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: 5.17). 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.

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    ABSTRACT: Introduction Although not often recommended, ethanol replacement is still used in hospitals, including ours. Since intravenous ethanol for alcohol withdrawal is mainly used in the intensive care units of our clinic, we reviewed literature to enable better liaison psychiatric consult for patients in this particular setting. Materials and methods We performed a MEDLINE search for pharmacological trials with alcohol dependent patients in intensive care units who were treated with, or who received intravenous ethanol as prophylaxis for alcohol withdrawal syndrome. Efficacy, eventual referral to addiction aid and post-interventional abstinence were chosen as outcome measures. If a withheld review article mentioned the search strategy, the search was carried forward from their end-date till ours in order to detect more recently published papers. In parallel, we initiated a small retrospective evaluation of our hospital’s electronic patient-records mentioning 96% ethanol 10ML ampoules. Results Retrospective analysis: Preliminary results indicate a rather anecdotic use of intravenous ethanol in our university hospital to prevent or treat alcohol withdrawal syndrome. Literature search: After our initial search, reference tracking and reproducing searches of relevant systematic reviews we identified 8 interventional trials. Those indicate, in accordance with recent systematic reviews, that intravenous ethanol is not more efficient than active control to prevent alcohol withdrawal syndrome. Numbers of referral to addiction aid and abstinence after discharge of patients was either unknown or low. Discussion Intravenous ethanol is not more efficient than active control to prevent alcohol withdrawal syndrome. Several reservations concerning methodology of trials on IVetOH use have been addressed. Consideration of a more unified study population (elective surgery vs. medical and trauma ICU patients) could be necessary. Ethical reflections and possible harm are also discussed. Conclusion In the selected interventional trials, intravenous ethanol was not superior to active control in preventing alcohol withdrawal syndrome. Furthermore, intravenous alcohol replacement is not advised due to its potential harm.

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