Download DVT Prophylaxis

Alcohol Withdrawal
Resident Rounds
July 10, 2007
Maggie Gordon, R2
Alcohol Withdrawal
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Importance in surgery
Definitions
Pathophysiology
Signs and symptoms
Treatment
Importance in Surgery
Importance
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~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
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 complications
 mortality
Importance
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Tolerance to anaesthesia, analgesia
 physiologic reserve
 stress response
 morbidity, mortality
 ICU, hospital stays
 bleeding
 infections
Tachycardias,  cardiac output
Definitions
At-risk drinking
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Men: > 16 drinks / week
Women: > 10 drinks / week
Alcohol Abuse (DSM IV)
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Maladaptive use with work / school / social /
interpersonal / legal consequences
At risk of withdrawal
Alcohol Dependence (DSM IV)
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Maladaptive use with ≥ 3 of:
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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
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EtOH = CNS depressant
 serotonin → tolerance, craving
Withdrawal
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 GABA →  arousal
 norepi
Signs and Symptoms
Signs and Symptoms
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Spectrum of
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Presentation
Severity
Timing
Minor Withdrawal Symptoms
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 CNS, sympathetic activity:
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Insomnia
Mild anxiety
Palpitations
Tremors
Diaphoresis
Headache
GI upset
Anorexia
Onset: 6 – 48 h post
EtOH cessation
Duration: 24 – 48 h
Withdrawal Seizures
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Generalized, tonic-clonic
Brief post-ictal period
Single episode, usually
3% → status epilepticus
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Risk Factors
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Long Hx
Chronic alcoholism
Investigate further
Onset: 2 – 48 h post
EtOH cessation
Alcoholic Hallucinosis
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Usually visual, specific hallucinations
Occasionally auditory, tactile
Onset: 12 – 24 h
post EtOH cessation
Duration: 24 – 48 h
No “clouding of
sensorium”
Delirium Tremens
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Hallucinations
Disorientation
 HR
 BP
 temperature
Diaphoresis
Agitation
Autonomic instability
Onset: 2 – 4 days
post EtOH cessation
Duration: 1 – 5 days
Delirium Tremens
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 cardiac output
 O2 consumption
 cerebral blood flow
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Hyperventilation →
Respiratory alkalosis
Risk factors
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Long binge
Significant clouding of sensorium
Delirium Tremens
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Risk Factors
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Sustained drinking
Previous DTs
> 30 y.o.
Concurrent illness
Delayed presentation to medical care /
assessment
Delirium Tremens
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5% mortality
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Arrhythmias
Complicating illness, e.g. pneumonia
Risk factors for death
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 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
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Pre-op CAGE questionnaire
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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
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Consider pre-op
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Collateral from family
LET’s
Prevention
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Thiamine, folate, multivitamins
Abstinence
Detox and rehab
Referrals
Early prophylaxis, i.e., before symptoms
appear
History First
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EtOH use
Hx of withdrawal syndromes, especially
seizures
Physical Exam
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Vitals
Tremor
Investigations
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Blood work
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CBC for Hgb, platelets
LFT’s
CT
LP
Investigations
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Rule out and treat
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Infection
Trauma
Metabolic derangements
Drug overdose
Liver failure
GI bleeding
Diagnosis of
exclusion
Keys to Therapy
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Substitute drug of abuse with long-acting
medication with similar effects, then taper
dose
Keys to Therapy
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Reevaluate frequently
Avoid complacency
Alleviate symptoms
Keys to Therapy
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Hydrate (dehydration ← diaphoresis,  T,
vomiting,  HR)
Correct electrolytes
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K ( K ← vomiting, aldosterone Δs)
Mg ( Mg →  DT risk)
PO4 ( PO4 ← malnutrition)
Therapy
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Wernicke’s encephalopathy, Korsakoff’s
syndrome prophylaxis
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Thiamine 100 mg im / iv
Folic acid 5 mg po / iv daily x 3 days
Multivitamin 1 tablet po daily x indefinite
Therapy
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Benzodiazepines
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Diazepam (Valium) 5 – 10 mg po / iv q 5-10 min
Lorazepam (Ativan) 1 – 2 mg po / sl / iv q 5-10 min
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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
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Consider prophylaxis w/out titration
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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
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Phenobarbital 130 – 260 mg iv q 15 – 20 min
Propofol 1 mg / kg iv push, intubate, then
titrate to sedation
Long-Term Therapy
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Evaluation
Referral to long-term follow-up
No evidence of effectiveness
References
NEJM
UpToDate
UpToDate
Symptom-Oriented Therapy
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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
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Detox program
Oxazepam
Fixed-dose
CIWA-triggered
Outcomes
Similar
Total dose
Greater
Lesser
Treatment duration
Greater
Lesser
For Discussion
Indications for ICU Admission
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Age > 40 y.o.
Cardiac disease
Hemodynamic instability
Marked acid-base
disturbances
Severe electrolyte
disturbances
Respiratory insufficiency
Potentially serious
infections
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GI pathology
Persistent hyperthermia
Rhabdomyolysis
Renal insufficiency
Previous DTs, seizures
Need for high doses of
sedatives, iv therapy
UpToDate