alcohal withdrwal syndrome-inpatient management ppt
DESCRIPTION
In Hospital Management of Acute Alcohol withdrawal Syndrome.TRANSCRIPT
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Lt Col Ashutosh OjhaCl Spl (Med)
151 Base Hospital
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My PatientMr XYZAge 39 yrsNCE ,AF Att. with small Det for more than 04 monthResident –Assam ,Distt-KamrupEdn-Xth Std MarriedA Chronic Alcohol abuser .
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PresentationNoted to have increased tremors,
tremulousness and irritable by colleaguesBlood tinged vomitus while brushingAlso blood ooze from gumsAlso had 03 episodes of seizures (not
witnessed)Also had incontinence of urine in lines once Yellowness of eyes
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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
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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
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Personal HistoryAlcohol -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 VegNon Smoker
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Personal History…contd Married 02 children staying Single at Guwahati
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Family History Alcohol abuse in family –father No h/o psy illness
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Summarily A case of Alcohol Dependence with relapse
and in Acute withdrawal state with features of Alcoholic liver disease
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On ExaminationGloomy look,Confused ,wandering Pulse-98/min /regBP=160/100mmHg Icteric Tremors-Digital /TongueResp rate-16/minTemp-99.8 Deg F (Axillary )
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Gen Examn…ContdParotomegalyAsterexis –Could not be elicited Dry blood on lips . fresh blood stains on shirtBreath –non alcoholicTesticular sensation intact
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Systemic examn Per -AbdomenSoft ,non distended Liver-4 cm ,soft ,non-tender, non pulsatile,
span -14cmSpleen –palapable-3cm,Firm No ascitis
No Neck Rigidity Lungs-Clear
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Mental state Examn Conscious Oriented -Time . Person Memory –Recent and Intermediate
compromisedIntelligence- Not tested … Not attentive Delusion and Visual hallucination –Nil Anxious
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Working Diagnosis A case of Alcohol Dependence Syndrome with
relapse and in Acute withdrawal state with Alcoholic Liver disease
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RxAdmitted with guards in Acute Medical wardInj Thiamin Inj Vit KInj Ceftazidime Inj Lorazepam Inj MVI Infusion Inj Pantoprazol
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Next morningFebrile -102 deg FHallucinating – Visual as well auditory Tremors RestlessRunning aroundPerspiringPulse-126/min BP-could not be recorded
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Diagnosed -Delirium tremens Restrained nursingInj 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
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DT Rx..Placed on DILAnti Malarial added (Artesunate)Continued Rx under advice of Sr Adv(Psy)
CH(EC)After enough sedation …. Pt was kept under
constant observation
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Investigations Hb-12.5g/dL,TLC-5600/cmm,DLC-
P80L16M02E02,Pl-1.52 lac/ccS.Bil-2.8mg/dLSGOT=128,SGPT=116,SGGT=486IU/L,Uric acid-5.3mg/dL.MCV-102fLRFT,Electrolytes –WNLECG-Tachycardia
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Investigations..contd USG- Normal scanHBsAg,Anti HCV,HIV-Neg INR-1.22MRI-Brain –Normal study
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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
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Course in HospitalGradually calmed down Attentive Afebrile All autonomic dysfunction signs settled Taken off DIL on day 07 Patient in Psy ward
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Rx contd……..Psycho-therapy incl group therapy and
Psycho-education is in progress
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DisposalInvalidation is planned after due course
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Discussion
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ObjectivesDescribe the different types of alcohol
withdrawalRecognize the symptoms of alcohol
withdrawal delirium Review the management of AWD
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Scope of the problem8 million people dependent on alcohol is the
US3.5 million dependent on illicit drugs500,000 episodes/yr of alcohol withdrawal15% of pts in primary care have either an
alcohol-related health problem or “at-risk” pattern of alcohol use
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ALCOHOL : INDIAN SCENARIOEstimated numbers of alcohol users - 62.5
million17.4% (10.6 million) dependant users 20-30%- admissions alcohol related 15% - general population10% - patients in family practice30% co morbidity with a psychiatric condition More common in younger people with low SES
and educational status
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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
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Patho-physiologyAlcohol 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
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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 seizuresSeizures – 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)
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Withdrawal Differential Diagnosis
Sepsis/Malaria ThyrotoxicosisHeat strokeHypoglycemiaIntracranial pathology: trauma/CVAEncephalitis/encephalopathy
Acute cocaine intoxicationAcute amphetamine intoxication
Olmedo et al. Withdrawal Syndromes. Emergency Med Clinics of North America 2000;18(2): 273-287
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AssessmentOptimal 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 of 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 http://www.aafp.org/afp/20040315/1443.html
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Laboratory testsParameter 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
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Mild Alcohol withdrawal6hrs after stop drinking (may occur w/
significant blood-alcohol levels)Resolves in 1-2 daysCNS overactivity
Insomnia, anxietyTremulousnessDiaphoresisGI upsetHeadaches
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Alcohol HallucinosisBegins 12-24 hours after cessation Lasts 1- 3 daysPatient 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
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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 generalizedFocal seizure = structural lesion High risk of progression to Delirium Tremens
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ALCOHOL WITHDRAWL SEIZURES
D/DStructural 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
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ALCOHOL WITHDRAWAL SEIZURES
MANAGEMENT Rule out other causes by history/examination/ lab
invTreat only for withdrawalDo not start anticonvulsantAdmission to detoxification centre
Indications for CT head: Focal seizure Focal neurologic findings Signs of head trauma Clinical deterioration
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5% of patients who withdrawTypically begin b/w 48 and 96 hours Typically last 1-5 daysEarly figures of associated mortality were as
high as 37%,present mortality rates - 5%.
Delirium Tremens:
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Delirium Tremens:: FactorsRisk History of sustained drinkingPrevious DTsold ageGreater number of days since last drinkPresence of other illnessesMortality risk is greater:Elderly Concomitant lung DiseaseCore body temp >104 deg F Co-existing liver Disease
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Delirium Tremens: symptoms and sign
Sensorium CloudingHallucinationsTremorsDisorientationTachycardiaHypertensionFeverAgitationDiaphoresis
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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:
GABAAR function
Seizures: 90%
Delirium: 70%McKinley MG, Crit Care Nurse. 2005;25: 40-48
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Fixed Schedule TherapyDay 1, one of these 6 h:
Chlorodiazepoxide, 50 – 100 mg
Diazepam, 10 – 20 mg
Lorazepam, 2 – 4 mg
Then dose 20% each day
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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
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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)
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MortalityMortality is ~5% Increased by older age, coexisting lung or
liver disease, and temp>104 FDeath due to arrhythmia, complicating illness
(pneumonia), or failure to recognize trigger illness (CNS infection, pancreatitis)
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Associated findings in DTsDehydration (increased losses)Hypokalemia (renal and extrarenal losses)Hypomagnesemia (increases risk for seizures
and arrhythmias)Hypophosphatemia (increases risk for
rhabdomyolysis and cardiac failure)
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Supportive Care for DTsReplace volume deficits - isotonic fluidsThiamine 100mg IV and glucoseMVI w/ folateAggressively correct abnormal K, Mg, Phos,
and glucose
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Overview of TreatmentBenzodiazepines = Mainstay of Alcohol
withdrawal treatment6 prospective trials comparing BZD to placeboRisk reduction of 7.7 in preventing seizures Risk reduction of 4.9 in preventing delirium
Work by stimulation GABA receptorsTreats agitation and prevents progression
Kosten TR. NEJM 2003; 348: 1786
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Benzos vs NeurolepticsMeta-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.
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The Bottom Line:2004 Practice GuidelinesBenzos should be primary agent for
managing AWD (gr A)Reduce mortality, duration of sx and have less
complications than neurolepticsInitial goal is control of agitation
Rapid, adequate control of agitation reduces adverse events
Arch Int Med, vol 164, 2004.
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BenzodiazepinesLong-acting formulations preferred ..Except
Hepatic DysfunctionShorter acting (lorazepam) may be preferred
in elderly or liver diseaseContinuous infusions of BZDs are not cost-
effective.Onset of action for BZDs: 15sec – 2minPeak action: 5-15 min
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Adjunctive meds: NeurolepticsInferior to benzodiazepinesIncreased risk of side effects, including lower
seizure threshold, prolonged QTc and hypotension
No studies done on “newer” atypicalsCan be used in conjunction w/ benzo in
setting of perceptual disturbances (gr C)
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Adjunctive medsBeta-blockers: not well studied
Mild reduction in autonomic manifestationsOne controlled study w/ propranolol: increased
incidence of deliriumCan be used if persistent HTN or tachycardia
(gr C) CarbamazepineEffective for mild-mod symptoms of withdrawalLimited data on preventing seizures or
delirium
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Adjunctive medsClonidine
Effective for mild-mod symptoms of withdrawalNo studies that show decrease rate of delirium
or seizuresEthyl Alcohol – not recommended
No controlled trials, potential GI/neuro effectsDifficult to titrate, not readily available
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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
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Humble AcknowledgementSr Adv(Psy) and Our Spl Psy Maj Surendra
Sharma
Team 151 Base Hospital
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References and ReadingFerguson 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.