Effect of early and focused benzodiazepine therapy on length of stay in severe alcohol withdrawal syndrome

Objective: Current evidence supports symptom-triggered therapy for alcohol withdrawal syndrome (AWS). Early, escalating therapy with benzodiazepines (BZD) appears to decrease ICU length of stay (LOS); however, the effect on hospital LOS remains unknown. The hypothesis of this study is that focused BZD treatment in the first 24?h will decrease hospital LOS.

Design: Pre–post cohort study.

Setting: Academic medical center.

Patients: This study included patients with severe AWS. The pre-intervention cohort (PRE) was admitted between January and November 2015. The post-intervention cohort (POST) was admitted between April 2016 and March 2017. Severe AWS was defined as patients requiring diazepam doses of >30?mg. Focused treatment was defined as >50% of total diazepam usage within the first 24?h of recognition of AWS.

Intervention: In the PRE group, patients received symptom-triggered, escalating doses of diazepam and phenobarbital based on their Richmond Agitation-Sedation Scale (RASS). In the POST group, patients received a revised, time-limited course of therapy: escalating doses of BZD and phenobarbital were given during a 24-h loading phase, and all therapy was discontinued after a 72-h tapering phase. The SHOT scale was used as an adjunct to RASS to assess non-agitation symptoms of AWS and guide additional diazepam doses.

Measurements and main results: The primary outcome was hospital LOS; secondary outcomes included ICU LOS, BZD use, and ventilator-free days. Five hundred thirty-two patients were treated using the AWS protocol; 113 experienced severe AWS. The PRE (n?=?75) and POST (n?=?38) groups were evenly matched in age, sex, history of AWS, and severity of illness. There was a substantial difference in POST patients who received focused treatment (51.3% vs. 73.7%, p?=?.03). The POST group had a significant decrease in hospital LOS (14.0 vs. 9.8 days, p?=?.03) and ICU LOS (7.4 vs. 4.4 days, p?=?.03).

Conclusion: Early, focused management of severe AWS was associated with a decrease in ICU and hospital LOS.     

Nicotine dependence criteria and nicotine withdrawal symptoms in relation to pain among an adult general population sample

Background: Evidence has shown that people who have smoked at any point in life have a higher probability of pain than those who have never smoked. The goal of this study was to analyze whether there are associations between nicotine dependence including nicotine withdrawal with pain and the number of pain locations. Methods: Data stems from a cross‐sectional survey study with a probability sample of residents of a northern German area with 4075 study participants, aged 18–64 years (participation rate 70.2%). Face‐to‐face in‐home computer‐aided interviews (Composite International Diagnostic Interview) were used to assess single pain locations, the diagnostic criteria of nicotine dependence, alcohol dependence, depressive, and anxiety disorders according to the Diagnostic and Statistical manual of the American Psychiatric Association (DSM‐IV). Results: Ever smokers with three or more nicotine dependence criteria after controlling for alcohol dependence, depressive, anxiety disorders, age and gender revealed an odds ratio (OR) of 4.2 (95% confidence interval, CI, 2.0–9.0) compared to ever smokers without nicotine dependence criteria, and ever smokers with four or more nicotine withdrawal symptoms displayed an OR of 3.6 (CI 1.5–8.7) compared to ever smokers who had not experienced withdrawal symptoms. Current smokers who used 20 or more cigarettes per day had an OR of 0.5 (CI 0.3–0.8) of experiencing pain in three or more locations compared to former smokers. Conclusion: Nicotine dependence criteria are associated with a higher probability of pain than having no nicotine dependence criteria in this general population sample.     

Increased pain sensitivity in alcohol withdrawal syndrome

Withdrawal from analgesic and addictive substances such as opioids or ethanol is associated with increased sensitivity to sensory stimulation in animal models. Here, we investigated perception of innocuous and noxious thermal or electric stimuli applied to the left hand or sternum in 30 male patients undergoing withdrawal from alcohol, 30 male abstained alcoholics and matched controls. The alcohol withdrawal scale and the Banger score were obtained to estimate the severity of withdrawal. In addition, the Beck depression inventory was used to estimate the influence of depressive symptoms on pain perception. The data presented provide substantial evidence that subjects undergoing alcohol withdrawal show increased heat pain sensitivity. Interestingly, this effect was observed both on the left hand and sternum. Pain thresholds and tolerances of electric stimuli did not differ between groups. However, in a subgroup analysis, a higher sensitivity for electrical pain thresholds and tolerances was observed in those patients that were identified to require pharmacological treatment for withdrawal according to disease severity. Furthermore, the perceived painful thermal and electrical sensation was substantially influenced by the affective state of patients. No differences were found between patients of the abstained group and control subjects for any pain parameter. In conclusion, we demonstrate withdrawal‐induced hyperalgesia upon thermal stimulation in patients. Since the influence of affective symptoms on pain perception during withdrawal is remarkable, we assume that peripheral and central mechanisms might account for this finding, which should be assessed in detail in future studies.     

Nursing implications of alcohol withdrawal in the postoperative orthopaedic patient

Early assessment and identification of patients experiencing alcohol withdrawal (AWD) in the postoperative period can be crucial to the outcomes for the orthopaedic patient. Accurate and swift identification of patients experiencing AWD can impact mortality, morbidity and length of stay in the postoperative period. This article follows a case study involving a postoperative right Total Knee Arthroplasty patient, outlines the current perceptions on pathophysiology and offers guidelines for prevention and interventions. The purpose is to increase the nurse’s knowledge and understanding of AWD and related safety issues in the hospitalised postoperative orthopaedic patient.     

食管癌术后继发酒精戒断综合征的综合护理

目的探讨21例食管癌术后继发酒精戒断综合征的护理方法,以期提高疾病治愈的成功率。方法 2010年1月~2014年10月本科共行食管癌手术961例,术后1~5 d出现不同症状的酒精戒断综合征共21例。除给予食管癌术后常规护理以外更侧重于患者的心理护理、安全管理及管道护理为主的综合性护理。结果 21例患者经治疗护理后均预期康复出院,出院随访完全戒酒率为89.3%,生活质量得到提高。结论手术继发酒精戒综合征患者通过早期发现戒断症状,经合理有效的围手术期处理,重视各环节综合护理,可促进患者术后早日康复。     

Influence of dexmedetomidine therapy on the management of severe alcohol withdrawal syndrome in critically ill patients

Purpose

Although benzodiazepines are first-line drugs for alcohol withdrawal syndrome (AWS), rapidly escalating doses may offer little additional benefit and increase complications. The purpose of this study was to evaluate dexmedetomidine's impact on benzodiazepine requirements and hemodynamics in AWS.

Materials and Methods

This retrospective case series evaluated 33 critically ill adults with a primary diagnosis of AWS from 2006 to 2012 at an academic medical center.

Results

Dexmedetomidine began a median (interquartile range) of 11 (2, 32) hours into intensive care unit admission and was titrated to an infusion rate of 0.7 (0.4, 0.7) μg kg^− 1 h^− 1 to achieve the desired depth of sedation. In the 12 hours after dexmedetomidine began, patients experienced a 20-mg reduction in median cumulative benzodiazepine dose used (P < .001), a 14-mm Hg lower mean arterial pressure (P = .03), and a 17-beats/min reduction in median heart rate (P < .001). Four (12%) patients experienced hypotension (systolic blood pressure < 80 mm Hg) during therapy, and there were no cases of bradycardia (heart rate < 40 beats/min).

Conclusion

Dexmedetomidine decreased benzodiazepine requirements and improved the overall hemodynamic profile of patients with severe AWS. These results provide promising evidence about the potential benefit of dexmedetomidine for AWS.     

酒精性肝病患者酒精戒断综合征的中医护理

目的：探讨酒精性肝病患者酒精戒断综合征的中医护理方法和效果。方法：综合运用护理评估、心理护理、健康教育、结合辨证药膳的饮食调护。结果：患者均能以积极的心态和行为应对、减轻、克服戒断症状带来的负性心理情绪反应,减轻患者“心病发作”,提高戒酒成功率。结论：采取积极有效的中医护理干预措施,对减轻戒断症状的不适感是有效的。     

Acute diarrhea-induced shock during alcohol withdrawal: a case study

We present the case of a 54-year-old man with severe acute diarrhea during alcohol withdrawal, despite special feeding, correction of vitamin deficiencies, and protection of the gastrointestinal mucosa. Diarrhea is often overlooked, so we aim to draw attention to the risk of combined malnutrition, acute diarrhea, and alcohol withdrawal because this can lead to lethal complications. We recommend that patient’s bowel movements should be carefully observed during alcohol withdrawal, even during hospitalization.     

Alcohol withdrawal severity is decreased by symptom-orientated adjusted bolus therapy in the ICU

Objective To examine the effect of bolus vs. continuous infusion adjustment on severity and duration of alcohol withdrawal syndrome (AWS), the medication requirements for AWS treatment, and the effect on ICU stay in surgical intensive care unit (ICU) patients.Design and setting Prospective randomized, double-blind controlled trial in a surgical ICU.Patients 44 patients who developed AWS after admission to the ICU.Interventions Patients were randomized to either (a) a continuous infusion course of intravenous flunitrazepam (agitation), intravenous clonidine (sympathetic hyperactivity), and intravenous haloperidol (productive psychotic symptoms) if needed (infusion-titrated group), or (b) the same medication (flunitrazepam, clonidine, or haloperidol) bolus adjusted in response to the development of the signs and symptoms of AWS (bolus-titrated group).Measurements and results The administration of as-needed medication was determined using a validated measure of the severity of AWS (Clinical Institute of Withdrawal Assessment). Although the severity of AWS did not differ between groups initially, it significantly worsened over time in the infusion-titrated group. This required a higher amount of flunitrazepam, clonidine, and haloperidol. ICU treatment was significantly shorter in the bolus-titrated group (median difference 6 days) due to a lower incidence of pneumonia (26% vs. 43%).Conclusions We conclude that symptom-orientated bolus-titrated therapy decreases the severity and duration of AWS and of medication requirements, with clinically relevant benefits such as fewer days of ventilation, lower incidence of pneumonia, and shorter ICU stay.Electronic Supplementary Material Supplementary material is available in the online version of this article .This study was sponsored in part by the German Research Society (DFG-SP 432/1-1 and 1-2)     

The role of carbamazepine and oxcarbazepine in alcohol withdrawal syndrome

Objective: The goal of this review is to evaluate the efficacy and safety of carbamazepine and oxcarbazepine in treatment of alcohol withdrawal syndrome (AWS) and determine the role in therapy of both agents. Methods: Relevant literature was identified through a search of MEDLINE (1966–June 2008), PubMed (1966–June 2008); Cochrane database was performed to identify English‐language publications. Search terms included carbamazepine, oxcarbazepine, AWS, alcoholism, substance syndrome withdrawal. Results: In seven studies, including 612 patients, carbamazepine demonstrated significant reduction in alcohol withdrawal scores. However, in comparative trials with a benzodiazepine agent, carbamazepine’s ability to prevent alcohol withdrawal seizures (OR = 0·93; 95% CI = 0·06–14·97, P = NS) and delirium tremens (DTs; OR = 1·25; 95% CI = 0·28–5·64, P = NS) was uncertain as a result of insufficient patient enrolment. In three trials, carbamazepine failed to reduce alcohol withdrawal symptoms possibly as a result of delayed administration, inadequate dosage or inadequate sample size. At daily doses of 800 mg either fixed or tapered over 5–9 days, carbamazepine was well tolerated, and safely administered when blood alcohol concentration dropped below 0·15%. The role of oxcarbazepine in AWS is undefined because of inconsistent findings in two trials. Conclusion: Carbamazepine has demonstrated safety, tolerability and efficacy in treatment of moderate to severe symptoms of alcohol withdrawal in the inpatient setting. However, trials of carbamazepine provide inconclusive evidence for prevention of alcohol withdrawal seizures and DTs in comparison with benzodiazepines. Benzodiazepines remain the primary treatment of moderate to severe AWS.     

小组心理护理对酒依赖患者戒断症状和心理渴求的影响

目的:探讨小组心理护理对酒依赖患者戒断症状和心理渴求的影响。方法:将48例酒依赖患者随机分为研究组和对照组各24例,均给予戒酒科常规治疗和护理,研究组同时给予小组心理护理。分别于入院时、入院后4周进行酒精戒断状态评定量表(AWS)和饮酒迫切性量表(AUQ)的测试。结果:重复测量的方差分析发现,时间因素对精神症状、植物神经症状和心理渴求分数均存在主效应(P<0.01);干预因素对精神症状和心理渴求分数存在主效应(P<0.05,P<0.01),对植物神经症状分数无明显主效应(P>0.05);干预因素和时间因素对精神症状和心理渴求分数存在交互作用(P<0.05,P<0.01)。逐步回归分析发现,酒精戒断后精神症状减少值受干预前精神症状和心理护理干预的影响(P<0.01),植物神经症状减少值受干预前植物神经症状和饮酒时间的影响(P<0.05,P<0.01),心理渴求减少值受干预前心理渴求、心理护理干预和饮酒时间的影响(P<0.01)。结论:小组心理护理能明显减轻酒依赖患者的戒断性精神症状和心理渴求症状,且干预前症状和饮酒时间可影响戒断症状和心理渴求的改善程度。     

尼古丁替代治疗联合心理行为干预对辅助戒烟的作用

目的:探讨尼古丁替代治疗联合心理行为干预对戒烟的临床效果。方法:随机选择60例符合试验要求的吸烟者,每天吸烟23.03±9.42支,FTP评分7.0±1.9,随机分成两组,一组进行单纯尼古丁替代治疗(NRT),另一组进行尼古丁替代治疗联合心理行为干预进行戒烟。结果:NRT辅助戒烟7周自述总戒断率约为58%。NRT联合心理行为干预治疗时7周及12周戒断率(分别为64%、52%)明显高于单纯NRT组(分别为52.17%、34.78%)(P<0.05)。NRT联合心理行为干预治疗组12周时复吸率(25%)明显低于单纯NRT组(33.33%)。而两组间NRT使用量、戒断症状、体重增加无明显差异(P>0.05)。结论:NRT辅助戒烟方式是安全且有效的,尼古丁替代治疗联合心理行为干预临床戒烟成功率更高。     

Nurse practitioner alcohol intervention for people with viral hepatitis: Randomised controlled trial

BackgroundIn Australia, alcohol use is accountable for 5.1% of the total burden of disease and injury along with being responsible for 24% of the burden as a result of chronic liver disease. There is a paucity of quality evidence-based programmes for alcohol use management and the chronic viral hepatitis population.AimsTo evaluate the effectiveness of an alcohol brief intervention for ambulatory patients with chronic viral hepatitis C attending a hepatology clinic.MethodsA randomised controlled trial determined the effectiveness of: a brief intervention and routine care (Group 1) compared to routine care only (no formalised intervention) (Group 2). Alcohol reduction is the primary outcome measure. Reduction in risky drinking and quality of life were also measured. Data was collected at three-time points, baseline prior to randomisation, four weeks and eight weeks.FindingsAlcohol intake reduced in both groups at 4 weeks, with 57% (intervention) and 41% (control) having a 50% reduction in alcohol (p = 0.295). This reduction was maintained by both groups at 8 weeks with 53% (intervention) and 43% (control) (p = 0.536). The intervention group showed a greater reduction over time, but this was not statistically significant.DiscussionIncreasing nurse led models of care, such as nurse practitioners specialising in hepatology, could provide an effective response for managing people with chronic viral hepatitis C and alcohol misuse.ConclusionAssessing for alcohol use using the AUDIT C and TLFB_A and providing a brief intervention with routine care by the Nurse Practitioner, Hepatology is an acceptable and useful intervention to reduce alcohol consumption in this population.     

Discontinuance of Life Sustaining Treatment Utilizing Ketamine for Symptom Management

We present the case of an otherwise healthy 21-year-old female who developed severe respiratory failure following a minor procedure requiring ECMO and bi-level ventilation. During her protracted ICU course, she had significant difficulties with agitation and was titrated to the following regimen: hydromorphone 30 mg/hour, fentanyl 200 mcg/hour, dexmedetomidine 1.5 mcg/kg/hour, propofol at 70 mcg/kg/min, and midazolam at 20 mg/hour. We were consulted to assist in withdrawal of life prolonging measures at the family's request and given high doses of commonly used opioid and sedative medications successfully utilized methadone and ketamine for symptom control. This case study would indicate that in selected patients on high dose opioid and sedative medications prior to withdrawal of life prolonging measures ketamine may be considered for symptom management.     

Genetics of alcohol and tobacco use in humans

The field of genetics holds great promise for furthering our understanding of the etiology of drug dependence and for identifying novel targets for treatment. Genetic studies utilizing twins and families have demonstrated a considerable role for genetics in nicotine and/or alcohol dependence. Risk for alcoholism or nicotine dependence is likely to be the result of a large number of genes, each contributing a small fraction of the overall risk. While this review will focus on studies in humans, many of the candidate genes for human nicotine and alcohol dependence listed here were originally postulated to be important, based on data from animal studies. The review will briefly summarize the results from twin and adoption studies that provide estimations of heritability, the results from chromosomal linkage studies that identify regions of chromosomes that may contain relevant genes, and the results of candidate gene studies. For each topic the data will be presented for nicotine dependence, alcohol dependence, and for nicotine and alcohol dependence together. In addition, each section will review briefly some of the confounding issues in the specific type of approach utilized.     

Drug-induced headache: long-term results of stationary versus ambulatory withdrawal therapy

Drug-induced headache is a well-known complication of the treatment of primary headache disorders, and its successful management is only possible by withdrawal therapy. However, it is unknown whether ambulatory or stationary withdrawal is the therapy preferred. We conducted a prospective study on the outcome of stationary versus ambulatory withdrawal therapy in patients with drug-induced headache according to the International Headache Society criteria. Out of 257 patients with the diagnosis of drug-induced headache during the study period, 101 patients (41 after ambulatory and 60 after stationary withdrawal therapy) could be followed up for 5.9 +/- 4.0 years. The total relapse rate after successful withdrawal therapy was 20.8% (14.6% after ambulatory and 25.0% after stationary withdrawal therapy, p < 0.2). The main risk factors for a relapse were male sex (OR = 3.9, CI = 1.3-11.6), intake of combined analgesic drugs (OR = 3.8, CI = 1.4-10.3), administration of naturopathy (OR = 6.0, CI = 1.2-29.3), and a trend to tension-type headache as the primary headache disorder (OR = 1.9, CI = 0.6-53.0). Our data suggest that neither the method of withdrawal therapy nor the kind of analgesic and other antimigraine drugs has a major impact on the long-term result after successful withdrawal therapy. Patients with risk factors according to our findings should be informed and monitored regularly, and combined drugs should be avoided. Furthermore, our data suggest that there is a need for research on individual psychological and behavioral risk factors for relapse after successful withdrawal therapy in drug-induced headache.