Title: Challenges in
Managing Alcohol Withdrawal Syndrome in Special Populations:
Focus on the Surgical
and Elderly Patients.
Joanna Piechniczek-Buczek, MD
Department of
Alcohol Medical Scholars Program (Slide1)
I.
INTRODUCTION (Slide 2)
A. Alcohol
misuse is common in the general population
1. 80 %
lifetime alcohol use[1]
2. 15 %
lifetime alcohol abuse
3. 10 %
lifetime alcohol dependence[2]
B. Alcohol Use Disorders (AUD) of abuse or
dependence common among
1. Medical inpatients
~ 20%[3]
2. Surgical
Patients: ~ 43% otorhinolaryngological
patients; 50% gastrointestinal tract
cancer patients[4]
3. Trauma
patients ~ 40% -50% intoxicated; 94% of those with intoxication have substance
abuse or dependence [5]
4. Elderly
~ 17%[6]
C. Alcohol abuse, dependence, withdrawal: DSM IV TR definitions [7] (Slide 3)
1. Abuse:
repeated alcohol–related problems in same 12
months with 1+ :
a. Inability
to fulfill role obligations
b. Use in
physically hazardous situations
c. Legal
problems
d. Social or interpersonal difficulties
e. Never
dependent
2. Dependence:
repeated alcohol-related problems over 12 months with 3 +:
a. Tolerance
b. Withdrawal
c. Use
heavier or longer than intended
d. Desire and inability to cut down
e. Activities
aborted
f.
Long time spent in alcohol-related activities
g. On-going
use despite consequences
3.
Alcohol Withdrawal Syndrome (AWS) 2 +: (Slide 4)
a. Autonomic hyperactivity
b. Tremor
c. Insomnia
d. Nausea
or vomiting
e. Hallucinations
or illusions
f. Agitation
g. Anxiety
h. Grand
mal seizures
D. Risk
factors for severe alcohol
withdrawal: (Slide 5)
1. Quantity
and frequency of intake (large amounts over long period of time) [8]
2. Number
and severity of prior episodes
3. Use of
other substances[9]
4.
Medical/surgical
co-morbidity[10]
5. Elevated
Blood Alcohol Concentration (BAC)[11]
6. High
severity of withdrawal upon presentation[12]
7.
Advanced
age[13]
E. Development of AWS associated with: (Slide 6)
1. More
complicated hospital stay
2. Longer
stay
3. ↑
need of intensive care[14]
4. ↑
mortality
F. This
lecture will cover: (Slide 7)
1. Neurobiology
of Alcohol Withdrawal Syndrome (AWS)
2. Signs
and symptoms of AWS
3. Evaluation
of patients
4. Treatment-
general principles
5. Special
considerations in:
a. Surgical/
trauma patients
l
b. Geriatric
patients
(Slide
8)
II. NEUROBIOLOGY
OF ALCOHOL
A. Acute
effects of alcohol: (Slide 9)
1.
activity at GABA A receptor [15]
2.
¯ glutamate transmission at NMDA receptor
3.
dopamine
4.
norepinephrine synthesis and release
5.
↑ effect of serotonin at 5HT3 receptor
6.
beta
endorphins levels / µ binding
B. Chronic
effects of alcohol:
1. Down-
regulation of GABA receptors [16]
2. Up-regulation
of NMDA receptors
3. Down-regulation
of dopamine receptors
4. Serotonin
depletion
5. ¯ postsynaptic
receptor norepinephrine sensitivity
6. ↓
in β-endorphine levels / binding
C. Withdrawal (Slide
10)
1. ↑excitatory
effect by: ↓ GABA, ↑ glutamateà
tremor, seizures
2. norepinephrine sensitivity à
autonomic instability
(Slide
11)
III. ALCOHOL
WITHDRAWAL SYMPTOMS
A.
Phase I[17](Slide 12)
1. Time
abstinent or cut down: 6-24 hrs
2. Signs and symptoms:
a. Tremor: hands most prominent
b. ↑
autonomic activity:
i. ↑ blood pressure
ii.
↑ reflexes
iii.
Fever
c. Insomnia
d. Nausea/vomiting
e. Sweating
f.
Anxiety
B.
Phase II
(Slide 13)
1. Time
abstinent: 7-48 hrs
2. Signs
and symptoms:
a. Distractibility
b. Autonomic
instability (↑↓heart rate, ↑↓ blood pressure)
c. Grand
mal seizures
3. 5-10%
lifetime risk of seizures
C.
Phase III (Slide
14)
1. Time
abstinent: 72-96 hrs
2. Only in
< 5%
3. Symptoms:
(Delirium+ severe autonomic instability + tremor = delirium tremens or DT)
a.
Confusion/disorientation
b.
Severe autonomic instability
c.
Auditory/tactile hallucinations
d.
Agitation
4. Mortality
rate ~ 1 %[18]
(Slide 15)
IV.
ALCOHOL WITHDRAWAL ASSESSMENT
A. History/Interview:
(Slide 16)
1. Duration
of use
Chronic use (weeks,
months) à↑ risk of withdrawal
2. Quantity,
frequency and drinking pattern
a.
> 5-6 drinks/ day
b.
Daily or almost daily use
c.
Age of first use, periods of heaviest use, periods of abstinence
3. Time
since last drink (~6+ hours)
4. Severity
of previous withdrawals (e.g. seizures
or DTs)
5. Concurrent
medical/psychiatric problems
6. Social
/domestic/emotional/occupational problems
B. History/Screening tools: (Slide 17)
1. Alcohol
Use Disorders Identification Test (AUDIT)
a. 10 items scale
b. Can be
self administered
c. Assesses:
frequency, quantity, lack of control, guilt, blackouts etc.
d. Sensitivity: 90%; Specificity: 85% at score of > 8
2. CAGE Cut down, Annoyed, Guilty, Eye opener
a.
Very brief
b.
2 or > + responsesà high likelihood of alcoholism
c.
Sensitivity 85%; Specificity 90%
d.
Not gender sensitive; does not identify recent
or episodic use
3. Michigan
Alcohol Screening Test (MAST)
a.
Structured interview
b.
25 questions
c.
Positive
answers to 4 + questions suggest alcohol “problem”
C. Physical exam: (Slide
18)
1. Focused
on identifying withdrawal symptoms (e.g. sweating, tremors, etc.)
2. Chronic
alcohol exposure stigmata:
a. Spider
angiomata-superficial spider-like cluster of capillaries,
b. Palmar
erythema- reddening of the palms
c. .
Hepatosplenomegaly-↑ liver and spleen
3. Assessment
of possible complicating medical
conditions:
a. Cardiac arrhythmias (irregular heart rate)
b.
Congestive heart failure (secondary to hypertension or cardiomyopathy)
c. Gastrointestinal bleeding (blood in vomit or
stool),
d. Cancer
(esophagus, stomach, head and neck, lungs)
e. Liver disease (fatty liver, hepatitis,
cirrhosis)
f. Pancreatitis[19]
(abdominal pain, ↑ pancreas enzymes
e.g. amylase)
g. Nervous system impairment:
i.
Central
(confusion, cerebellar damage)
ii.
Peripheral (neuropathy e.g. “pins+ needles” in
hands/feet)
D.
Laboratory investigations:[20] (Slide 19)
1. Blood
count:↑ red blood cells size; mean corpuscular volume (MCV) > 100
2. Liver functions tests (LFTs)
a. ↑
Aspartate aminotransferase (AST); > 40 u/l
b. ↑ Alanine aminotransferase (ALT); >
40 u/l
c. AST/ALT
ratio > 2 e.g. à
suggestive of alcoholic liver disease;
3. ↑
Carbohydrate deficient transferrin (CDT) : high sensitivity and specificity/
good indicator of early relapse: 20U or 2.6 %
4. ↑ Gamma-glutamyl transferase (GGT): levels↑ after 70 drinks/week for
several weeks; > 35 u/l
5. Urine/serum
toxicology screen: to exclude other drug use
6. Electrolytes:
↓ Na, ↓Mg à
↑ risk of seizures
7. Blood
alcohol concentration (BAC):
BAC ~ 150 w/o intoxication or ~ 300 w/o
somnolenceà evidence of tolerance à ↑ risk of withdrawal
(Slide
20)
V.
ALCOHOL WITHDRAWAL TREATMENT[21]
A. General
care: (Slide 21)
1. Multivitamins
(MVI): 1 tablet daily
2. Thiamine:
100 mg daily
3. Folic
acid: 1 mg daily
4. Fluid
repletion if dehydration evident
B. Medication
regimen- benzodiazepines (BZDs) [22](Slide 22)
1. First
line treatment
2. BZD are
effective to decrease:
a. Severity
of withdrawal
b. Incidence
of delirium
c. Incidence
of seizures
3. Are 2
types:
a. Longer
acting ( ½ life ~ 30 hours)
E.g. diazepam (Valium)
b. Shorter
acting ( ½ life ~15 hours)
e.g. lorazepam (Ativan)
4. Longer
acting better at preventing seizures, but
sedation
5. Two
main strategies:
a. “ Fixed
schedule” (Slide 23)
i.
Description:
ü Specific
doses administered at specific intervals
ü Additional doses used as needed based on the severity of symptoms
ii.
Examples:
ü Lorazepam 2 mg
every 4 hours;
ü Diazepam
10-20 mg every 6 hours;
ü Chlordiazepoxide
(Librium) 25-50 mg every 6 hours
iii.
Tapered gradually over several days
iv.
Problems: over / under- medication ( too
difficult to control symptoms)
b. “Symptom–triggered”
(Slide 24)
i.
Description:
ü Medication given when CIWA-AR >8
ü Clinical
Institute Withdrawal Assessment, Revised (CIWA- Ar) - severity scale 0-7 on the
following items: (Slide 25)
·
Nausea, vomiting
·
Tremor
·
Diaphoresis (sweating)
·
Anxiety
·
Agitation
·
Tactile hallucinations (touch)
·
Auditory hallucinations
·
Visual hallucinations
·
Headache
·
Orientation and clouding of sensorium (confusion)
ii.
Examples:
ü Lorazepam
2 mg q 1 hour for CIWA 8-13
ü Lorazepam 3 mg q 1 hour for CIWA 14-20
ü Lorazepam
4 mg q 1 hour for CIWA >20
iii. Problems: cost/
staff time
C.
Non-pharmacological treatments: (Slide 26)
1. Reassurance
2. Reality-orientation
techniques (time, place, situation)
3. Rest/sleep
4. Adequate
nutrition.
(Slide 27)
VI. ALCOHOL WITHDRAWAL IN SURGICAL AND TRAUMA PATIENTS
A. Epidemiology (Slide 28)
1. 50-60%
prevalence of alcohol abuse/dependence in trauma patients
2. 16%
incident of AWS post-surgery vs. 8% in general population[23]
3. Pre-operative
assessment/prophylaxis prevents post-operative AWS complications in 75% of
patients
4. Highest
risk of DTs: in 40+ year olds and s/p
fall or burn
B. Risks
1. operative and post operative morbidity and
mortality[24]
2. Postoperative
morbidity 2-3 X ↑ if 21+
drinks/week[25]
3. 50% longer hospital stay
4. Poorer
3 month outcomes: infections, bleeding, cardiopulmonary
C.
Challenges (Slide 29)
1. During
surgery:
a. Alcohol
can or ¯sensitivity to anesthesia[26]
b. Alcohol
↓ coagulation
c. ↑
risk of hypoxia and poor BP control
2. After
surgery:
a. Alcohol
¯ immune functions;
surgery immunosuppressionà risk
of inflammation/ infection
b. Alcohol
↑ metabolic acidosis and ↑ surgery stress response[27]
c. DTs
often confused with[28]
i.
Sepsis
ii.
↓ Circulation to brain
iii.
Worsening of closed head injury
d. Autonomic
instability ( e.g.
↑ or↓ blood pressure) due to alcohol withdrawal à incorrectly attributed to traumatic injury
e. Agitation
due
to withdrawal
i. Challenges
nursing care
ii. Risks
displacement of monitors and dressings
f.
Hallucinations àdifficult
to assess in intubated patients
D. Assessment and treatment
1.
History
(Slide 30)
a. Scheduled
surgeries:[29]
i. Good
pre-operative assessment to screen for AUDs
ii. Advise
abstinence if not at risk of AWS
iii. Pre-surgical
detoxification should be considered if needed
b. Trauma
and emergency surgeries
i.
History taking difficult
ii.
Collateral informants (family, friends,
witnesses) important
iii.
Physical exam/ laboratory findings important
2. Differential
diagnosis/common surgical causes of agitation[30]: (Slide 31)
a.
Bleeding,
b.
Metabolic/electrolyte abnormalities
c.
Infection
d.
Pain
3. Supportive
care (Slide 32)
a.
Pain management
b.
Pulmonary toileting
c.
Eliminate unnecessary catheters
d.
Early mobility
4. Pharmacological
treatment[31]
a. BZDs
b. Symptom-triggered
approach most effective
c. Dosages
generally larger
(Slide 33)
iii.
A
VII. ALCOHOL
WITHDRAWAL IN THE ELDERLY:
A. Epidemiology (Slide
34)
1. 11% of
elderly in acute medical settings have alcohol abuse or dependence
2. 20% in
psychiatric settings
3. 14% in emergency departments
B. Risks[32]
1. Even
moderate drinking in the elderly : ↑ disease burden and ↑ risk of
complicated withdrawal
2. Aging
affects alcohol levels:[33]
a.
↓
body water à↓ volume of
distributionà↑ alcohol
concentration
b.
↓ gastric alcohol dehydrogenase à↑ alcohol concentration
3. Alcohol
↑ risk of falls leading to hip fractures/ subdural hematomas ( bleed under skull)
4. Alcohol
interacts with many common medications
C.
Challenges (Slide 35)
1. Age
aloneà predictor of ↑
withdrawal severity[34]
2. Early onset drinkersà long useà
↑ probability of prior withdrawalsà
↑ severity of AWS [35]
3. Functional
reserve and tolerance of physiological stressors ↓ with age[36]
4. ↑
risk of adverse effects from use of BZDs
[37]
a. Cognitive
impairment[38]
b. Daytime
sedation
c. Falls
D. Assessment and treatment (Slide 36)
1. History:
a. Difficult
because:
i.
Patient
ashamed to admit
ii.
Family
reluctant to share
iii.
Physicians not likely to suspect[39]
b. Clues
that should ↑ suspicion of AUD in the elderly:
i.
Frequent falls
ii.
Bruises
iii.
Many ED visits
iv.
↑ blood pressure
v.
Depressed mood and suicidal thoughts
vi.
Insomnia
2. Differential
diagnosis[40] (Slide 37)
a. Withdrawal
from other substances (e.g. BZDs,
Barbiturates)
b. Delirium
of other causes ( see DTs differential diagnosis described above)
c. Psychiatric conditions (anxiety, dementia, psychosis)
3. Supportive treatment (Slide
38)
a. Safe/
well lit environment
b. Gentle/empathic/
non-judgmental approach
c. Hearing
aids/glasses as individually indicated
d. Extremes
of sensory input- to be avoided
e. Sleep/rest/nutrition
4. Pharmacological interventions (Slide 39)
a. Shorter
acting agents (lorazepam, oxazepam)
preferred because:
a. No
active metabolites
b. ↓
rate of side effects [41]
b. Symptom-triggered approach preferred
c. For
some patients (with history of sz and DTs) àfixed
schedule preferred Medication held for
sedation
d. Medication
dosages typically lower.
(Slide
40)
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