Have you ever wondered how much alcohol a person has to drink and for how long before he or she risks developing a withdrawal syndrome after sudden abstinence?
Have you ever wondered which methods are best to diagnose and quantify the severity of alcohol withdrawal? Have you been uncertain about which strategies can best manage alcohol withdrawal? If you have, then the following discussion and review of the literature should serve as a stimulus to enhance your understanding of the problem and to create effective solutions.
Descriptions of alcohol withdrawal, including delirium tremens DTshave filled the medical literature since the late s. Our understanding of these syndromes grew when Victor and Adams 6 used a naturalistic setting to study patients hospitalized for alcoholism.
Victor and Adams 6 as well as others 78 believed that these symptoms were related to the cessation of alcohol consumption. Several years later, Isbell 9 conducted a classic study on 10 former morphine addicts who had consumed large quantities of alcohol for prolonged periods and then abruptly discontinued their alcohol consumption.
Over the years, a variety of treatments eg, poultice, digitalis, alcohol, chloroform, paraldehyde, chloral hydrate, lumbar punctures, hydrotherapy, electroconvulsive therapy, insulin coma therapy, and morphine have been tried for symptoms of alcohol withdrawal. In the s, lumbar punctures were utilized, in the s, hydrotherapy became a common treatment, and in the s, both electroconvulsive shock therapy and insulin coma therapy were seen as choices for the treatment of alcohol withdrawal.
With the introduction of the phenothiazines in the s, these agents also gained acceptance as a treatment for alcohol withdrawal. InFriedhoff and Zitrin 14 demonstrated that those who received paraldehyde recovered more quickly than did those who received chlorpromazine.
Gruenwald et al 15 determined in that patients with mild-to-moderate symptoms of alcohol withdrawal se sopravvivono dopo delirium tremens to either promazine or triflupromazine, but those with severe symptoms of alcohol withdrawal did not respond as well to either se sopravvivono dopo delirium tremens and often required use of additional sedating medications.
InHart 16 demonstrated that there was no difference in se sopravvivono dopo delirium tremens recovery time for patients treated with promazine and paraldehyde for DTs; however, those with less severe illness recovered faster with paraldehyde. Thomas and Freedman 12 conducted a study in that compared paraldehyde and promazine in the treatment of a continuum of conditions from alcohol withdrawal to DTs.
They studied male patients who were admitted to a state hospital with a diagnosis of alcohol withdrawal or DTs ; these se sopravvivono dopo delirium tremens groups were then divided into treatment groups that received promazine mg q 4—6 h or paraldehyde 10 mL q 4—6 h utilizing a fixed-dosage schedule.
However, promazine nonresponders did poorly 4 developed DTs and 1 died. Those with DTs who were treated with paraldehyde became symptom free in 4 days, while promazine-treated patients had a high mortality rate. InKaim et al 7 evaluated the efficacy and safety of 4 drugs commonly used in the treatment of alcohol withdrawal chlordiazepoxide, chlorpromazine, se sopravvivono dopo delirium tremens, and thiamine ; these agents were matched against placebo for the treatment of alcohol withdrawal and the prevention of seizures and DTs.
Widely used reference manuals have recommended a wide se sopravvivono dopo delirium tremens of treatments for alcohol withdrawal syndrome AWS.
The use of paraldehyde 10 mL q 4 h—10 mL q 2 h and chloral hydrate 0. While no specific treatment for DTs was stated, it was recommended that agitation be managed with environmental cues including keeping the room well lit and avoiding phenothiazines, as the medication class decreases the seizure threshold.
Inthe Massachusetts General Hospital Handbook of General Hospital Psychiatry 19 described the treatment of DTs as being similar to the treatment of other types of delirium; it was advised that the most important intervention included surveillance with constant nursing and that physicians must be aware that these patients are at a high risk for unsafe behaviors including falling from windows and through glass doors.
The chapter author of that text also recommended that restraints be avoided unless absolutely necessary. Another study in compared the use of barbital and diazepam in the treatment of alcohol withdrawal symptoms; barbital was found to be superior to diazepam in the treatment of DTs.
Benzodiazepines with a short half-life eg, oxazepam or lorazepam were recommended for patients with liver disease; however, medications with longer half-lives eg, chlordiazepoxide or diazepam were generally preferred. At present, benzodiazepines are the most commonly used class of medication for the treatment of alcohol withdrawal.
The 4 most commonly used benzodiazepines se sopravvivono dopo delirium tremens diazepam which is characterized by a rapid onset and a long se sopravvivono dopo delirium tremenslorazepam which has an intermediate onset and half-life and an absence of oxidative metabolism in the liverchlordiazepoxide which has an intermediate onset of action and a long half-lifeand oxazepam which has a slow onset, a short half-life, and absence of oxidative metabolism in the liver.
In addition, a few reports have suggested that barbiturates are useful in the treatment of alcohol withdrawal. Ranging from Google Health 26 to WebMD 27 to Wikipedia 28 to the American Academy of Family Physicians, 29 results for information on se sopravvivono dopo delirium tremens withdrawal for patients and their family members come from far and wide.
However, the Internet is not the only source for information concerning alcohol withdrawal and its risks. Many books on alcohol withdrawal have been published. Described as referring to symptoms that may occur when a person who has been drinking too much alcohol every day suddenly stops drinking alcohol, some patients are more susceptible to alcohol withdrawal than are others.
Information regarding risk factors for alcohol withdrawal are readily available to the general public including patients and their family members. Information about the onset of alcohol withdrawal after excessive use followed by abstinence includes its development within 5—10 hours after one's last drink; however, it may not appear until 7—10 days following cessation of use.
The more heavily one drinks, the greater the likelihood that symptoms of alcohol withdrawal will appear once drinking ceases. The likelihood of developing severe withdrawal symptoms also increases if the patient has or experiences other medical problems. When evaluating the treatment se sopravvivono dopo delirium tremens alcohol withdrawal's symptoms, goals range from the immediate to the long term.
The most pressing goal is to treat the withdrawal symptoms in a timely fashion; thereafter, one needs to prevent complications of alcohol withdrawal and to begin long-term therapy to promote and ensure abstinence so that the patient does not drink in the future. The information available to the general public reflects the fact that in most cases, the patient should stay at the hospital or in an inpatient facility for constant observation that will include, but is not limited to, the monitoring of blood pressure, body temperature, breathing, and heart rate, as well as fluid and electrolyte levels.
The Internet informs readers that a variety of treatments are available and may consist of sedating the patient moderately for over a week until withdrawal has completely run its course. Testing for and treatment of various other medical problems associated with alcohol use including liver disease, blood clots, brain and heart disorders, malnutrition, and nerve damage are both recommended se sopravvivono dopo delirium tremens necessary.
The best long-term treatment for those who have undergone alcohol withdrawal is lifelong abstinence, which can be aided by rehabilitation involving social, as well as medical, support. In the short term, alcohol intake depresses the inhibitory centers of the cerebral cortex resulting in early symptoms of intoxication eg, euphoria, exaggerated feelings se sopravvivono dopo delirium tremens well-being, ataxia, loss of self-control, and dose-dependent sedation. Se sopravvivono dopo delirium tremens the case of habituated individuals, abstinence from alcohol leads to se sopravvivono dopo delirium tremens rebound stimulatory effect and increased excitability of the nervous system eg, with enhanced NMDA receptor function, dysregulation of the dopaminergic system, and reduced GABAergic se sopravvivono dopo delirium tremens.
These changes inhibit the sensitivity of the autonomic adrenergic system with a resulting receptor se sopravvivono dopo delirium tremens and adrenergic hypersensitivity. Studies have shown a significant decrease in hypothalamic NE levels 1 hour after a single dose of se sopravvivono dopo delirium tremens. In fact, chronic alcohol intake led to acceleration in the turnover of central and some peripheral NE-containing neurons eg, in the heart and in the adrenal medulla.
Animal studies have also confirmed that alcohol administered as either an acute or chronic dose affects both central and peripheral NE neurons and the adrenal medulla.
The animals were then sacrificed 10, 30, 60,or minutes later. At every interval, the labeled NE was found at a higher level in the alcohol group, suggesting that the synthesis of NE was higher in the ethanol-treated rats.
The rate of release of 3H-NE also appeared to be higher in these animals, since the accumulation of 3H-metabolites was also significantly greater. Since the synthesis of NE controlled mainly by the activity of tyrosine hydroxylase 47 was increased, tyrosine hydroxylase activity in the brain was probably higher in rats exposed chronically to ethanol; this leads to higher levels of 3H-NE metabolite by-products.
In fact, cerebrospinal fluid Se sopravvivono dopo delirium tremens concentrations of 3-methoxyhydrophenylglycol MHPG were markedly elevated during acute alcohol intoxication and successively declined during 1 and 3 weeks of abstinence.
Dexmedetomidine is a lipophilic imidazole derivative approved by the US Food and Drug Administration in for sedation in the intensive care setting. Clonidine has been efficacious in managing the physical eg, elevated heart rate and blood pressure as well as the psychological eg, anxiety symptoms associated with alcohol withdrawal. For example, Baumgartner and associates 53 randomly assigned 50 adults experiencing AWS to receive either prophylactic chlordiazepoxide or transdermal clonidine Catapres patch.
They found that no patient in either group developed seizures or progressed to DTs. Yet, the group that received clonidine had a better overall response to medical therapy as assessed by the Alcohol Withdrawal Assessment Scalewere less anxious as assessed by the Hamilton Anxiety Rating Scaleand had lower heart rates and blood pressure readings.
Finally, patients who received diazepam were more likely to develop tachycardia and an elevated blood pressure 24 to 72 hours after surgery; whereas, none of the clonidine-treated patients manifest a hyperdynamic circulatory reaction. Unfortunately, there are less data on the use of dexmedetomidine in alcohol withdrawal; this may be more a function of how new and expensive this agent is than of its efficacy.
However, Riihioja and colleagues 61 — 64 have demonstrated that dexmedetomidine effectively controls alcohol withdrawal in laboratory animals. Numerous case reports of dexmedetomidine's efficacy for management of severe alcohol withdrawal exist; typically, these are cases that have failed more conventional management strategies eg, use of benzodiazepines.
To date, no randomized clinical trials have been published on the use of dexmedetomidine for treatment of AWS; however, 3 abstracts containing case series were presented at the American Society of Anesthesiology on the potential of this drug in AWS. The first by Cooper and colleagues 71 presented a case series of 64 patients collected over a 6-month period; all had a history of heavy alcohol use and were admitted for elective surgical procedures.
Of these, 8 patients In an attempt to control heart rate, blood pressure, and agitation, each patient underwent and failed an IV lorazepam trial 2—4 mg every 6 h. Then, dexmedetomidine was initiated via a 1. None of the patients required adjunctive support of their airway, had a decrease in O 2 saturation, or required endotracheal intubation. No complications were noted, and dexmedetomidine was weaned slowly after 48 hours without signs or symptoms of further withdrawal.
Prieto and coworkers' 72 case series was se sopravvivono dopo delirium tremens on a retrospective review of medical-surgical patients with AWS during a 4-year period — treated with dexmedetomidine after failure to respond to benzodiazepine treatment. Kandiah and colleagues 73 reported on the use of dexmedetomidine in 7 critically ill patients who failed a trial of IV benzodiazepines.
Their results suggested that se sopravvivono dopo delirium tremens and autonomic control was achieved within 2 hours of the initiation of dexmedetomidine. None of the patients developed seizures. Patients were extubated while taking dexmedetomidine, and its discontinuation was not associated with recurrence of AWS. Dexmedetomidine has been found to be an excellent alternative for sedation in ICU settings, and studies se sopravvivono dopo delirium tremens its use has been associated with a significant reduction in the development of postoperative withdrawal.
The first clinical trial of propofol an alkyl phenol administered intravenously was conducted in by Kay and Rolly 78 and established the potential benefit of propofol as an anesthetic induction agent. Although a variety of agents act in a similar fashion at the benzodiazepine-barbiturate-alcohol receptor and are cross-reactive with alcohol, benzodiazepines have become the cornerstone of therapy for AWS.
Several of se sopravvivono dopo delirium tremens properties account for its efficacy in severe complicated alcohol withdrawal and DTs. Propofol appears to have less cross-tolerance than benzodiazepines, is easily titratable, and is rapidly cleared from the body. Case series have described the use of propofol in treatment-refractory AWS.
McCowan and Marik 88 described 4 patients with AWS initially and inadequately treated with escalating doses of benzodiazepines. These patients improved ie, they achieved autonomic stability and became calm with subsequent treatment se sopravvivono dopo delirium tremens propofol.
Subramaniam and colleagues 90 described 3 se sopravvivono dopo delirium tremens with AWS refractory to benzodiazepines alone; however, they were treated successfully with addition of propofol. Propofol distributes rapidly throughout the body, including the CNS; its pharmacokinetic profile is best described by a 3-compartment model. In phase 2, there is rapid metabolic clearance from the blood, with a half-life of 34 to 56 minutes.
In phase 3, there is a slow return of the drug from poorly perfused tissue compartments into the bloodstream, with an mean half-life of se sopravvivono dopo delirium tremens hours. Numerous clinical trials and published reports have described the use of ethanol for the prevention and treatment of alcohol withdrawal. They studied alcohol-dependent patients undergoing resection of upper gastrointestinal carcinomas and randomly assigned them to 1 of 4 prophylactic treatment regimens: flunitrazepam-clonidine, chlormethiazole-haloperidol, flunitrazepam-haloperidol, or ethanol.
The investigators found no difference between the groups with respect to the development of AWS and detected no significant se sopravvivono dopo delirium tremens in the length of stay in se sopravvivono dopo delirium tremens ICU or in the frequency of complications. Large variability exists in the quality of the methodology including doses used and monitoring of blood alcohol concentrations as well as the results regarding use of IV ethanol.
Goal blood level concentrations have ranged from undetectable in asymptomatic patients to maintaining a state of intoxication with concentrations of 0.
Due to ethanol's pharmacokinetic profile and its relatively narrow therapeutic index, its use has not been advised in critically ill se sopravvivono dopo delirium tremens.
Therapeutic serum levels of alcohol with this method have not been established, although levels would be expected to vary among patients given differences in patients' alcohol histories. Patients should not be discharged from the hospital less than 24 hours after discontinuation of the infusion to allow the metabolism and excretion of ethanol and to ensure that relapse with autonomic instability from re-emerging se sopravvivono dopo delirium tremens withdrawal does not develop.
Since clinicians working at the bedside must collaborate on the identification and treatment of alcohol withdrawal as well as on safety interventions and interpersonal management of the confused patientstrategies to improve both knowledge and skills are sorely needed.
Overlapping symptoms of alcohol withdrawal, se sopravvivono dopo delirium tremens from other causes, dementia, and comorbid conditions can contribute to diagnostic errors. Teaching should target nurses, medical students, residents, and faculty from medical and surgical specialties. Traditional models of education have included lectures, reading materials, 232466— and bedside rounds that se sopravvivono dopo delirium tremens a breadth of opportunities to hone individual skills.