prealbumin levels and delirium tremens marcey furlow, rn, ccrn, srna hamot medical center school of...
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Prealbumin Levels and Delirium Tremens
Marcey Furlow, RN, CCRN, SRNA
Hamot Medical Center School of Anesthesia/Gannon University
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• 63 year old male• 85 kg 70 inches• Planned Surgery: Bilateral Total Knee
Replacement
• PMH: HTN, hyperlipidemia, bruises easily, hypothyroidism, peripheral neuropathy, GERD, depression, consume alcohol almost every day “but not a lot”, denies smoking
• PSH: Right knee arthroscopy, cystoscopy x 2, TURP, left shoulder SLAP repair, No history of problems with anesthesia
Clinical Scenario
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Clinical Scenario
• EKG- NSR with possible LVH and atrial enlargement
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Clinical Scenario
CXR- no acute pulmonary disease, moderate pulmonary hyperinflation, moderate cardiomegaly
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Clinical Scenario
• Bilateral femoral catheters placed for post-op pain control
• Operation was uneventful • Post-op course:
• Day 1: pt slightly agitated, family states that his disposition is normal
• Day 2: pt still agitated, slightly tachycardic, HR 100’s, complaining of headache. Given Ativan, Norco, and Lopressor restarted from home med list. Still agitated when awake but very drowsy, HR decreased to 70’s
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Clinical Scenario
• Post-op course: (cont.)– Day 3: Hallucinating, physical therapy notices a decline
in patient’s coordination. Patient falls during physical therapy is taken back to his room and has a seizure.
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Clinical Scenario
• What happened?
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Presentation Objectives
• Describe effects of chronic alcohol consumption on the brain
• Learn about alcohol withdrawal syndrome and delirium tremens
• Recognize a link between nutrient deficits and neurologic disorders
• Review research comparing prealbumin levels and incidence of delirium tremens
• Understand relevance to a CRNA’s practice
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Statistics
• Nearly 27% of adults (age 18-64) meet the criteria for alcohol dependency (2005, McKinley)
• Medical costs related to alcohol abuse, both acute and chronic, are estimated to be 100 billion dollars a year (2004, Baynard)
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DSM-IV Criteria for alcohol dependence
• At least three out of seven of the following criteria must be manifest during a 12 month period:– Tolerance– Withdrawal symptoms or clinically defined Alcohol Withdrawal
Syndrome– Use in larger amounts or for longer periods than intended– Persistent desire or unsuccessful efforts to cut down on alcohol use– Time is spent obtaining alcohol or recovering from effects– Social, occupational and recreational pursuits are given up or
reduced because of alcohol use– Use is continued despite knowledge of alcohol-related harm
(physical or psychological)
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Possible Long-Term Effects of Alcohol
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Areas of the Brain Affected by Alcohol
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Comparative PET scan (PET=positron emission tomography)
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NMDA Receptors(N-methyl-d-aspartate receptor)
• Excitatory • Neurotransmitter- Glutamate• Blocked by acute ingestion of ETOH• Up-regulated due to chronic consumption of
ETOH
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GABA Receptors (γ-aminobutyric acid receptor)
• Inhibitory• ETOH binds to receptor and increases Cl-
influx• Down- Regulated by chronic ETOH
consumption
• GABA remodeling
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Alcohol Withdrawal Syndrome
• Symptoms develop approximately 48-72 hours following last drink
• Prophylaxis- multivitamins, folic acid, thiamine and low to moderate dose benzodiazepines
• Treatment- high dose benzodiazepines• CIWA- Assessment
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Signs and Symptoms of Alcohol Withdrawal Syndrome
• Agitation/Anxiety• Confusion• Depression• Diaphoresis• Fear• Panic Attacks• Headache• Hyperthermia
• Tachycardia
• Palpitations• Tremors • Weakness• Hypertension• Gastrointestinal Upset
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Delirium Tremens Latin for “shaking frenzy”
• First described in literature approximately 200 years ago
• Most severe form of alcohol withdrawal syndrome
• Exact etiology still unknown• Hypothesized that the sudden decrease in
alcohol unmasks remodeled receptors resulting in an extreme hyper-excitable state
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• Progression from alcoholic withdrawal syndrome
• Severe autonomic instability and hyperactivity• Intense visual disturbances and hallucinations• Severe uncontrolled tremors• Seizures• Mortality is approximately 5% when treated
and 35% untreated
Delirium Tremens
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Isolated Risk Factors for Developing Delirium Tremens
• Presence of infectious disease• Severe tachycardia • Over activity of the nervous
system while patient is still intoxicated
• Previous history of delirium tremens
• Concurrent epileptic disorders and multiple co-morbidities
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Wenicke-Korsakoff Syndrome
• Combination of Wernicke’s encephalopathy and Korsakoff’s psychosis
• Results from a Vitamin B1 (Thiamine) deficiency causing damage in the thalamus and hypothalamus
• Signs and Symptoms:– Ataxia -- Leg tremors– Confusion -- Double vision– Memory loss -- Nystagmus – Hallucinations
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Conceptual Framework
• Evidence based application• Lutz and Przyulski (2006)- Identified the role of
pyridoxine (vitamin B6)• Co-enzyme in the synthesis and catabolism of
amino acids including neurotransmitters • Involved in the metabolism and synthesis of over
100 enzymes• Pyridoxine must be ingested, deficiency is rare in
the general population but common in people with chronic alcohol ingestion
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Nutrition Deficits Associated with Chronic Alcohol Consumption
• Vitamin B– B1 (Thiamine)– B2 (Riboflavin)– B3 (Niacin)– B6 (Pyridoxine) – B12 (Cobalamin)
• Vitamin C• Vitamin D
• Folic Acid• Vitamin K• Vitamin A• Phosphate • Magnesium• Amino Acid/Protein
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Prealbumin (transthyretin)
• Carrier protein esp. (thyroxine and retinol)• Found in blood and CSF• Routinely used to determine nutrition status• Lab value reflects current nutrition status due
to sensitivity of 2-4 days
Half Life (days)
Normal Levels (mg/dL)
Malnutrition (mg/dL)
Mild Moderate Severe
2-4 15.7-29.6 12-15 8-12 < 8
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Statement and Significance of the Problem
• Delirium tremens is an acute—sometimes fatal—psychotic reaction caused by cessation of alcoholic beverages
• Patients who develop delirium tremens have prolonged and complicated hospital stays
• Medical treatments are mostly reactionary, not proactive or preventative
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• Quantitative, descriptive research study
• Retrospective chart review
• Setting 375 bed urban medical center in northwestern Pennsylvania
Research Design
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Sample Demographics
• Out of 464 charts reviewed 24 met the inclusion criteria
• 12 patients who experienced delirium tremors and 12 patients who did not were included
• Each sub-group was comprised of 11 men and 1 woman
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Prealbumin results
Group Range (mg/dL) Mean (mg/dL) Median (mg/dL)
Delirium Tremens 3.9-42.5 17.8 16.1
Non Delirium Tremens
13.3-42.3 27.9 28.2
Overall sample 3.9-42.5 22.5 24.4
Prealbumin levels for the delirium tremens group were on average 10.1 mg/dL lower
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Statistical Analysis
• Analysis using a paired t test found the difference significant at the .001 level
• These findings suggest there is a 99.9% chance that the levels are significantly different
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Limitations
• The sample size was small• Lack of a set diagnosis criteria for Delirium
Tremens• Inability to control extraneous variables • Prealbumin is not a routine lab for patients
with chronic alcohol abuse• Patients with liver disease were not excluded
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Recommendations for Future Research
• Larger Sample size• Prospective study so that variables can be
controlled • Increased exclusion criteria
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Relevance to CRNA Practice
• Identifying risk factors may aide in early identification and proactive treatment
• Elective procedures with subsequent hospital admission could be discouraged d/t increased patient risk
• To assist in differential diagnosis
• To add to a CRNA’s body of knowledge
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Special Thanks:
Dr. Sharon J. Thompson, PhD, RN, MPH Chairperson of Thesis Committee
Krista L.Yoder, MSN, CRNA Program Director/Thesis Committee
Tara Morrison, MSN, CRNA Thesis Committee
Carin Shollenberger, BSN, RN, SRNA co-researcher
Greg McMichael, MSN, SRNAco-researcher
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References
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