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In Hospital Management of Acute Alcohol withdrawal Syndrome.

In Hospital Management of Acute Alcohol withdrawal Syndrome.

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  • hello sir, just one question why didnt it treated as hepatic encephalopathy which would require bowel purgation?? waiting for response thx
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  • “ At-risk” drinking for men is >4drinks/sitting or14 drinks/wk. For women, >7 drinks/wk or >3/sitting. Equates to amt of alcohol that puts a person “at-risk” for health consequences related to drinking.
  • A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged. B. Two (or more) of the following, developing within several hours to a few days after Criterion A. 1. Autonomic hyperactivity (e.g., diaphoresis or HR>100) 2. Increased hand tremor 3. Insomnia 4. Nausea and vomiting 5. Transient visual, tactile, or auditory hallucinations or illusions 6. Psychomotor agitation 7. Anxiety 8. Grand mal seizures clinically significant distress or impairment in functioning. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder
  • Alcohol enhances the effect of GABA on GABA-A neuroreceptors, resulting in decreased overall brain excitability. Chronic exposure to alcohol results in a compensatory decrease of GABA-A neuroreceptor response to GABA, evidenced by increasing tolerance of the effects of alcohol. Alcohol inhibits NMDA neuroreceptors, and Chronic alcohol exposure results in up-regulation of these receptors. Abrupt cessation of alcohol exposure results in brain hyperexcitability ….. receptors previously inhibited by alcohol are no longer inhibited. Brain hyperexcitability manifests clinically as anxiety, irritability, agitation, and tremors.……
  • Predictors of AW severity: Older age Severity drinking/tolerance Prior AW (“kindling”) Major medical/surgical problems Sedative/hypnotic use Signs of chronic drinking: General Other (g astrointestinal, neurological, psychiatric,etc Standardized assessment of AW symptoms ((CIWA-Ar) Score 8-10 (mild) Score 10-15 (moderate) Score > 15 (severe) impending delirium tremens Every 4-8 hours until score < 8-10 for 24 hours
  • - 5% of patients who withdraw - Typically begin b/w 48 and 96 hours Typically last 1-5 days Early figures of associated mortality were as high as 37%,present mortality is felt to be 5%. This is likely due to earlier diagnosis, improved pharmacological, and non-pharmocologic management, and improved treatment of co-morbid conditions.
  • Hallucinations Disorientation Tachycardia Hypertension Low Grade Fever Agitation Diaphoresis Elevated cardiac indices, oxygen delivery and oxygen consumption Hyperventilation and Respiratory alkalosis which result in reduced cerebral blood flow Sensorium Clouding Fluid and electrolyte concerns Hypokalemia is common Hypomagnesemia - may predispose to sz. Activity Hypophosphatemia - may be present and contribute to heart failure and rhabdomyolysis.
  • The American Society of Addiction Medicine lists three immediate goals for detoxification of alcohol and other substances: “ To provide a safe withdrawal from the drug(s) of dependence and enable the patient to become drug-free"; “ To provide a withdrawal that is humane and thus protects the patient's dignity"; and “ To prepare the patient for ongoing treatment of his or her dependence on alcohol or other drugs."
  • Quiet environment Nutrition and hydration: Oral thiamine (prevents Wernicke- Korsakoff) / folic acid Oral fluids / electrolytes Orientation to reality Brief interventions / motivate to change Referral for relapse prevention tx.
  • Parentheses are most common causes
  • Studies dating back to 1960s provided evidence that BZDs were effective (and more so than neuroleptics)

Alcohal withdrwal syndrome-Inpatient Management ppt Alcohal withdrwal syndrome-Inpatient Management ppt Presentation Transcript

  • Lt Col Ashutosh Ojha Cl Spl (Med) 151 Base Hospital
  • My Patient Mr XYZ Age 39 yrs NCE ,AF Att. with small Det for more than 04 month Resident –Assam ,Distt-Kamrup Edn-Xth Std Married A Chronic Alcohol abuser .
  • Presentation Noted to have increased tremors, tremulousness and irritable by colleagues Blood tinged vomitus while brushing Also blood ooze from gums Also had 03 episodes of seizures (not witnessed) Also had incontinence of urine in lines once  Yellowness of eyes
  • Presentation Contd….. No H/o alcohol consumption X 4 days Taking tablets for Headache Unable to sleep the night before Unable to attend House keeping and attendant job Noted to be talking to self and unable to pay attention
  • Past History Known case of Alcohol Dependence Syndrome for 3 yrs and was upgraded 1 yr back Multiple relapses Admitted with DT and seizures History elicited after recovery of acute stage
  • Personal History Alcohol -120ml/day since 1993 Been Rxed in different Primary care centres of services. Come in eval. and observed in Med category 2009- 2012 With relapses  After up gradation in Dec2012 Indulged in drinking 150 ml to 350ml of IMFL incl desi off and on Non Veg Non Smoker
  • Personal History…contd Married 02 children  staying Single at Guwahati
  • Family History Alcohol abuse in family –father No h/o psy illness
  • Summarily A case of Alcohol Dependence with relapse and in Acute withdrawal state with features of Alcoholic liver disease
  • On Examination Gloomy look,Confused ,wandering Pulse-98/min /reg BP=160/100mmHg Icteric Tremors-Digital /Tongue Resp rate-16/min Temp-99.8 Deg F (Axillary )
  • Gen Examn…Contd Parotomegaly Asterexis –Could not be elicited Dry blood on lips . fresh blood stains on shirt Breath –non alcoholic Testicular sensation intact
  • Systemic examn Per -Abdomen Soft ,non distended Liver-4 cm ,soft ,non-tender, non pulsatile, span -14cm Spleen –palapable-3cm,Firm No ascitis No Neck Rigidity Lungs-Clear
  • Mental state Examn Conscious Oriented -Time . Person Memory –Recent and Intermediate compromised Intelligence- Not tested … Not attentive Delusion and Visual hallucination –Nil Anxious
  • Working Diagnosis A case of Alcohol Dependence Syndrome with relapse and in Acute withdrawal state with Alcoholic Liver disease
  • Rx Admitted with guards in Acute Medical ward Inj Thiamin Inj Vit K Inj Ceftazidime Inj Lorazepam Inj MVI Infusion Inj Pantoprazol
  • Next morning Febrile -102 deg F Hallucinating – Visual as well auditory Tremors Restless Running around Perspiring Pulse-126/min BP-could not be recorded
  • Diagnosed -Delirium tremens Restrained nursing Inj Lorazepam 4mg IV stat and repeated 03 times after every 15 mins Inj Haloperidol 5 mg IV stat given IV fluid-liberally @125-200ml/hr Condom drain placed
  • DT Rx.. Placed on DIL Anti Malarial added (Artesunate) Continued Rx under advice of Sr Adv(Psy) CH(EC) After enough sedation …. Pt was kept under constant observation
  • Investigations Hb-12.5g/dL,TLC-5600/cmm,DLC-P80L16M02E02,Pl- 1.52 lac/cc S.Bil-2.8mg/dL SGOT=128,SGPT=116,SGGT=486IU/L, Uric acid-5.3mg/dL. MCV-102fL RFT,Electrolytes –WNL ECG-Tachycardia
  • Investigations..contd USG- Normal scan HBsAg,Anti HCV,HIV-Neg INR-1.22 MRI-Brain –Normal study
  • Course of Rx After adequate sedation gradually the de-escalation of Benzodiazapines were done Inj Halpopridol stopped Tab Heptral (S Adnosyl amine )400mg BD added Tab Multi-Vit added after 07 days of IM Thiamin supplementation
  • Course in Hospital Gradually calmed down Attentive Afebrile All autonomic dysfunction signs settled Taken off DIL on day 07 Patient in Psy ward
  • Rx contd…….. Psycho-therapy incl group therapy and Psycho- education is in progress
  • Disposal Invalidation is planned after due course
  • Discussion
  • Objectives Describe the different types of alcohol withdrawal Recognize the symptoms of alcohol withdrawal delirium  Review the management of AWD
  • Scope of the problem 8 million people dependent on alcohol is the US 3.5 million dependent on illicit drugs 500,000 episodes/yr of alcohol withdrawal 15% of pts in primary care have either an alcohol- related health problem or “at-risk” pattern of alcohol use
  • ALCOHOL : INDIAN SCENARIO Estimated numbers of alcohol users - 62.5 million 17.4% (10.6 million) dependant users  20-30%- admissions alcohol related 15% - general population 10% - patients in family practice 30% co morbidity with a psychiatric condition  More common in younger people with low SES and educational status
  • Alcohol Withdrawal syndrome A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged. B. Two (or more) of the following, developing within several hours to a few days after Criterion A. 1. Autonomic hyperactivity (e.g., diaphoresis or HR>100) 2. Increased hand tremor 3. Insomnia 4. Nausea and vomiting 5. Transient visual, tactile, or auditory hallucinations or illusions 6. Psychomotor agitation 7. Anxiety 8. Grand mal seizures
  • Patho-physiology Alcohol enhances the effect of GABA on GABA-A neuro-receptors - decreases overall brain excitability Chronic exposure to alcohol results in a compensatory decrease of GABA-A receptor Alcohol inhibits NMDA receptors  Chronic alcohol exposure results in up-regulation of these receptors Abrupt cessation of alcohol exposure results in brain hyper excitability Brain hyper excitability manifests clinically as anxiety, irritability, agitation, and tremors McKinley MG, Crit Care Nurse. 2005;25: 40-48
  • STAGES OF WITHDRAWAL TIMING Tremulousness, mild anxiety, headache, diaphoresis, palpitations, anorexia, GI upset Mild Withdrawal – resolve 24-48 hr 6 to 36 hours Visual, auditory, and/or tactile hallucinations Alcoholic Hallucinosis – resolve 24-48 hr 12 to 24 hours Generalized, tonic-clonic seizures Seizures – 3% among chronic alcoholics from which 3% status epilepticus 12 to 48 hours Delirium, tachycardia, hypertension, agitation, fever, diaphoresis. Delirium Tremens 48 to 96 hours (peaks within 5 days)
  • Withdrawal Differential Diagnosis Sepsis/Malaria Thyrotoxicosis Heat stroke Hypoglycemia Intracranial pathology: trauma/CVA Encephalitis/encephalopathy Acute cocaine intoxication Acute amphetamine intoxication Olmedo et al. Withdrawal Syndromes. Emergency Med Clinics of North America 2000;18(2): 273-287
  • Assessment Optimal Assessment of AW:Optimal Assessment of AW: - Complete history- Complete history - Physical, and mental status exam- Physical, and mental status exam - Laboratory test- Laboratory test Standardized assessment ofStandardized assessment of AW symptoms - (CIWA-Ar) - Score 8-10 (mild) - Score 10-15 (moderate) - Score > 15 (severe) impending delirium tremens  Every 4-8 hours until score < 8-10 for 24 hours http://www.aafp.org/afp/20040315/1443.html
  • Laboratory tests Parameter Normal value Value in patients with chronic alcohol use Mean corpuscular volume (fl ) 82-98 Increased Serum level of γ-glutamyl transferase, U/L Men 4-25 Women 7-40 Increased Serum level of uric acid (mg/dL) 4.0-8.5 Increased Carbohydrate-deficient transferrin, g/L (mg/dL) 2.0-3.8 (200-300) Increased McKinley MG, Crit Care Nurse. 2005;25: 40-48
  • Mild Alcohol withdrawal 6hrs after stop drinking (may occur w/ significant blood-alcohol levels) Resolves in 1-2 days CNS overactivity Insomnia, anxiety Tremulousness Diaphoresis GI upset Headaches
  • Alcohol Hallucinosis Begins 12-24 hours after cessation Lasts 1- 3 days Patient remains oriented  Autonomic activation is minimal or absent  Varies from tactile, visual, and auditory hallucinations  Visual hallucinations of animals on the walls common  Tactile hallucinations of bugs crawling all over  Auditory hallucinations of hearing voices  Visual are most common
  • ALCOHOL WITHDRAWL SEIZURES 40% of seizures are alcohol related seizures Clinical Features  Onset usually 6 - 48 hrs (have been described up to 14 days) Usually generalized Focal seizure = structural lesion High risk of progression to Delirium Tremens
  • ALCOHOL WITHDRAWL SEIZURES D/D Structural lesion Co ingestant: Stimulants , anticholinergic, phenothiazine Metabolic cause: Hypoglycemia, Ca, Na, Po4 CNS infections  Non compliance with seizure treatment  Exacerbation of post-traumatic seizure disorder or idiopathic epilepsy
  • ALCOHOL WITHDRAWAL SEIZURES MANAGEMENT  Rule out other causes by history/examination/ lab inv Treat only for withdrawal Do not start anticonvulsant Admission to detoxification centre Indications for CT head: Focal seizure Focal neurologic findings Signs of head trauma Clinical deterioration
  • 5% of patients who withdraw Typically begin b/w 48 and 96 hours Typically last 1-5 days Early figures of associated mortality were as high as 37%,present mortality rates - 5%. Delirium Tremens:
  • Delirium Tremens:: Factors Risk History of sustained drinking Previous DTs old age Greater number of days since last drink Presence of other illnesses Mortality risk is greater: Elderly  Concomitant lung Disease Core body temp >104 deg F  Co-existing liver Disease
  • Delirium Tremens: symptoms and sign Sensorium Clouding Hallucinations Tremors Disorientation Tachycardia Hypertension Fever Agitation Diaphoresis
  • Goals of therapy To provide a safe withdrawal from the drug(s) To prepare the patient for ongoing treatment of dependence  BZD -First line agent, best efficacy, safety and cost All are effective: ↑GABAA R function ↓ Seizures: 90% ↓ Delirium: 70% McKinley MG, Crit Care Nurse. 2005;25: 40-48
  • Fixed Schedule Therapy Day 1, one of these 6 h:  Chlorodiazepoxide, 50 – 100 mg  Diazepam, 10 – 20 mg  Lorazepam, 2 – 4 mg  Then↓ dose 20% each day
  • Symptom-triggered Therapy Treatment triggered by severity threshold  One of these 1 h when CIWA ≥ 8:  Chlordiazepoxide, 50 - 100 mg  Diazepam, 10 - 20 mg  Lorazepam, 2 - 4 mg 2 controlled trials vs. fixed schedule:  Equal efficacy / safety  ↓ Dose / side effects / treatment time
  • Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial Figure 1 . Kaplan-Meier curves illustrate treatment times for both groups. Treatment time was shorter in the patients receiving symptom-triggered therapy (log rank test P <.001)
  • Mortality Mortality is ~5% Increased by older age, coexisting lung or liver disease, and temp>104 F Death due to arrhythmia, complicating illness (pneumonia), or failure to recognize trigger illness (CNS infection, pancreatitis)
  • Associated findings in DTs Dehydration (increased losses) Hypokalemia (renal and extrarenal losses) Hypomagnesemia (increases risk for seizures and arrhythmias) Hypophosphatemia (increases risk for rhabdomyolysis and cardiac failure)
  • Supportive Care for DTs Replace volume deficits - isotonic fluids Thiamine 100mg IV and glucose MVI w/ folate Aggressively correct abnormal K, Mg, Phos, and glucose
  • Overview of TreatmentBenzodiazepines = Mainstay of Alcohol withdrawal treatment 6 prospective trials comparing BZD to placebo Risk reduction of 7.7 in preventing seizures Risk reduction of 4.9 in preventing delirium Work by stimulation GABA receptors Treats agitation and prevents progression Kosten TR. NEJM 2003; 348: 1786
  • Benzos vs Neuroleptics Meta-analysis based on 5 studies Benzos more effective in reducing mortality from AWD (RR 6.6 for neuroleptics, CI 1.2-34) Time to achieve adequate sedation was less w/ BZDs (1.1 vs 3 hr, p=0.02) Arch Int Med, vol 164, 2004.
  • The Bottom Line: 2004 Practice Guidelines Benzos should be primary agent for managing AWD (gr A) Reduce mortality, duration of sx and have less complications than neuroleptics Initial goal is control of agitation Rapid, adequate control of agitation reduces adverse events Arch Int Med, vol 164, 2004.
  • Benzodiazepines Long-acting formulations preferred ..Except Hepatic Dysfunction Shorter acting (lorazepam) may be preferred in elderly or liver disease Continuous infusions of BZDs are not cost-effective. Onset of action for BZDs: 15sec – 2min Peak action: 5-15 min
  • Adjunctive meds: Neuroleptics Inferior to benzodiazepines Increased risk of side effects, including lower seizure threshold, prolonged QTc and hypotension No studies done on “newer” atypicals Can be used in conjunction w/ benzo in setting of perceptual disturbances (gr C)
  • Adjunctive meds Beta-blockers: not well studied Mild reduction in autonomic manifestations One controlled study w/ propranolol: increased incidence of delirium Can be used if persistent HTN or tachycardia (gr C) Carbamazepine Effective for mild-mod symptoms of withdrawal Limited data on preventing seizures or delirium
  • Adjunctive meds Clonidine Effective for mild-mod symptoms of withdrawal No studies that show decrease rate of delirium or seizures Ethyl Alcohol – not recommended No controlled trials, potential GI/neuro effects Difficult to titrate, not readily available
  • Take Home Message Alcohol withdrawal includes a number of clinical syndromes that exists along a time and severity continuum Benzodiazepines are the mainstay of Treatment Admin should be guided by CIWA scores (>8) Identification of a trigger for AWD and supportive Rx w/ thiamine, glucose and electrolyte replacement are crucial
  • Humble Acknowledgement Sr Adv(Psy) and Our Spl Psy Maj Surendra Sharma Team 151 Base Hospital
  • References and Reading Ferguson JA, et al. Risk factors for delirium tremens development. J Gen Intern Med 1996; 11: 410. Hack JB, et al. Thiamine before glucose to prevent Wernicke Encephalopathy: examining the conventional wisdom. JAMA 1998; 279: 583. Kosten TR. Management of Drug and Alcohol Witdrawal. NEJM 2003; 348: 1786. Mayo-Smith MF. Pharmacological management of alcohol withdrawal. JAMA 1997; 278: 144 Mayo-Smith MF, et al. Management of Alcohol Withdrawal Delirium. Arch Intern Med 2004; 164: 1405 Ntais C, et al. Benzodiazepines for alcohol withdrawal. Cochrane Database Syst Rev 2005. Saitz R, et al. Individualized treatment for alcohol withdrawal. JAMA 1994; 272: 519.