Transcript presentation-07-managing alcohol withdrawal

7: Managing
Alcohol Withdrawal
Prepared by J. Mabbutt & C. Maynard
NaMO
September 2008
7: Managing withdrawal
Objectives
1.
During the session nurses & midwives will learn how to identify,
assess & manage a patient in alcohol withdrawal
2.
By the end of the session nurses & midwives will have an
understanding or use of the AWS/CIWAR-Ar withdrawal scales
3.
At the end the session, nurses & midwives will have a basic
understanding & knowledge to safely & effectively identify, monitor
& manage alcohol withdrawal
7: Managing withdrawal

Effective management of withdrawal in its early stages can
reduce or prevent progression to complicated withdrawal

Complicated withdrawal may be life-threatening due to:

Accidental injury, dehydration, electrolyte imbalance, seizures,
delirium tremens, or the negative impact on other concurrent
disorders, including acute infection, renal disease or diabetes
7: Indications and guidelines:
Assessing withdrawal

Severe alcohol withdrawal is potentially life threatening

The most important thing is to anticipate when it may occur & to suspect
it when an unexplained acute organic brain syndrome is detected

Before continuing to assess alcohol withdrawal, the following information
focuses on a form of brain injury called the Wenicke’s-Korsakoff
syndrome
7: Indications and guidelines:
Complications of misuse –
Wernicke-Korsakoff syndrome (1)

This is a form of brain injury resulting from thiamine deficiency, which
complicates alcohol dependence

If not treated early it can lead to permanent brain damage & memory loss –
young alcohol-dependent people are at risk

Signs & symptoms of Wernicke’s encephalopathy, which is usually
the first stage of the syndrome, are:

Ophthalmoplegia (reduced eye movements or nystagmus)

Ataxia & confusion
7: Indications and guidelines:
Complications of misuse –
Wernicke-Korsakoff syndrome (2)

This condition is reversible if recognised and treated with parenteral vitamin B1

Parenteral thiamine should be administered before any form of glucose

Glucose in the presence of thiamine deficiency risks precipitating
Wernicke’s encephalopathy
7: Indications and guidelines:
Assessing withdrawal – Onset &
duration of alcohol withdrawal (1)

Onset of alcohol withdrawal is usually 6-24 hours after the last drink

Consumption of benzodiazepines or other sedatives may delay the onset of
withdrawal

In some severely dependent drinkers, simply reducing the level of consumption
may precipitate withdrawal, even if they have consumed alcohol recently
7: Indications and guidelines:
Assessing withdrawal – Onset &
duration of alcohol withdrawal (2)

Usually withdrawal is brief & resolves after 2-3 days without treatment;
occasionally, withdrawal may continue for up to 10 days

Withdrawal can occur when the blood alcohol level is decreasing, even
if the patient is still intoxicated
Figure 9.1: Progress of alcohol withdrawal syndrome
7: Indications and guidelines:
Assessing withdrawal – Index for
Suspicion of Alcohol withdrawal (1)

Severity of alcohol withdrawal ranges from mild to severe

The following questions, known as the Index for Suspicion of Alcohol
Withdrawal, will help you determine whether the patient is likely to
move into alcohol withdrawal:

A regular intake of 80 grams (8 drinks-Males) or 60 grams (6 drinks-Females)
of alcohol or more per day?

Taken even smaller amounts of alcohol in conjunction with other CNS
depressants?

Previous episodes of alcohol withdrawal?
7: Indications and guidelines:
Assessing withdrawal – Index for
Suspicion of Alcohol withdrawal (2)

Current admission for an alcohol-related reason?

Physical appearance indicate chronic alcohol use:
– parotid swelling (swelling in the gland under the ear)
– cushingoid face (full/moon looking face)
– facial telangiectasia (red spots/blood vessels)
– eyes reddened or signs of liver disease
– ascites, jaundice, limb muscle wasting
7: Indications and guidelines:
Assessing withdrawal – Index for
Suspicion of Alcohol withdrawal (3)

Pathology results show raised serum GGT

Raised mean cell volume (MCV)

Displaying symptoms such as
– anxiety,
– agitation,
– tremor,
– sweatiness or early morning retching, which
might be due to an alcohol withdrawal syndrome?
7: Indications and guidelines: Signs
& symptoms of alcohol withdrawal (1)

Alcohol withdrawal is a syndrome of central nervous system hyperactivity
characterised by symptoms that range from mild to severe

The symptoms and signs of alcohol withdrawal may be grouped
into three major classes: See Table 9.4
Autonomic overactivity
Gastrointestinal
Cognitive & perceptual changes
Sweating
Anorexia
Anxiety
Tachycardia
Nausea
Vivid dreams
Hypertension
Vomiting
Illusions
Insomnia
Dyspepsia
Hallucinations
Tremor
Delirium
Fever
Table 9.4: Main signs & symptoms of alcohol withdrawal
7: Indications and guidelines: Signs
& symptoms of alcohol withdrawal (2)

Seizures occur in about 5% of patients withdrawing from alcohol

They occur early (usually 7-24 hours after the last drink), are grand mal
in type (i.e. generalised, not focal) & usually (though not always) occur
as a single episode

Delirium tremens (“the DTs”) is rare & is a diagnosis by exclusion

It is the most severe form of alcohol withdrawal syndrome, & a medical
emergency
7: Indications and guidelines: Signs
& symptoms of alcohol withdrawal (3)

DT’s usually develops 2-5 days after stopping or significantly reducing
alcohol consumption

The usual course is 3 days, but can be up to 14 days

Its clinical features are:

Confusion & disorientation

Extreme agitation or restlessness – the patient often requires restraining
7: Indications and guidelines: Signs
& symptoms of alcohol withdrawal (4)

Gross tremor

Autonomic instability (e.g. fluctuations in BP & pulse), disturbance
of fluid balance & electrolytes, hyperthermia

Paranoid ideation, typically of delusional intensity

Distractibility & accentuated response to external stimuli

Hallucinations affecting any of the senses, but typically visual
(highly coloured, animal form)
7: Indications and guidelines:
Alcohol withdrawal scales (1)

The most systematic & useful way to measure the severity of withdrawal
is to use a withdrawal scale

These provide a baseline against which changes in withdrawal severity
may be measured over time

Research shows that the use of scales minimises both under-dosing &
overdosing with benzodiazepines for alcohol withdrawal syndromes
7: Indications and guidelines:
Alcohol withdrawal scales (2)

There has been considerable debate about the application of withdrawal scales

Two different scales, the Alcohol Withdrawal Scale (AWS) and the Clinical
Institute Withdrawal Assessment for Alcohol (revised) (CIWA-Ar) are both are
recommended for use (see Appendices 2 and 3)

Being familiar with the alcohol withdrawal scale used in your local area is a
priority
7: Indications and guidelines:
Alcohol withdrawal scales (3)

Note that withdrawal scales do not diagnose withdrawal, but are merely
guides to the severity of an already diagnosed withdrawal syndrome

The nurse or midwife should re-evaluate the patient to ensure that it is
alcohol withdrawal & not another condition that is being measured,
particularly if the patient does not respond well to treatment
7: Alcohol withdrawal scales
Clinical Institute Withdrawal Assessment
for Alcohol Revised Version (CIWA-Ar) (1)

The CIWA-Ar (see Appendix 2) is a 10-item scale that can be administered
as part of supportive care

Several studies have shown that the CIWA-Ar scale is a valid, reliable &
sensitive instrument for assessing the clinical course of simple alcohol
withdrawal
7: Alcohol withdrawal scales
Clinical Institute Withdrawal Assessment
for Alcohol Revised Version (CIWA-Ar) –
Videos

Video options show either of the following from the CIWA-Ar CD ROM

E5 Using the CIWA-Ar alcohol withdrawal scale (withdrawal symptoms are
demonstrated) (10.37 min)

E8 – A Case study
7: Alcohol withdrawal scales
Clinical Institute Withdrawal Assessment
for Alcohol Revised Version (CIWA-Ar) (2)

This scale allows a quantitative rating (from 0 to 7 with a maximum
possible score of 67) of the following components of withdrawal:

Nausea & vomiting

Tremor

Paroxysmal sweats

Anxiety
7: Alcohol withdrawal scales
Clinical Institute Withdrawal Assessment
for Alcohol Revised Version (CIWA-Ar) (3)

Agitation

Tactile disturbances

Auditory disturbances

Visual disturbances

Headache and fullness in head

Orientation & clouding of sensoria
7: Alcohol withdrawal scales
Clinical Institute Withdrawal Assessment
for Alcohol Revised Version (CIWA-Ar) (4)
Using the CIWA-Ar in presentation to the emergency department:

Monitor the patient hourly for at least 4 hours using the CIWA-Ar

Contact the medical officer or drug & alcohol nurse practitioner for assessment
and monitor hourly if:
– the alcohol score increases by at least 5 points over this 4-hour period, or
– the CIWA-Ar total score reaches 10
7: Alcohol withdrawal scales
Clinical Institute Withdrawal Assessment
for Alcohol Revised Version (CIWA-Ar) (5)
Using the CIWA-Ar for hospitalised patients:

Monitor the patient 4-hourly, using the CIWA-AR, for at least 3 days

If the total score reaches 10, monitor hourly & notify the medical officer
or drug & alcohol nurse practitioner
7: Alcohol withdrawal scales
Alcohol withdrawal scale (AWS) (1)
Alcohol Withdrawal Scale (AWS)

The AWS (see Appendix 3) is a widely used scale in NSW

If a patient’s history or presentation suggests possible withdrawal,
the patient’s condition must be monitored & documented
7: Alcohol withdrawal scales
Alcohol withdrawal scale (AWS) (2)

The AWS (see Appendix 3) is a widely used scale in NSW and is a 7 item
scale that allows a quantitative rating (from 0 to 4) of the following components:

Perspiration

Tremor

Anxiety

Agitation

Axilla temperature

Hallucinations

Orientation
7: Alcohol withdrawal scales
Alcohol withdrawal scale (AWS) (3)
Using the AWS in presentation to the emergency department:

Monitor the patient hourly for at least 4 hours using the AWS

Contact the medical officer or drug & alcohol nurse practitioner for
assessment & monitor hourly if:
– the alcohol score increases by at least 5 points over this 4-hour period, or
– the AWS total score reaches 5
7: Alcohol withdrawal scales
Alcohol withdrawal scale (AWS) (4)
Using the AWS for hospitalised patients:

Monitor the patient 4-hourly, using the AWS, for at least 3 days

If the total score reaches 5, monitor hourly & notify the medical officer
or drug & alcohol nurse practitioner

Depending on the resources of the local area, these may need review
7: Indications and guidelines:
Pharmacological Treatment (1)
From NSW Drug & Alcohol Withdrawal Clinical Practice Guidelines NSW
Health 2007

The most commonly prescribed pharmacological treatment for alcohol
withdrawal is diazepam because of its cross-tolerance with alcohol &
anti-convulsant properties

Two types of regimes for specialist residential or inpatient setting

Diazepam loading regime

Symptom-triggered sedation
7: Indications and guidelines:
Pharmacological Treatment (2)
Diazepam loading regime

On the development of withdrawal symptoms initiate diazepam loading

20mg initially, increasing to 80mg over 4-6 hours

Or until pt is sedated

Medial review required if dose exceeds 80mg & more diazepam can
be ordered depending on withdrawal condition
7: Indications and guidelines:
Pharmacological Treatment (3)
Symptom-triggered sedation

Mild withdrawal CIWA-AR <10 & AWS <4

Supportive care, observations 4 hourly

If sedation necessary; 5-10mg oral diazepam every 6-8 hours for first 48 hrs
7: Indications and guidelines:
Pharmacological Treatment (4)
Symptom-triggered sedation

Moderate withdrawal CIWA-AR 10-20 & AWS <5-14

Medical officer to assess

If alcohol withdrawal confirmed: hourly observations; give 10-20 oral
diazepam immediately; repeat 10mg hourly or 10-20mg 2hrly until the
pt achieves good symptom control (up to a total dose of 80mg)

Repeat medical review after 80mg of diazepam and if pt is not
settling, consider olanzepine (zyprexia) 5-10mg
7: Indications and guidelines:
Pharmacological Treatment (5)
Symptom-triggered sedation

Severe withdrawal CIWA-AR 20+ & AWS 14+

Urgent management. Give a loading dose

Review more frequently until score falls

A rising score indicates a need for more aggressive management
7: Indications and guidelines:
Pharmacological Treatment (6)

Contraindications to diazepam include:
– respiratory failure,
– significant liver impairment,
– possible head injury or cerebrovascular accident – in these situations,
specialist consultation is essential
From NSW Drug and Alcohol Withdrawal Clinical Practice
Guidelines NSW Health 2007
http://www.health.nsw.gov.au/policies/gl/2008/GL2008_011.html