Alcohol Withdrawal
★Alcohol withdrawal usually begins 6-48 hours after reducing or ceasing prolong alcohol use, but can begin as late as 5 days after after the last drink. The symptoms usually seen are nausea, weakness, autonomic hyperreactivity, anxiety, irritability, and insomnia.
The tremor associated with alcohol withdrawal usually begins 24-48 hours after the last drink and can persist for 5-7 days.
Essential points in managing inpatient alcohol withdrawal
Check vital signs with sufficient frequency.
Cover patient with an adequate amount of benzodiazepine.
Don't give more benzodiazepines before the last dose has reached its peak.
Preferably use a long-acting benzodiazepine unless you wish to keep the overnight call person awake. (Recent research suggests that the outcome and length of hospitalization does not vary as a function of benzodiazepine half-life, however.)
Lorazepam is only necessary if someone has end stage cirrhosis. Otherwise, just reduce the dose of the long-acting benzodiazepine.
Only cover for seizure (e.g., phenytoin) if the person has a history of seizures.
Only cover for psychosis (e.g., haloperidol or risperidone) if the person has a history of psychosis on withdrawal.
Be cautious in the use of benzodiazepines in patients who are still intoxicated, as they can cause respiratory depression and delirium.
In some cases, instability of vital signs may necessitate exceeding the recommended maximum daily dosage for chlordiazepoxide. Such cases would like benefit from a review of vital signs over the day.
Often, but not always, it can be reasonable to discontinue chlordiazepoxide after approximately 24 hours of treatment. This is not the case for short-acting benzodiazepines such as lorazepam.
If someone shows signs of delirium tremens (including gross tremor, diaphoresis, confusion, disorientation, tachycardia, and hypotension) they need immediate attention and should be transferred to an internal medicine service.
★Thiamine and folate are typically only necessary in chronic alcoholism, the former helps prevent Wernicke's encephalopathy. They can be discontinued after a few days and a multivitamin used instead.
Water is the only drink for a wise man. --Thoreau
You might want to check out the article on managing alcohol withdrawal published by Mayo-Smith et al. (1997).
Sample Alcohol Withdrawal Orders
VS q 2h while awake x 24h, then q 4h while awake
Privileges: Maintain on unit during withdrawal
Labs: CBC, Panel 7, LFT, Urine Tox screen
Place PPD unless pt is known positive or documented negative in past 6 months
Push fluids
Medications:
Chlordiazepoxide 50 mg po q 2h prn HR > 105, DBP > 100, SBP > 160 (MDD = 300 mg)
or
Chlordiazepoxide 50 mg q 6h x 4 doses, then 25 mg qid x8 doses, then 10 mg qid x8 doses
Maalox Plus 15cc po q 4h prn stomach upset
MOM 30cc po q hs prn constipation
Folate 1 mg po qd x5d
Thiamine 100 mg po qd x 5d
Withdrawal seizures
Withdrawal seizures usually occur 7-38 hours after the last use of alcohol, but most commonly occur 24 hours later. Note that patients can still have seizures outside this window. It is important to monitor laboratory values because hypomagnesemia, hypokalemia, respiratory alkalosis, and hypoglycemia can increase the risk of seizure.
Delirium Tremens
Delirium tremens is classically characterized by confusion, disorientation, fluctuating consciousness, and perceptual disturbances. DT typically arise 2-3 days after the last drink and peak in intensity on days 4-5. DT, even if well-treated, can continue to wax and wane for several weeks. The risk of DT increases with the number of drinks per day, number of lifetime withdrawal episodes, infection, subdural hematoma, liver disease, or metabolic disorders.
★In one study where patients had DT even after benzodiazepine treatment, all of them had the following risk factors:
Outpatient alcohol withdrawal
For patients with less severe withdrawal issues or a variety of other factors that would make inpatient withdrawal infeasible, sometimes outpatient withdrawal can be done. A standard regimen for outpatient withdrawal is chlordiazepoxide 50 mg q 6h x4 doses followed by 25 mg q 6h x8 doses. This seems rather brief, but bear in mind that oxazepam, which is one of the active metabolites of chlordiazepoxide, has a fairly long half-life.