DVT Prophylaxis
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Transcript DVT Prophylaxis
Alcohol Withdrawal
Resident Rounds
July 10, 2007
Maggie Gordon, R2
Alcohol Withdrawal
Importance in surgery
Definitions
Pathophysiology
Signs and symptoms
Treatment
Importance in Surgery
Importance
~15% primary care and hospitalized patients
have problem drinking
23% admitted general surgery patients meet
“alcohol abuse” criteria
Early detection and intervention are very
effective
complications
mortality
Importance
Tolerance to anaesthesia, analgesia
physiologic reserve
stress response
morbidity, mortality
ICU, hospital stays
bleeding
infections
Tachycardias, cardiac output
Definitions
At-risk drinking
Men: > 16 drinks / week
Women: > 10 drinks / week
Alcohol Abuse (DSM IV)
Maladaptive use with work / school / social /
interpersonal / legal consequences
At risk of withdrawal
Alcohol Dependence (DSM IV)
Maladaptive use with ≥ 3 of:
At risk of
withdrawal
Tolerance
Withdrawal
Used in larger quantity than intended
Desire to cut down or control use
Time is spent obtaining, using, or recovering
Social, occupational, or recreational tasks are
sacrificed
Use continues despite physical and psychological
problems
Pathophysiology
Pathophysiology
EtOH = CNS depressant
serotonin → tolerance, craving
Withdrawal
GABA → arousal
norepi
Signs and Symptoms
Signs and Symptoms
Spectrum of
Presentation
Severity
Timing
Minor Withdrawal Symptoms
CNS, sympathetic activity:
Insomnia
Mild anxiety
Palpitations
Tremors
Diaphoresis
Headache
GI upset
Anorexia
Onset: 6 – 48 h post
EtOH cessation
Duration: 24 – 48 h
Withdrawal Seizures
Generalized, tonic-clonic
Brief post-ictal period
Single episode, usually
3% → status epilepticus
Risk Factors
Long Hx
Chronic alcoholism
Investigate further
Onset: 2 – 48 h post
EtOH cessation
Alcoholic Hallucinosis
Usually visual, specific hallucinations
Occasionally auditory, tactile
Onset: 12 – 24 h
post EtOH cessation
Duration: 24 – 48 h
No “clouding of
sensorium”
Delirium Tremens
Hallucinations
Disorientation
HR
BP
temperature
Diaphoresis
Agitation
Autonomic instability
Onset: 2 – 4 days
post EtOH cessation
Duration: 1 – 5 days
Delirium Tremens
cardiac output
O2 consumption
cerebral blood flow
Hyperventilation →
Respiratory alkalosis
Risk factors
Long binge
Significant clouding of sensorium
Delirium Tremens
Risk Factors
Sustained drinking
Previous DTs
> 30 y.o.
Concurrent illness
Delayed presentation to medical care /
assessment
Delirium Tremens
5% mortality
Arrhythmias
Complicating illness, e.g. pneumonia
Risk factors for death
age
Pulmonary disease
T > 40°C
Liver disease
Withdrawal Syndromes
Description
Onset (since last EtOH)
Duration
Comments
Minor
Withdrawal
Insomnia
Mild anxiety
Palpitations
Tremors
Diaphoresis
Headache
GI upset
Anorexia
<6h
x 24 – 48 h
Consistent in each patient
Seizures
Generalized
Tonic-clonic
2 – 48 h
3% of chronic alcoholics
Alcoholic
Hallucinosis
Usually visual
Occasionally auditory, tactile
12 – 24 h
x 24 – 48 h
No clouding of sensorium
Delirium
Tremens
Hallucinations
Disorientation
HR
BP
temperature
Agitation
Diaphoresis
2–4d
x1–5d
5% of patients w/
withdrawal
Treatment
Prevention
Pre-op CAGE questionnaire
Have you ever felt the need to Cut down on
drinking?
Have you ever felt Annoyed by criticism of your
drinking?
Have you ever had Guilty feelings about your
drinking?
Do you ever take a morning Eye opener (a drink
first thing in the morning to steady your nerves or
get rid of a hangover)?
Prevention
Consider pre-op
Collateral from family
LET’s
Prevention
Thiamine, folate, multivitamins
Abstinence
Detox and rehab
Referrals
Early prophylaxis, i.e., before symptoms
appear
History First
EtOH use
Hx of withdrawal syndromes, especially
seizures
Physical Exam
Vitals
Tremor
Investigations
Blood work
CBC for Hgb, platelets
LFT’s
CT
LP
Investigations
Rule out and treat
Infection
Trauma
Metabolic derangements
Drug overdose
Liver failure
GI bleeding
Diagnosis of
exclusion
Keys to Therapy
Substitute drug of abuse with long-acting
medication with similar effects, then taper
dose
Keys to Therapy
Reevaluate frequently
Avoid complacency
Alleviate symptoms
Keys to Therapy
Hydrate (dehydration ← diaphoresis, T,
vomiting, HR)
Correct electrolytes
K ( K ← vomiting, aldosterone Δs)
Mg ( Mg → DT risk)
PO4 ( PO4 ← malnutrition)
Therapy
Wernicke’s encephalopathy, Korsakoff’s
syndrome prophylaxis
Thiamine 100 mg im / iv
Folic acid 5 mg po / iv daily x 3 days
Multivitamin 1 tablet po daily x indefinite
Therapy
Benzodiazepines
Diazepam (Valium) 5 – 10 mg po / iv q 5-10 min
Lorazepam (Ativan) 1 – 2 mg po / sl / iv q 5-10 min
liver disease → t½
First dose when CIWA ≥ 8
Titrate until patient “calm, but alert”, i.e. to
CIWA score < 16
May need “massive” doses
CIWA
Therapy
Consider prophylaxis w/out titration
Emergency surgery
Patient unable to communicate
Diazepam 2.5 – 10 mg po / iv q 6 h
Lorazepam 0.5 – 2 mg po / iv q 6 h
Refractory Seizures, DTs
Phenobarbital 130 – 260 mg iv q 15 – 20 min
Propofol 1 mg / kg iv push, intubate, then
titrate to sedation
Long-Term Therapy
Evaluation
Referral to long-term follow-up
No evidence of effectiveness
References
NEJM
UpToDate
UpToDate
Symptom-Oriented Therapy
ICU patients
Flunitrazepam, clonidine, halperidol
Fixed-dose
CIWA-triggered
Withdrawal severity
Worse
Better
Total dose
Greater
Lesser
Days ventilated
Greater
Fewer
Pneumonia
Greater
Fewer
ICU stay
Longer
Shorter
Symptom-Triggered Doses
Detox program
Oxazepam
Fixed-dose
CIWA-triggered
Outcomes
Similar
Total dose
Greater
Lesser
Treatment duration
Greater
Lesser
For Discussion
Indications for ICU Admission
Age > 40 y.o.
Cardiac disease
Hemodynamic instability
Marked acid-base
disturbances
Severe electrolyte
disturbances
Respiratory insufficiency
Potentially serious
infections
GI pathology
Persistent hyperthermia
Rhabdomyolysis
Renal insufficiency
Previous DTs, seizures
Need for high doses of
sedatives, iv therapy
UpToDate