MANAGEMENT OF ALCOHOL WITHDRAWAL IN A GENERAL HOSPITAL SETTING- CL PSYCHIATRY PERSPECTIVE

R.HEWKO MD FRCPCCL PSYCHIATRIST

rhewko@telus.net

DISCLOSURE

NOTHING TO DISCLOSE

CL PSYCHIARTY ROLE ?

• PRIMARY MANAGMENT ?• SECONDARY MANAGEMENT - FAILED PRIMARY SERVICE MANAGEMENT - CLEAN UP - DEPENDANT ON UNDERSTANDING

PRIMARY SERVICE MODEL – CIWA PROTOCOL

CIWA MODEL

• CIWA MODEL -CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT -

ALCOHOL

- 9 ITEMS ASSESSED BY NURSING STAFF

- LINKED TO A PREPRINTED ORDER SET

- PRIMARY AGENTS - BENZODIAZPINES

CIWA PROTOCOL - ADVANTAGES

• EVIDENCE BASED PRACTICE• REQUIRE LESS BENZO’S THAN FIXED DOSE

MODELS• CONSISTANT TREATMENT • MINIMAL PHYSICIAN INVOVLEMENT• PRIMARILY NURSING BASED CARE• ONE SIZE FITS ALL

MAYO CLINIC ARTICLE

• TITLE – Inappropriate use of Symptom-Triggered Therapy for Alcohol Withdrawal in the General Hospital

• Authors – KA Hecksel, JM Bostwick, TM Jaeger• Ref. Mayo Clin. Proc. 2008;83(3):2004 274-279

METHODOLOGY

• 124 OF 495 PATIENTS RX WITH CIWA PROTOCOL IN TWO MAYO CLINIC AFFILIATED HOSPTIALS

• RANDOM SELECTION ACCOUNTING FOR AGE/GENDER

• ADMISSION CRITERIA FOR CIWA PROTOCOL MALES - > 4 DRINKS /DAY WK PRIOR TO HOSP. FEMALES - > 2 DRINKS /DAY WK PRIOR TO HOSP. ABLE TO COMMUNICATE MEANINGFULLY

RESULTS

• 52 % - 64/124 OF PATIENTS RX DID NOT MEET INCLUSION CRITERIA

• 14 % - 9 PTS UNABLE TO COMMUNICATE• 55 % - 35 PTS HAD NO RECENT ALCOHOL HX• 31 % - 20 PTS MET NEITHER CRITERIA

CIWA DEVOPMENT AND VALIDATION

• PRIVATE HOSPITAL DETOX

• AGE < 60 YRS OLD

• PTS MEDICALLY CLEAR

• GEN. HOSPTIAL STUDIES EXCLUSION CRITERIA - AGE -SEVERITY OF ILLNESS

PREPRINTED ORDERS

• DEVELOPED BY ASAM

- 300 PTS. IN A VA DETOX

- 3 PTS OVER AGE 60

- PTS MEDICALLY CLEAR

CLINICAL LITERATURE – BENZODIAZEPINESAGENTS OF CHOICE

META-ANALYSIS HOSPITAL BASED MANAGEMENT OF AW HOLBROOK,CMAJ,MAR 9,1999. 160(5) 649-655

COMPARITIVE STUDIES – BENZO’S. NEUROLEPTICS, ANTICONVULSANTS, CHLORAL HYDRATE

BENZODIAZIPINES SAFE AND EFFECTIVE

AGENT OF CHOICE FOR TREATMENT OF AW

NO BENZODIAZEPINE SUPERIOR IN EFFICACY / SAFETY

LIMITATIONS

• 11 “GOOD” STUDIES• N’s 20-30 PATIENTS PER STUDY• MEAN AGE 35-45• 5 STUDIES LTD PTS TO MILD ILLNESS• ALL STUDIES EXCLUDED SEVERELY ILL

CIWA PROTOCALADVANTAGES = DISADVANTAGES

• EASE AND EFFICIENCY• PHYSICIAN INVOLVEMENT “IDENTIFY” AT RISK PT INITIATE CIWA – TICK BOXES• NURSING STAFF MANAGE THE PATIENT ON

“AUTOPILOT” -ASSESS CIWA SCORE -GIVE BENZOS UNTIL SCORE < 10• MINIMAL ONGOING PHYSICIAN INVOLVEMENT

IMPLICATIONSCIWA PROTOCOL

• VALIDATED FOR RELATIVELY YOUNG, HEALTHY PTS• PTS INAPPROPRIATELY STARTED INTO PROTOCOL• MOST PHYSICIANS UNAWARE OF LIMITATIONS• MINIMAL FORMAL TEACHING• LIMITED PHYSICIAN MONITERING• DELAYED RECOGNITION OF COMPLICATIONS• POTENTIAL FOR SIGNIFICANT MORBIDITY/MORTALITY• PSYCHIATRIC REFERRAL - ONGOING AGITATION /

CONFUSION - DELIRIUM

DELIRIUM – ALCOHOL HX / SEQUELAE OF CIWA PROTOCOL

• DDX - DT’S 1/300 - DELIRIUM “OTHER” ETIOLOGY - BENZODIAZEPINE INTOXICATION - AW AND DELIRIUM OTHER ETIOLOGY - DELIRIUM AND BENZO INTOXICATION

ASSESSMENT/MANAGEMENT

• EVIDENCE / ABSENCE OF AUTONOMIC AROUSAL (AA) -AA CONTINUE BENZO’S ADD NEUROLEPTICS REG/PRN -DROWSY / MIN. AA - TAPER BENZO’S - TITRATE REG/PRN NEUROLEPTICS - NORMALIZE SLEEP - QUETIAPINE

AW - MAJOR AUTONOMIC AROUSAL

• REFRACTORY AW - AGGRESSIVE BENZO’S - LORAZEPAM 2-4 mg QIH PRN - REG. BENZO’S – LORAZEPAM / DIAZEPAM - HYPOMAGNESEMIA ?

HYPOMAGNESEMIA

• COMMON ISSUE IN PATIENTS AT RISK -MAJOR AW• HYPOMAG. - INCR. RISK /SEVERITY OF AW - INCR. RISK SEIZURES / SEIZURE STATUS - REFRACTORY HYPOKALEMIA - REFRACTORY WITHDRAWAL? - BENZO INSENSITIVITY - ANIMAL STUDIES• REPLACEMENT – 5 GMs IV Q12H/Q8H 3-6 DOSES

REFRACTORY DELIRIUM

• 42 Y/O MALE – ONGOING DELIRIUM• DAY 4 – DROWSY/ DISORIENTED• AVERAGING 10 mg LORAZEPAM LAST 2 DAYS• CONFUSION/NYSTAGMOUS/ATAXIA• DX ?• RX ?

WERNICKE’S ENCEPHALOPATHY

• THIAMINE DEFICIENCY• MEDICAL EMERGENCY• 30 % NEUROLOGIC SEQUELAE EVEN WITH RX• RX - THIAMINE -PARENTERAL IM/IV 100mg - AT LEAST 3 DAYS -RELIABLE UNTIL ORAL INTAKE

SUMMARY

• CIWA PROTOCOL NOT VALIDATED IN EDLERLY MEDICALLY COMPRISED

• OVERUSED WITH INADEQUATE ASSESSMENT• LOSS OF CLINICAL SKILLS / JUDGEMENT• SIGNIFICANT INCIDENCE RESIDUAL DELIRIUM• A LAW SUIT WAITING TO HAPPEN !