Symptom 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 Medicine Family Practice Residency at Conemaugh Memorial Hospital in PA >10 years of rural experience working for the IHS doing full spectrum family practice

Case Study 34 y/o male presents to ER Progressing Left Leg Cellulitis 4 days of oral outpatient antibiotics 2-3 week drinking binge Vitals: Temp 101, HR 110, bp 125/80, Pulse Oximetry (PO) is 95% on room air Blood alcohol level of 250 Significant Labs: WBC 15,000; CRP 95; K is 2.9 and Mg is 1.5 Awake and cooperative Not acting intoxicated

Case Study Continued Admitted: intravenous antibiotics, oral replacement of K+ and Mg and Thiamin. Six hours later: ptagitated, tremulous, hallucinating about spiders crawling on him Pt pacing his room and hall, scared and wants to leave Trying to pull out his IV as he is yelling profanity Vital signs: HR 150, BP is 175/105, Temp 98.9, PO is 95% on room air.

Questions??? What is the most likely cause of his condition in regards to his mental status? Can this be prevented? Does this patient need to be transferred to an intensive care unit?

Explanation Alcohol withdrawal Early detection and treatment: <sx progressing to agitation and combativeness Benzodiazepines: the most beneficial medications to treat this condition (Institute of medicine report shows Benzo s superior to other agents.1,2) Treatment on a medical surgical floor vs. being transferred to a higher level of care

Moving Beyond Tradition Small hospital tradition: all withdrawal patients should be transferred to an ICU Alcohol Withdrawal Protocol: Provider increased responsibility Accept some patients will have to be transferred for higher level of care- this is the minority of patients. No prognostic tool to reliably and accurately predict progression: tx = flexible and start early to prevent worsening clinical status(5)

Disposition of the Patient Sub-optimal response to usual doses of benzodiazepines: transfer to intensive care unit Managing alcohol l withdrawal patient on medical surgical floor: focus of this presentation Success with CIWA protocol

Basic Physiology The major inhibitory neurotransmitter in the brain is Gamma Amino Butyric Acid (GABA)(1) Alcohol high affinity for (GABA) (+) inhibitory tone as a central nervous system depressant (-) excitatory tone

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Pathophysiology continued Prolonged stimulation of receptors: Receptors desensitized Require more alcohol to maintain the inhibition tone of the particular receptor. Sudden drop in blood alcohol: GABA receptors become hyper-stimulated from the lack of GABA receptors become hyper stimulated from the lack of alcohol inhibition alcohol withdrawal symptoms The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.

Determining Severity of Withdrawal The Clinical Institute Withdrawal Assessment (CIWA) clinical tool to assess alcohol withdrawal Patients are scored Receive specific treatment doses

CIWA Calculations 10 different categories Scaled from 1-7 regarding the severity of the following: Nausea and Vomiting Tremors Paroxysmal Sweats Anxiety Agitation Tactile Disturbances Auditory Disturbances Visual Disturbances Headache Orientation and Sensorium **Online CIWA calculation tools are available**

CIWA Scoring Sheet

Autonomy The CIWA scoring system: (+) nursing autonomy and clinical skills Using hospital based protocol: Nurse doses the needed amount of medication Patient not responding: Nurse alerts physician

Initial Fixed Dose CIWA Protocol Tapered dosing over 6 days Two dosages were used depending on the patient s need Low CIWA Protocol: 5 Days Diazepam 10mg PO/IV Every 6 hours For 48 hours Diazepam 5mg PO/IV Every 6 hours For 24 hours Diazepam 5mg PO/IV Every 8 hours For 24 hours Diazepam 5mg PO/IV Every 12 hours for 24 hours High CIWA Protocol: 6 Days Diazepam 20mg PO/IV Every 6 hours For 24 hours Diazepam 10mg PO/IV Every 6 hours For 48 hours Diazepam 5mg PO/IV Every 6 hours For 24 hours Diazepam 5mg PO/IV Every 8 hours For 24 hours Diazepam 5mg PO/IV Every 12 hours For 24 hours

We noticed we could improve Full 6 day course rarely needed Medication Utilization Review (MUE) in 2009: 30 out of 47 patients receiving CIWA protocol were randomly selected- only 1 completed a 6 day protocol. 29 patients finished withdrawing <6 days. Average dosage of Diazepam - 150mg

More Research Needed Literature review found multiple studies that support use of a symptom based alcohol withdrawal treatment protocol: JAMA published an article in 1994 that showed patients in a fixedscheduled group used 425mg Chlordiazepoxide verses 100mg of the same medicine i in the symptom triggered group(2) Archives of Internal Medicine published a study involving 117 patients that showed the mean Oxazepam dose for the symptom triggered group was 37.5mg over 20 hours and the fixed treatment group used 231.4mg over 62.7 hours, (P<.001)(4)

Research Continued Mayo Clinic published a study that involved 216 admissions for alcohol withdrawal; this study did not show a shorter duration of treatment, but did show a decrease in the morbidity of delirium tremens in the symptom based treatment group (5) Journal of Addictive Diseases in 2006 did a study on 183 patients that showed a statistically lower dose of Lorazepam in the symptom based group than the fixed dosage group (6)

Changing Our Protocol Simplified, Symptom based: CIWA Score Medication Dose Repeat Assessment < 5 None In 4 hours 5-8 Diazepam 5mg PO/IV In 4 hours 9-11 Diazepam 10mg PO/IV In 2 hours > 12 Diazepam 20mg PO/IV In 1 hour

Repeat MUE 30 out of 47 randomly selected patients receiving revised CIWA protocol (June 2010 to January 2011) Data was collected using the Electronic Health Record (EHR) system Cumulative dosage of diazepam ranged from 5 to 725mg Average cumulative dosage of diazepam = 111 mg vs. 150mg Total days of CIWA assessment ranged from 1-7 days, with average of 3 days

Demographics

Admitting Diagnosis Most intoxicated patients are admitted for soft tissue infection (cellulitis) or pneumonia: CIWA protocol controls withdrawal symptoms during tx of concurrent infection Benefit: patient is safely treated on the local medical Benefit: patient is safely treated on the local medical floor w/o transfer to a tertiary care center

Non-Responders Withdraw so hard (-) conventional CIWA protocol Need sedated on a benzodiazepine drip Assess need for intubation? safety of the flight crew Control of their symptoms Send to an ICU Citi CriticalPatients t may require massive amounts of benzodiazepines: Ie. Versed drip of 30mg an hour or more

Improved Protocol-Effective March 2012 - March 2013: 184 alcohol related admissions only 5 patients (2.7%) had to be transferred out due to not responding to the alcohol withdrawal protocol. Correlates to a 97.3% success rate of keeping alcohol abuse and withdrawal patients in a small hospital Cost saving of transfer to ICU or another medical floor admission Patients transferred directly from the ER were not included in the above chart review

CURRENT PROTOCOL for patients with high scores: CIWA Score Medication Dose Repeat Assessment > 12 Diazepam 20mg PO/IV In 1 hour Notify physician i if CIWA is >12 after 5th dose NEW CHANGES TO THE PROTOCOL:. If CIWA is still >12 One hour after the above 20mg Diazepam dose: 30mg Diazepam and repeat assessment in 30 minutes - May repeat diazepam dose q30 minutes x 3 doses for CIWA 12 or greater - Notify MD if CIWA remains greater than 12 after 4th dose

Preventing Alcohol Withdrawal Associated with prolonged binge drinking Patients need support, encouragement, and education Most continually relapse, occasionally a patient will heed a providers counsel to stop etoh Assess motivation to change Providers cannot change patients, we can only change ourselves

Social Pressure and Fear Some patients state they do not abuse alcohol to get drunk, but stay continually intoxicated to avoid the pain of the alcohol withdrawal and/or harassment from friends/family.

Everybody has to take their medicine. Dr. Rick Robinson Encourage patients to have a substitute for their alcohol. Providers need to establish a healthy lifestyle to be an example of fitness.

Conclusion: Prolonged drinking Etoh causes w/drawal Regular CIWA scoring with corresponding benzodiazepine dosing is effective in treating most alcohol withdrawal Facilities may need to adjust their protocol to fit the needs of their population Providers need to be an example of health and encourage a healthy lifestyle alternative to alcohol abuse

Healthy Recreation=Addiction Substitute

References 1. http://www.uptodate.com/contents/management-of-moderate-and-severe- alcohol-withdrawalsyndromes?source=preview&anchor=h4&selectedtitle=1~65#h4 2. Institute of Medicine. Prevention and Treatment of Alcohol Problems. Washington, DC: National Academy Press; 1990: 268-269 3. JAMA. Individualized Treatment for Alcohol Withdrawal. A randomized double-blind Controlled Trial. August 17, 1994- Vol 272, No. 7:519-523 4. Archives of Internal Medicine. Symptom-Triggered vs Fixed-Schedule Doses of Benzodiazepine for Alcohol Withdrawal. May 27, 2002. Vol 162, 1117-1121 1121 5. Mayo Clinic Proceedings. Symptom-Triggered Therapy for Alcohol Withdrawal Syndrome in Medical Inpatients.2001;76:695-701 6.Journal of Addictive Disease. Alcohol Withdrawal Pharmacotherapy for Inpatients with Medical Comorbidity. 2006;Vol. 25(2): 17-24 7. Clinical Institute Withdrawal Assessment: A Medication Utilization Evaluation (MUE). (Done at an undisclosed rural Public Service Hospital)