intensive. Care Chest Jan;103(1): Lukan JK, Reed DN, Looney SW, Spain DA, Blondell RD. Risk factors for delirium tremens in trauma patients. J Trauma Nov;53(5): De Wit M, Jones DG, Sessler CN, Zilberberg MD, Weaver MF. Alcohol-use disorders in the critically ill. Chest Oct;138(4): Marik P, Mohedin B. Alcohol-related admissions to an inner city hospital intensive care unit. Alcohol & Alcoholism Jul;31(4): Fernandez-Sola J, Junque A, Estruch R, Monforte R, Torres A, Urbano-Marquez A. High alcohol intake as a risk and prognostic factor for community-acquired pneumonia. Arch Intern Med Aug;155(15): De Roux A, Cavalcanti M, Marcos MA, Garcia E, Ewig S, Mensa J, et al. Impact of alcohol abuse in the etiology and severity of community and severity of community-acquired pneumonia. Chest Oct;129(5): De Wit M, Goldberg S, Hussein E, Neifeld J. Health care-associated infections in surgical patients undergoing elective surgery: are alcohol use disorders a risk factor? J Am Coll Surg Aug;215(2): First MB. Diagnostic and statistical manual-text revision (DSM-IV-TR, 2000). Washington DC: American Psychiatric Association; Al-Sanouri I, Dikin M, Soubani AO. Critical care aspects of alcohol abuse. South Med J Mar;98(3): Foy A, Kay J, Taylor A. The course of alcohol withdrawal in a general hospital. Q J Med Apr;90(4): Bayard M, McIntyre J, Hill KR,Woodside J. Alcohol withdrawal syndrome. Am Fam Physician Mar;69(6): Hoffman PL, Tabakoff B. Alcohol dependence: a commentary on mechanisms. Alcohol Alcohol Jul;31(4): Littleton J. Neurochemical mechanisms underlying alcohol withdrawal. Alcohol Health Res World. 1998;22 (1): Fuller RK, Gordis E. Refining the treatment of alcohol withdrawal. JAMA Aug;272(7): Worner TM. Propranolol versus diazepam in the management of the acute alcohol withdrawal syndrome: doubleblind controlled trial. Am J Drug Alcohol Abuse. 1994;20(1): Mayo-Smith MF, Beecher LH, Fischer TL, Gorelick DA, Guillaume JL, Hill A, et al. Management of alcohol withdrawal delirium: an evidence-based practice guideline. Arch Intern Med Jul;164(13): Mayo-Smith MF. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence based guideline. JAMA Jul;278(2): Bird RD, Makela EH. Alcohol withdrawal: what is the benzodiazepine of choice? Ann Pharmacother Jan;28(1): Guglielminotti J, Maury E, Alzieu M,Delhotal Landes B, Becquemont L, Guidet B, et al. Prolonged sedation requiringmechanical ventilation and continuous flumazenil infusion after routine doses of clorazepam for alcohol withdrawal syndrome. Intensive Care Med Dec;25(12): Cammarano WB, Pittet JF, Weitz S, Schlobohm RM, Marks JD. Acute withdrawal syndrome related to the administration of analgesic and sedative medications in adult intensive care unit patients. Critical Care Med Apr;26(4): Daeppen JB, Gache P, Landry U, Sekera E, Schweizer V, Gloor S, et al. Symptom-triggered vs fixed-schedule Compe ng interests: none declared. Conflict of interests: none declared.
5 Page 5 of 5 doses of benzodiazepine for alcohol withdrawal. Arch Intern Med May;162(10): Saitz R, Mayo-Smith MF, Roberts MS, Redmond HA, Bernard DR, Calkins DR. Individualized treatment for alcohol withdrawal. A randomized double blind trial. JAMA Aug;272(7): Spies CD, Otter HE, Huske B, Sinha P, Neumann T, Rettig J, et al. Alcohol withdrawal severity is decreased by symptom-orientated adjusted bolus therapy in the ICU. Intensive Care Med Dec;29(12): Maldonado JR, Nguyen LH, Schader EM, Brooks JO (3rd). Benzodiazepine loading versus symptom-triggered treatment of alcohol withdrawal: a prospective, randomized clinical trial. Gen Hosp Psychiatry Dec;34(6): Hayes PC, Faestel PM, Shimamoto PL, Holland C. Alcohol withdrawal requiring massive prolonged benzodiazepine infusion. Mil Med May;172(5): Kunkel EJ, Rodgers C, DeMaria PA Jr, Holleran D, Zaimes J, Gray C, et al. Use of high dose benzodiazepines in alcohol and sedative withdrawal delirium. Gen Hosp Psychiatry Jul;19(4): Wolf KM, Shaughnessy AF, Middleton DB. Prolonged delirium tremens requiring massive doses of medication. J Am Board Fam Pract Sep;6(5): Kahn DR, Barnhorst AV, Bourgeois JA. A case of alcohol withdrawal requiring 1,600 mg of lorazepam in 24 hours. CNS Spectr Jul;14(7): Weinberg JA, Magnotti LJ, Fischer PE, Edwards NM, Schroeppel T, Fabian TC,et al. Comparison of intravenous ethanol versus diazepam for alcohol withdrawal prophylaxis in the trauma ICU: results of a randomized trial. J Trauma 2008 Jan;64(1): de Wit M, Jones DG, Sessler CN, Zilberberg MD, Weaver MF. Alcohol-use disorders in the critically ill patient. Chest Oct;138(4): Hendey GW, Dery RA, Barnes RL, Snowden B, Mentler P. A prospective, randomized, trial of phenobarbital versusbenzodiazepines for acute alcohol withdrawal. Am J Em Med May;29(4): Gold JA, Rimal B, Nolan A, NelsonLS. A strategy of escalating doses of benzodiazepines and Phenobarbital administration reduces the need for mechanical ventilation in delirium tremens. Crit Care Med Mar;35(3): Subramanian K, Gowda RM, Jani K, Zewedie W, Ute R. Propofol combined with lorazepam for severe poly substance misuse and withdrawal states in intensive care: a case series and review. Emerg Med J Sep;21(5): McCowan C, Marik P. Refractory delirium tremens treated with propofol: a case series. Crit Care Med Jun;28(6): Muzyk AJ, Fowler JA, Norwood DK, Chilipko A. Role of α2-agonists in the treatment of acute alcohol withdrawal. Ann Pharmacother May;45(5): DeMuro JP, Botros D, Wirkowski E, Hanna AF. Use of dexmedetomidine for the treatment of alcohol withdrawal syndrome in critically ill patients: A Retrospective Case Series. J Anesth Aug;26(4): Rayner SG, Weinert CR, Peng H, Jepsen S, Broccard AF. Dexmedetomidine as adjunct treatment for severe alcohol withdrawal in the ICU. Ann Intensive Care May;2(1): Tolonen J, Rossinen J, Alho H, Harjola VP. Dexmedetomidine in addition to benzodiazepine-based sedation in patients with alcohol withdrawal delirium. Eur J Emerg Med Dec 7. [Epub ahead of print] 43. Gottlieb LD. The role of beta blockers in alcohol withdrawal syndrome. Postgrad Med Feb 29;Spec No: Lansford CD, Guerriero CH, KocanMJ, Turley R, Groves MW, Bahl V, et al. Improved outcomes in patients with head and neck cancer using a standardized care protocol for postoperative alcohol withdrawal. Arch Otolaryngol Head Neck Surg Aug;134(8): Sarff M, Gold JA. Alcohol withdrawal syndromes in the intensive care unit. Crit Care Med Sep; 38 (Suppl 9): S494 S501.
Case. History of psoriatic arthritis, htn, essential tremor Meds: propranolol, etodolac, etanercept No history of prior psychiatric disease.
Case 48 year old man admitted complaining of hallucinations. Mild hallucinations for a year. Worsened tremor for 3 weeks and then markedly worse hallucinations last 2 days History of psoriatic arthritis,
More informationAlcohol withdrawal syndromes in the intensive care unit
本 檔 僅 供 內 部 教 學 使 用 檔 案 內 所 使 用 之 照 片 之 版 權 仍 屬 於 原 期 刊 公 開 使 用 時, 須 獲 得 原 期 刊 之 同 意 授 權 Alcohol withdrawal syndromes in the intensive care unit MaryClare Sarff, MD; Jeffrey A. Gold, MD Crit Care Med 2010
More informationAlcohol Withdrawal. Introduction. Blood Alcohol Concentration. DSM-IV Criteria/Alcohol Abuse. Pharmacologic Effects of Alcohol
Pharmacologic Effects of Alcohol Alcohol Withdrawal Kristi Theobald, Pharm.D., BCPS Therapeutics III Fall 2003 Inhibits glutamate receptor function (NMDA receptor) Inhibits excitatory neurotransmission
More informationOutpatient Treatment of Alcohol Withdrawal. Daniel Duhigg, DO, MBA
Outpatient Treatment of Alcohol Withdrawal Daniel Duhigg, DO, MBA DSM V criteria for Alcohol Withdrawal A. Cessation or reduction of heavy/prolonged alcohol use B. 2 or more of the following in hours to
More informationPhenobarbital in Severe Alcohol Withdrawal Syndrome. Jordan Rowe Pharm.D. Candidate UAMS College of Pharmacy
Phenobarbital in Severe Alcohol Withdrawal Syndrome Jordan Rowe Pharm.D. Candidate UAMS College of Pharmacy Disclosure: No relevant financial relationship exists. Objectives 1. Describe the pathophysiology
More informationAlcohol Withdrawal Syndromes
Alcohol Withdrawal Syndromes Should You Treat This Patient s Alcohol Withdrawal With Benzodiazepines?! Meta-analysis of RCTs of benzodiazepines for the treatment of alcohol withdrawal! 11 RCTs identified,
More informationPhenobarbital Use as Adjunct to Benzodiazepines in the Treatment of Severe Alcohol Withdrawal Syndrome
Journal of Pharmacy and Pharmacology (014) 1-7 D DAVID PUBLISHING Phenobarbital Use as Adjunct to Benzodiazepines in the Treatment of Severe Alcohol Withdrawal Cristina Roman, Sibusisiwe Gumbo and Kevin
More informationPhilip Moore DO, Toxicology Fellow, PinnacleHealth Toxicology Center Joanne Konick-McMahan RN MSRN, Staff RN, PinnacleHealth
Philip Moore DO, Toxicology Fellow, PinnacleHealth Toxicology Center Joanne Konick-McMahan RN MSRN, Staff RN, PinnacleHealth I. II. Background A. AWS can occur in anyone who consumes alcohol B. Risk correlates
More informationSymptom Based Alcohol Withdrawal Treatment
Symptom Based Alcohol Withdrawal Treatment -Small Rural Hospital- Presenter CDR Dwight Humpherys, DO dwight.humpherys@ihs.gov Idaho State University Baccalaureate Nursing Program Lake Erie College of Osteopathic
More informationHow To Treat Alcohol Withdrawal In The Elderly
ALCOHOL ABUSE AND WITHDRAWAL SYNDROME IN THE ELDERLY Colin Muscat Family Medicine Case 90 year old Female Lives with son on vacation Admitted for FTT Consult -? GARP Develops increasing confusion during
More informationJason Hoppe, D.O. Department of Emergency Medicine University of Colorado
Jason Hoppe, D.O. Department of Emergency Medicine University of Colorado Remember that patient you admitted 56 yo M broken hip and mild alcohol withdrawal, no other complaints, non-focal exam and workup
More informationHow To Treat An Alcoholic Withdrawal
Alcohol Withdrawal Sorrento, Italy (September 19, 2007) Lewis R. Goldfrank, MD Professor and Chairman, Emergency Medicine New York University School of Medicine Director, Emergency Medicine Bellevue Hospital/NYU
More informationAlcohol Withdrawal Recognition and Treatment
Alcohol Withdrawal Recognition and Treatment Thomas Meyer BS EMS, MICP SREMSC Page 1 Purpose As EMTs a mantle of responsibility is placed upon you to ensure the safety and well-being of those in your charge
More informationAlcohol Withdrawal Syndrome & CIWA Assessment
Alcohol Withdrawal Syndrome & CIWA Assessment Alcohol Withdrawal Syndrome is a set of symptoms that can occur when an individual reduces or stops alcoholic consumption after long periods of use. Prolonged
More informationAlcohol withdrawal A challenge in caring for patients after heart surgery
Abteilung Praxisentwicklung Pflege Alcohol withdrawal A challenge in caring for patients after heart surgery Wolfgang Hasemann, RN, PhD Deborah Leuenberger, MScN.cand. June 2015 Content Alcohol consumption
More informationGeneral Internal Medicine Grand Rounds. Julie Taub, MD Denver Health & Hospital Authority, Denver CO
The Treatment of Acute Alcohol Withdrawal General Internal Medicine Grand Rounds February 14, 2012 Julie Taub, MD Denver Health & Hospital Authority, Denver CO Pharmacology Ethanol Benzodiazepines Chlormethiazole
More informationHow To Screen For Alcohol Dependence
Commonwealth of Massachusetts Board of Registration in Medicine Quality and Patient Safety Division Advisory Alcohol Screening and Management Protocols July 2013 Background The Quality and Patient Safety
More informationBackground. Population/Intervention(s)/Comparison/Outcome(s) (PICO) List of the systematic reviews identified by the search process
updated 2012 Treatment of alcohol withdrawal delirium Q3: In the treatment of alcohol withdrawal delirium, are benzodiazepines or antipsychotics safe and effective when compared to a placebo/appropriate
More informationSource: National Institute on Alcohol Abuse and Alcoholism. Bethesda, Md: NIAAA; 2004. NIH Publication No. 04-3769.
Diagnosis and Treatment of Alcohol Dependence Lon R. Hays, MD, MBA Professor and Chairman Department of Psychiatry University of Kentucky Medical Center Defining the Standard Drink A standard drink = 14
More informationAddition of dexmedetomidine to benzodiazepines for patients with alcohol withdrawal syndrome in the intensive care unit: a randomized controlled study
DOI 10.1186/s13613-015-0075-7 RESEARCH Open Access Addition of dexmedetomidine to benzodiazepines for patients with alcohol withdrawal syndrome in the intensive care unit: a randomized controlled study
More informationThere are approximately 18.3 million people
Hosp Pharm 2015;50(3):208 213 2015 Thomas Land Publishers, Inc. www.hospital-pharmacy.com doi: 10.1310/hpj5003-208 Original Article Retrospective Review of Critically Ill Patients Experiencing Alcohol
More informationSource: National Institute on Alcohol Abuse and Alcoholism. Bethesda, Md: NIAAA; 2004. NIH Publication No. 04-3769.
Diagnosis and Treatment of Alcohol Dependence Lon R. Hays, MD, MBA Professor and Chairman an Department of Psychiatry University of Kentucky Medical Center Defining the Standard Drink A standard drink
More informationNew York State Office of Alcoholism & Substance Abuse Services Addiction Services for Prevention, Treatment, Recovery
New York State Office of Alcoholism & Substance Abuse Services Addiction Services for Prevention, Treatment, Recovery USING THE 48 HOUR OBSERVATION BED USING THE 48 HOUR OBSERVATION BED Detoxification
More informationALCOHOL WITHDRAWAL. Ravi Dhanisetty 11/30/2007
ALCOHOL WITHDRAWAL SYNDROME Ravi Dhanisetty 11/30/2007 Veterans Affairs Hospital ACGME CORE COMPETENCIES Medical Knowledge Patient Care Interpersonal Skills Practice Based Learning Systems Based Learning
More informationAlcohol Withdrawal Syndrome. Jeffrey P Schaefer MSc MD FRCPC GI Emergencies Update October 14, 2007 http:dr.schaeferville.com
Alcohol Withdrawal Syndrome Jeffrey P Schaefer MSc MD FRCPC GI Emergencies Update October 14, 2007 http:dr.schaeferville.com Objectives Alcohol Intoxication Take-Aways diagnosis avoid mis-diagnosis management
More informationInternal Medicine Residency Noon Lecture October 30, 2007
Internal Medicine Residency Noon Lecture October 30, 2007 Rebecca J. Beyth, MD, MSc Associate Professor GRECC, NF/SGVHS UF COM, Dept of Aging & Geriatrics Case 82 year old man with history of DJD, and
More informationALCOHOL DETOXIFICATION (IN-PATIENTS) PRESCRIBING GUIDELINE
ALCOHOL DETOXIFICATION (IN-PATIENTS) PRESCRIBING GUIDELINE Authors Sponsor Responsible committee Ratified by Consultant Psychiatrist; Pharmacist Team Manager Medical Director Medicines Management Group
More informationCare of the Patient Undergoing Alcohol Withdrawal. Meggen Platzar RN, BSN, CMSRN Jennifer Wilhelm RN, BSN, CMSRN
Care of the Patient Undergoing Alcohol Withdrawal Meggen Platzar RN, BSN, CMSRN Jennifer Wilhelm RN, BSN, CMSRN If you know someone who tries to drown their sorrows, you might tell them sorrows know how
More informationMOH CLINICAL PRACTICE GUIDELINES 2/2008 Prescribing of Benzodiazepines
MOH CLINICL PRCTICE GUIELINES 2/2008 Prescribing of Benzodiazepines College of Family Physicians, Singapore cademy of Medicine, Singapore Executive summary of recommendations etails of recommendations
More informationIn 1992, approximately 13.8 million
Alcohol Withdrawal Syndrome MAX BAYARD, M.D., JONAH MCINTYRE, M.D., KEITH R. HILL, M.D., and JACK WOODSIDE, JR., M.D. East Tennessee State University James H. Quillen College of Medicine, Johnson City,
More informationIntroduction to Alcohol Withdrawal. Richard Saitz, M.D., M.P.H.
Introduction to Alcohol Withdrawal Richard Saitz, M.D., M.P.H. Heavy drinkers who suddenly decrease their alcohol consumption or abstain completely may experience alcohol withdrawal (AW). Signs and symptoms
More informationIn the United States, alcohol is the most commonly abused. Alcohol Withdrawal. Review Article
Review Article Alcohol Withdrawal Anton Manasco, BS, Shannon Chang, MD, Joseph Larriviere, MD, L. Lee Hamm, MD, and Marcia Glass, MD Abstract: Alcohol withdrawal is a common clinical condition that has
More informationGUIDELINES FOR COMMUNITY ALCOHOL DETOXIFICATION IN SHARED CARE
GUIDELINES FOR COMMUNITY ALCOHOL DETOXIFICATION IN SHARED CARE Dr Millicent Chikoore MBBS MRCPsych Dr O Lagundoye MBBS MRCPsych Community based alcohol detoxification is a safe and effective option for
More informationThe Role of Diazepam Loading for the Treatment of Alcohol Withdrawal Syndrome in Hospitalized Patients
The American Journal on Addictions, 22: 113 118, 2013 Copyright American Academy of Addiction Psychiatry ISSN: 1055-0496 print / 1521-0391 online DOI: 10.1111/j.1521-0391.2013.00307.x The Role of Diazepam
More informationALCOHOL WITHDRAWAL SYNDROME
ALCOHOL WITHDRAWAL SYNDROME INTRODUCTION Alcohol is the most commonly abused drug in the United States and when someone who chronically abuses alcohol does not drink, that person is at risk for developing
More informationMEDICATION ABUSE IN OLDER ADULTS
MEDICATION ABUSE IN OLDER ADULTS Clifford Milo Singer, MD Adjunct Professor, University of Maine, Orono ME Chief, Division of Geriatric Mental Health and Neuropsychiatry The Acadia Hospital and Eastern
More information4/18/14. Background. Evaluation of a Morphine Weaning Protocol in Pediatric Intensive Care Patients. Background. Signs and Symptoms of Withdrawal
Background 1 Evaluation of a Morphine Weaning Protocol in Pediatric Intensive Care Patients Alyssa Cavanaugh, PharmD PGY1 Pharmacy Resident Children s Hospital of Michigan **The speaker has no actual or
More informationDevelopment and Implementation of an Evidence-Based Alcohol Withdrawal Order Set. Kathleen Lenaghan MSN, RN-BC
Development and Implementation of an Evidence-Based Alcohol Withdrawal Order Set Kathleen Lenaghan MSN, RN-BC 1 2 Genesis Medical Center Davenport, Iowa Objectives Identify the process of developing and
More informationGP Drug & Alcohol Supplement No.7 May 1997
GP Drug & Alcohol Supplement No.7 May 1997 This is the seventh of the monthly Drug and Alcohol Supplements prepared for Central Coast GPs. Detoxification from Alcohol Dr Tony Gill Introduction The management
More informationRunning head: BEST TREATMENT FOR ALCOHOL WITHDRAWAL SYNDROME 1
1 Best Treatment for Alcohol Withdrawal Syndrome Kathryn Obert Auburn University School of Nursing 2 Abstract Alcoholism is defined as a pattern of uncontrolled drinking leading to medical, legal, and
More information1. According to recent US national estimates, which of the following substances is associated
1 Chapter 36. Substance-Related, Self-Assessment Questions 1. According to recent US national estimates, which of the following substances is associated with the highest incidence of new drug initiates
More informationTHE BASICS. Community Based Medically Assisted Alcohol Withdrawal. World Health Organisation 2011. The Issues 5/18/2011. RCGP Conference May 2011
RCGP Conference May 2011 Community Based Medically Assisted Alcohol Withdrawal THE BASICS An option for consideration World Health Organisation 2011 Alcohol is the world s third largest risk factor for
More informationSymptom-Triggered Alcohol Detoxification: A Guideline for use in the Clinical Decisions Unit of the Emergency Department.
Symptom-Triggered Alcohol Detoxification: A Guideline for use in the Clinical Decisions Unit of the Emergency Department. Dr Eugene Cassidy, Liaison Psychiatry; Dr Io har O Sulliva, E erge cy Department,
More informationINTOXICATED PATIENTS AND DETOXIFICATION
VAMC Detoxification Decision Tree Updated May 2006 INTOXICATED PATIENTS AND DETOXIFICATION Patients often present for evaluation of substance use and possible detoxification. There are certain decisions
More informationHIV Case Conference: Use of Common Benzodiazepines
F/C AETC Faculty Psych Thursday, May 15, 2014 12:30 1:30pm (EDT) Didactic Presenter Patrick Marsh, MD University of South Florida Facilitator Debbie Cestaro Seifer, MS, RN University of South Florida HIV
More informationSPECIFICATION FOR THE LOCAL COMMISSIONED SERVICE FOR THE MANAGEMENT ALCOHOL MISUSE
SPECIFICATION FOR THE LOCAL COMMISSIONED SERVICE FOR THE MANAGEMENT OF ALCOHOL MISUSE Date: March 2015 1 1. Introduction Alcohol misuse is a major public health problem in Camden with high rates of hospital
More informationA COMPARATIVE STUDY OF EFFICACY & TOLERABILITY OF LORAZEPAM AND GABAPENTIN IN THE TREATMENT OF ALCOHOL WITHDRAWAL SYNDROME
A COMPARATIVE STUDY OF EFFICACY & TOLERABILITY OF LORAZEPAM AND GABAPENTIN IN THE TREATMENT OF ALCOHOL WITHDRAWAL SYNDROME Dr. Ashutosh Chourishi,* Dr. O.P. Raichandani**, Dr. Sunita Chandraker***, Dr.
More informationBenzodiazepines: A Model for Central Nervous System (CNS) Depressants
Benzodiazepines: A Model for Central Nervous System (CNS) Depressants Objectives Summarize the basic mechanism by which benzodiazepines work in the brain. Describe two strategies for reducing and/or eliminating
More informationAlcohol and nicotine are widely abused substances and are often used together One study showed that 15% of patients visiting a primary care practice
Dr IM Joubert Alcohol and nicotine are widely abused substances and are often used together One study showed that 15% of patients visiting a primary care practice for any reason had either an at-risk pattern
More informationALCOHOL WITHDRAWAL SUMMARY
DISCLAIMER: These guidelines were prepared by the Department of Surgical Education, Orlando Regional Medical Center. They are intended to serve as a general statement regarding appropriate patient care
More informationSUBSTANCE USE DISORDER SOCIAL DETOXIFICATION SERVICES [ASAM LEVEL III.2-D]
SUBSTANCE USE DISORDER SOCIAL DETOXIFICATION SERVICES [ASAM LEVEL III.2-D] I. Definitions: Detoxification is the process of interrupting the momentum of compulsive drug and/or alcohol use in an individual
More informationDexmedetomidine for Alcohol Withdrawal Syndrome: Should we add it to the tab?
Dexmedetomidine for Alcohol Withdrawal Syndrome: Should we add it to the tab? Lauren Hernandez, Pharm.D. PGY2 Critical Care Pharmacy Resident University Health System, San Antonio, TX Division of Pharmacotherapy,
More informationMinimum Insurance Benefits for Patients with Opioid Use Disorder The Opioid Use Disorder Epidemic: The Evidence for Opioid Treatment:
Minimum Insurance Benefits for Patients with Opioid Use Disorder By David Kan, MD and Tauheed Zaman, MD Adopted by the California Society of Addiction Medicine Committee on Opioids and the California Society
More informationCare Management Council submission date: August 2013. Contact Information
Clinical Practice Approval Form Clinical Practice Title: Acute use of Buprenorphine for the Treatment of Opioid Dependence and Detoxification Type of Review: New Clinical Practice Revisions of Existing
More informationHow To Know If You Should Be Treated
Comprehensive ehavioral Care, Inc. delivery system that does not include sufficient alternatives to a particular LOC and a particular patient. Therefore, CompCare considers at least the following factors
More informationLorraine Wilson, 74 years of age, is admitted. Alcohol Withdrawal. During Hospitalization. Early recognition and consistent intervention are critical.
1.9 h o u r s Continuing Education Withdrawal During Hospitalization Early recognition and consistent intervention are critical. Overview: For a chronic drinker, sudden alcohol withdrawal because of an
More informationORIGINAL INVESTIGATION. Symptom-Triggered vs Fixed-Schedule Doses of Benzodiazepine for Alcohol Withdrawal
Symptom-Triggered vs Fixed-Schedule Doses of Benzodiazepine for Alcohol Withdrawal A Randomized Treatment Trial ORIGINAL INVESTIGATION Jean-Bernard Daeppen, MD; Pascal Gache, MD; Ulrika Landry, BA; Eva
More informationTargeting patients for use of dexmedetomidine
Targeting patients for use of dexmedetomidine H a n n a h W u n s c h, M D M S c H e r b e r t I r v i n g A s s i s t a n t P r o f e s s o r o f A n e s t h e s i o l o g y & E p i d e m i o l o g y
More informationAlcohol Dependence and Motivational Interviewing
Alcohol Dependence and Motivational Interviewing Assessment of Alcohol Misuse Checklist Establish rapport patients are often resistant Longitudinal history of alcohol use Assess additional drug use Establish
More informationAtrial Fibrillation in the ICU: Attempting to defend 4 controversial statements
Atrial Fibrillation in the ICU: Attempting to defend 4 controversial statements Salmaan Kanji, Pharm.D. The Ottawa Hospital The Ottawa Hospital Research Institute Conflict of Interest No financial, proprietary
More informationOriginal Contributions
http://dx.doi.org/10.1016/j.jemermed.2012.07.056 The Journal of Emergency Medicine, Vol. 44, No. 3, pp. 592 598, 2013 Copyright Ó 2013 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$
More informationNewYork-Presbyterian Hospital Sites: All Centers Medication Use Manual: Guideline Page 1 of 12
Page 1 of 12 TITLE: ALCOHOL WITHDRAWAL (AWD) SYMPTOM-TRIGGERED THERAPY GUIDELINES (PILOT) FOR MEDICAL PATIENTS (NYP/CU: EMERGENCY DEPARTMENT, MEDICAL ICU/A AND B, 6GN/S, AND 7GS) GUIDELINE: Alcohol Withdrawal
More informationAnnals of Intensive Care 2012, 2:12
Annals of Intensive Care This Provisional PDF corresponds to the article as it appeared upon acceptance. Fully formatted PDF and full text (HTML) versions will be made available soon. Dexmedetomidine as
More informationAlcohol use disorders: sample chlordiazepoxide dosing regimens for use in managing alcohol withdrawal
Alcohol use disorders: sample chlordiazepoxide dosing regimens for use in managing alcohol withdrawal February 2010 NICE clinical guidelines 100 and 115 1 These sample chlordiazepoxide dosing regimens
More informationGuidelines for Cancer Pain Management in Substance Misusers Dr Jane Neerkin, Dr Chi-Chi Cheung and Dr Caroline Stirling
Guidelines for Cancer Pain Management in Substance Misusers Dr Jane Neerkin, Dr Chi-Chi Cheung and Dr Caroline Stirling Patients with a substance misuse history are at increased risk of receiving inadequate
More informationDowners/Depressants (pages 40-50)
Downers/Depressants (pages 40-50) Read pages 49-54, 59-60, and 78-79 of the booklet, Street Drugs. Pages 40-50 of the text. Narcotics: Prescription Origin: Southeast Asia, Southwest Asia, and in the Western
More informationUniversity of Michigan Alcohol Withdrawal Guidelines Overview
University of Michigan Alcohol Withdrawal Guidelines Overview The following document contains the University of Michigan Alcohol Withdrawal Guidelines. These guidelines were developed through an intensive
More informationAddiction Medicine 2013
Addiction Medicine 2013 Pharmacotherapy for alcohol dependence Part I: alcohol withdrawal Roy M Stein, MD Durham Veterans Affairs Medical Center Duke University School of Medicine Objectives Identify goals
More informationAlcohol Withdrawal in the AMU. Dr Ewan Forrest Glasgow Royal Infirmary
Alcohol Withdrawal in the AMU Dr Ewan Forrest Glasgow Royal Infirmary The Society for Acute Medicine, 7 th International Conference, 3-4 October 2013 AWS: The Scale of the Problem Hospital Admissions (England):
More information75-09.1-08-02. Program criteria. A social detoxi cation program must provide:
CHAPTER 75-09.1-08 SOCIAL DETOXIFICATION ASAM LEVEL III.2-D Section 75-09.1-08-01 De nitions 75-09.1-08-02 Program Criteria 75-09.1-08-03 Provider Criteria 75-09.1-08-04 Admission and Continued Stay Criteria
More informationThe American Society of Anesthesiologists (ASA) has defined MAC as:
Medical Coverage Policy Monitored Anesthesia Care (MAC) sad EFFECTIVE DATE: 09 01 2004 POLICY LAST UPDATED: 11 04 2014 OVERVIEW The intent of this policy is to address anesthesia services for diagnostic
More informationin the Elderly Thomas Robinson, MD Surgery Grand Rounds March 10 th, 2008
Post- Operative Delirium in the Elderly Thomas Robinson, MD Surgery Grand Rounds March 10 th, 2008 What is the most common post-operative complication in elderly patients? What is the most common post-operative
More informationEmergency Room Treatment of Psychosis
OVERVIEW The term Lewy body dementias (LBD) represents two clinical entities dementia with Lewy bodies (DLB) and Parkinson s disease dementia (PDD). While the temporal sequence of symptoms is different
More informationAlcohol-use disorders
Issue date: February 2011 Alcohol-use disorders Diagnosis, assessment and management of harmful drinking and alcohol dependence Alcohol dependence: NICE guideline FINAL DRAFT (February 2011) 1 NICE clinical
More informationPharmacological Management of Alcohol Dependence Syndrome
Pharmacological Management of Alcohol Dependence Syndrome Cite as : Doyle, L. Keogh, B. & Lynch, A., Pharmacological Management of Alcohol Dependence Syndrome, Mental Health Practice, 14, (1), 2010, p14-19
More informationSection Editor Stephen J Traub, MD
Official reprint from UpToDate www.uptodate.com 2015 UpToDate Management of moderate and severe alcohol withdrawal syndromes Authors Robert S Hoffman, MD Gerald L Weinhouse, MD Section Editor Stephen J
More informationAlcohol Liaison Service. Alcohol Withdrawal. Information
Alcohol Liaison Service Alcohol Withdrawal Information Alcohol withdrawal If you are dependent on alcohol and suddenly stop drinking, there are a series of symptoms that you may experience. These include:
More informationUpdate and Review of Medication Assisted Treatments
Update and Review of Medication Assisted Treatments for Opiate and Alcohol Use Disorders Richard N. Whitney, MD Medical Director Addiction Services Shepherd Hill Newark, Ohio Medication Assisted Treatment
More informationWITHDRAWAL OF ANALGESIA AND SEDATION
WITHDRAWAL OF ANALGESIA AND SEDATION Patients receiving analgesia and/or sedation for longer than 5-7 days may suffer withdrawal if these drugs are suddenly stopped. To prevent this happening drug doses
More informationAlcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence
Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence Issued: February 2011 guidance.nice.org.uk/cg115 NICE has accredited the process used by the Centre
More informationDexmedetomidine as adjunct treatment for severe alcohol withdrawal in the ICU
Rayner et al. Annals of Intensive Care 2012, 2:12 RESEARCH Dexmedetomidine as adjunct treatment for severe alcohol withdrawal in the ICU Open Access Samuel G Rayner 1*, Craig R Weinert 2, Helen Peng 3,
More informationManagement of Neonatal Abstinence Syndrome and Iatrogenic Drug Withdrawal
Management of Neonatal Abstinence Syndrome and Iatrogenic Drug Withdrawal Kirsten H. Ohler, Pharm.D., BCPS Clinical Assistant Professor Neonatal / Pediatric Clinical Pharmacist University of Illinois at
More informationSUBSTANCE ABUSE SCREENING
OVERVIEW Substance abuse in the elderly is a common problem that is frequently under- diagnosed by primary care doctors and families. Alcohol abuse is present in 10% to 15% of elderly individuals who seek
More informationAlcohol Withdrawal. Julie Teater, MD. Associate Professor - Clinical Department of Psychiatry The Ohio State University Wexner Medical Center
Alcohol Withdrawal Julie Teater, MD Associate Professor - Clinical Department of Psychiatry The Ohio State University Wexner Medical Center Learning Goals/Objectives Discuss the diagnosis of and screening
More informationAlcohol Withdrawal. Julie Teater, MD Associate Professor - Clinical Department of Psychiatry The Ohio State University Wexner Medical Center
Julie Teater, MD Associate Professor - Clinical Department of Psychiatry The Ohio State University Wexner Medical Center Learning Goals/Objectives Discuss the diagnosis of and screening for alcohol use
More informationEvaluation of a Morphine Weaning Protocol in Pediatric Intensive Care Patients
Evaluation of a Morphine Weaning Protocol in Pediatric Intensive Care Patients Jennifer Kuhns, Pharm.D. Pharmacy Practice Resident Children s Hospital of Michigan **The speaker has no actual or potential
More informationPain Management in the Critically ill Patient
Pain Management in the Critically ill Patient Jim Ducharme MD CM, FRCP President-Elect, IFEM Clinical Professor of Medicine, McMaster University Adjunct Professor of Family Medicine, Queens University
More informationSubstance Abuse in Brief
Alcohol use is legal for persons age 21 and older, and the majority of people who drink do so without incident. However, there is a continuum of potential problems associated with alcohol consumption.
More informationEMS Branch / Office of the Medical Director. Active Seziures (d) Yes Yes Yes Yes. Yes Yes No No. Agitation (f) No Yes Yes No.
M07 Medications 2015-07-15 All ages EMS Branch / Office of the Medical Director Benzodiazepines Primary Intermediate Advanced Critical INDICATIONS Diazepam (c) Lorazepam (c) Midazolam (c) Intranasal Midazolam
More informationHospice and Palliative Medicine
Hospice and Palliative Medicine Maintenance of Certification Examination Blueprint Purpose of the exam The exam is designed to evaluate the knowledge, diagnostic reasoning, and clinical judgment skills
More informationADVANCED BEHAVIORAL HEALTH, INC. Clinical Level of Care Guidelines - 2015
The Clinical Level of Care Guidelines contained on the following pages have been developed as a guide to assist care managers, physicians and providers in making medical necessity decisions about the least
More informationJames Bell May 2011 GBL
James Bell May 2011 GBL Day 1 M 32, lives alone, data analyst 12 noon - presented CDAT seeking help - wrong borough, referred to local service - went home, agitated and hallucinating - Took large dose
More informationAwareness of the inappropriate use of GI prophylaxis and its cost. Adverse effects of proton pump inhibitor
Understand the indication for stress ulcer/gi prophylaxis Awareness of the inappropriate use of GI prophylaxis and its cost Adverse effects of proton pump inhibitor A. 65yo w/ HTN and ESRD on HD p/w left
More informationObjectives. Important Principles
Management of the Intubated Patient Christopher J. Edwards, PharmD, BCPS Clinical Pharmacist - Emergency Medicine March 19 th, 2013 REPS EC SAG 2 Objectives Describe the rationale for post intubation analgesia
More informationAlcohol-use disorders
Issue date: February 2011 Alcohol-use disorders Diagnosis, assessment and management of harmful drinking and alcohol dependence Alcohol dependence: NICE guideline FINAL DRAFT (February 2011) 1 NICE clinical
More informationPain Medication Taper Regimen Time frame to taper off 30-60 days
Pain Medication Taper Regimen Time frame to taper off 30-60 days Medication to taper Taper Regimen Comments Methadone Taper by no more than 25% Morphine Taper by no more than 25% Tramadol Taper by no more
More informationBENZODIAZEPINE CONSIDERATIONS IN WORKERS COMPENSATION: IMPLICATIONS FOR WORK DISABILITY AND CLAIM COSTS By: Michael Erdil MD, FACOEM
3 rd Quarter 2015 BENZODIAZEPINE CONSIDERATIONS IN WORKERS COMPENSATION: IMPLICATIONS FOR WORK DISABILITY AND CLAIM COSTS By: Michael Erdil MD, FACOEM Introduction Benzodiazepines, sometimes called "benzos",
More informationMedical Coverage Policy Monitored Anesthesia Care (MAC)
Medical Coverage Policy Monitored Anesthesia Care (MAC) Device/Equipment Drug Medical Surgery Test Other Effective Date: 9/1/2004 Policy Last Updated: 1/8/2013 Prospective review is recommended/required.
More informationAlcoholism and Problem Drinking
Page 1 of 5 Alcoholism and Problem Drinking Alcoholism is a word which many people use to mean alcohol dependence (alcohol addiction). Some people are problem drinkers without being dependent on alcohol.
More informationOmega-3 fatty acids improve the diagnosis-related clinical outcome. Critical Care Medicine April 2006;34(4):972-9
Omega-3 fatty acids improve the diagnosis-related clinical outcome 1 Critical Care Medicine April 2006;34(4):972-9 Volume 34(4), April 2006, pp 972-979 Heller, Axel R. MD, PhD; Rössler, Susann; Litz, Rainer
More information