Background/Purpose: In the United States, 2 to 7% of heavy alcohol users admitted to the hospital for general medical care will develop severe alcohol withdrawal (AW) requiring treatment. The most dangerous complications of AW are delirium tremens and seizures. Benzodiazepines (BZD) are considered first-line therapy, with varying modality options available to providers. Fixed-dosing has historically been used to manage AW. However, studies suggest that symptom-triggered therapy (STT) can decrease length of stay and BZD duration of therapy. The purpose of this study was to evaluate the current fixed-dose protocol and outline the transition to STT in the intensive care unit (ICU) at South Miami Hospital.
Methodology: This was a retrospective chart review of patients treated for AW with a fixed-dose BZD protocol at South Miami Hospital. Data was obtained from November 2017 through December 2019. Patients were included if they were admitted to the ICU and underwent treatment for AW with chlordiazepoxide or lorazepam (intravenous or oral). Patients were excluded if age less than 18 years, pregnant, or with an allergy to BZD. Primary outcomes included amount of BZD(s) used, duration of BZD therapy, and time to symptom control. The secondary objectives were incidence of adverse drug reactions (ADR) and length of stay in the critical care unit.
Results: A total of 90 patients were reviewed, with 46 patients meeting inclusion criteria. Median chlordiazepoxide use was determined to be 75 mg daily. Sixty-five percent of patients received BZD therapy while asymptomatic, 26% continued BZDs after symptoms were controlled, and 9% used BZDs for the same duration as symptoms. The average duration of BZD therapy was 5.4 days, while time to symptom control was 4.25 days. BZD-related ADRs occurred in 46% of patients. In patients that experienced an ADR, 42% were receiving BZDs while asymptomatic or after symptoms were controlled. The length of stay in the ICU was 3 days, following which a majority of patients were transferred to a medical floor. Additional findings included 21% use of the AW PowerPlan and 30% use of the Clinical Institute Withdrawal Assessment of Alcohol Scale Revised (CIWAR-Ar). As a result, the institution will be transitioning to STT for the management of AW. The BZD of choice will be lorazepam and nurses will monitor response to therapy. The escalation or de-escalation of therapy will be based on predetermined parameters, taking into account the patient’s presentation and scale score.
Conclusions: The current fixed-dose protocol led to patients receiving unnecessary treatment for AW and consequently, a large percentage of patients experienced an ADR. Areas for improvement for appropriate patient monitoring were identified, given the lack of use of the AW PowerPlan and poor documentation of CIWA-Ar scores
