Article

Alcohol withdrawal and delirium tremens in the critically ill: a systematic review and commentary

Pharmacy Department, Hôpital Maisonneuve-Rosemont, 5415 Boulevard de l'Assomption, Montreal, PQ, H1T 2M4, Canada.
European Journal of Intensive Care Medicine (Impact Factor: 5.54). 11/2012; 39(1). DOI: 10.1007/s00134-012-2758-y
Source: PubMed

ABSTRACT INTRODUCTION: Alcohol withdrawal is common among intensive care unit (ICU) patients, but no current practice guidelines exist. We reviewed published manuscripts for prevalence, risk factors, screening tools, prophylactic and treatment strategies, and outcomes for alcohol withdrawal syndrome (AWS) and delirium tremens (DT) in the critically ill. METHODS: The following databases: PubMed, MEDLINE, Embase, Cochrane Database of Systematic Reviews and Central Register of Controlled Trials, CINAHL, Scopus, Web of Knowledge, pain, anxiety and delirium (PAD) Guidelines REFWORKS, International Pharmaceutical Abstracts and references for published papers were searched. Publications with high or moderate Grading of Recommendations Assessment, Development and Evaluation (GRADE) and Oxford levels of evidence were included. RESULTS: Reported AWS rates range from <1 % in 'all ICU comers' to 60 % in highly selected alcohol-dependent ICU patients. Alcohol dependence and a history of withdrawal are significant risk factors for AWS occurrence. No screening tools for withdrawal have been validated in the ICU. The benefit of alcohol withdrawal prophylaxis is unproven, and proposed regimens appear equivalent. Early and aggressive titration of medication guided by symptoms is the only feature associated with improved treatment outcome. CONCLUSIONS: Treatment of AWS is associated with higher ICU complication rates and resource utilization. The optimal means of identification, prevention and treatment of AWS in order to establish evidence-based guidelines remain to be determined.

4 Followers
 · 
676 Views
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background To date, no screening tools for alcohol withdrawal syndromes (AWS) have been validated in the medically ill. Although several tools quantify the severity of AWS (e.g., Clinical Institute Withdrawal Assessment for Alcohol [CIWA]), none identify subjects at risk of AWS, thus missing the opportunity for timely prophylaxis. Moreover, there are no validated tools for the prediction of severe AWS in the medically ill. Objectives Our goals were (1) to conduct a systematic review of the published literature on AWS to identify clinical factors associated with the development of AWS, (2) to use the identified factors to develop a tool for the prediction of alcohol withdrawal among patients at risk, and (3) to conduct a pilot study to assess the validity of the tool. Methods For the creation of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS), we conducted a systematic literature search using PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines for clinical factors associated with the development of AWS, using PubMed, PsychInfo, MEDLINE, and Cochrane Databases. Eligibility criteria included: (i) manuscripts dealing with human subjects, age 18 years or older, (ii) manuscripts directly addressing descriptions of AWS or its predisposing factors, including case reports, naturalistic case descriptions, and all types of clinical trials (e.g., randomized, single-blind, or open label studies), (iii) manuscripts describing characteristics of alcohol use disorder (AUD), and (iv) manuscripts dealing with animal data (which were considered only if they directly dealt with variables described in humans). Obtained data were used to develop the Prediction of Alcohol Withdrawal Severity Scale, in order to assist in the identification of patients at risk for moderate to severe AWS. For the Pilot Study A pilot study was conducted to assess the new tool’s psychometric qualities on patients admitted to a general inpatient medicine unit over a 2-week period, who agreed to participate in the study. Blind to PAWSS results, a separate group of researchers retrospectively examined the medical records for evidence of AWS. Results The search produced 2802 articles describing factors potentially associated with increased risk for AWS, increased severity of withdrawal symptoms, and potential characteristics differentiating subjects with various forms of AWS. Of these, 446 articles met inclusion criteria and underwent further scrutiny, yielding a total of 233 unique articles describing factors predictive of AWS. A total of 10 items were identified as correlated with moderate to severe AWS (i.e., withdrawal hallucinosis, withdrawal-related seizures, and delirium tremens) and used to construct the PAWSS. During the pilot study, a total of 68 subjects underwent evaluation with PAWSS. In this pilot sample the sensitivity, specificity, and positive and negative predictive values of PAWSS were 100%, using the threshold score of 4. Discussion The results of the literature search identified 10 items which may be correlated with risk for moderate to severe AWS. These items were assembled into a tool to assist in the identification of patients at risk: PAWSS. The results of this pilot study suggest that PAWSS may be useful in identifying risk of moderate to severe AWS in medically ill, hospitalized individuals. PAWSS is the first validated tool for the prediction of severe AWS in the medically ill and its use may aid in the early identification of patients at risk for moderate to severe AWS, allowing for prophylaxis against AWS before severe alcohol withdrawal syndromes develop.
    Alcohol (Fayetteville, N.Y.) 06/2014; DOI:10.1016/j.alcohol.2014.01.004 · 2.04 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective: In 2013, the American College of Critical Care Medicine published a revised version of the pain, agitation, and delirium guidelines. The guidelines included an ICU pain, agitation, and delirium care bundle designed to facilitate implementation of the pain, agitation, and delirium guidelines. Design: Review article. Setting: Multispecialty critical care units. Patients: Adult ICU patients. Interventions: This article describes: 1) the ICU pain, agitation, and delirium care bundle in more detail, linking pain, sedation/agitation, and delirium management in an integrated and interdisciplinary fashion; 2) pain, agitation, and delirium implementation strategies; and 3) the potential synergistic benefits of linking pain, agitation, and delirium management strategies to other evidence-based ICU practices, including spontaneous breathing trials, ICU early mobility programs, and ICU sleep hygiene programs, in order to improve ICU patient outcomes and to reduce costs of care. Results: Linking the ICU pain, agitation, and delirium management strategies with spontaneous awakening trials, spontaneous breathing trials, and early mobility and sleep hygiene programs is associated with significant improvements in ICU patient outcomes and reductions in their costs of care. Conclusions: The 2013 ICU pain, agitation, and delirium guidelines provide critical care providers with an evidence-based, integrated, and interdisciplinary approach to managing pain, agitation/sedation, and delirium. The ICU pain, agitation, and delirium care bundle provides a framework for facilitating implementation of the pain, agitation, and delirium guidelines. Widespread implementation of the ICU pain, agitation, and delirium care bundle is likely to result in large-scale improvements in ICU patient outcomes and significant reductions in costs.
    Critical Care Medicine 01/2013; 41:S99-S115. DOI:10.1097/CCM.0b013e3182a16ff0 · 6.15 Impact Factor
  • Source
    Critical Care 03/2013; 17(2). DOI:10.1186/cc12336 · 5.04 Impact Factor