ALCOHOL WITHRAWAL SYDROME

Prepared by: group 2b

DELIRIUM TREMENS

Alcohol withdrawal syndrome

is the set of symptoms seen when an individual reduces or stops alcohol consumption after prolonged periods of excessive alcohol intake. Excessive use of alcohol leads to tolerance, physical dependence, and an alcohol withdrawal syndrome. The withdrawal syndrome is largely due to the central nervous system being in a hyper-excitable state. The withdrawal syndrome can include seizures and delirium tremens and may lead to excito-neurotoxicity.

delirium tremens (DTs)

A more serious syndrome. it involves profound confusion, hallucinations, and severe autonomic nervous system over-activity, typically beginning between 48 and 96 hours after the last drink (Victor 1983). Estimates vary on the incidence of serious consequences of alcohol withdrawal. Regardless of actual incidence, recent evidence suggests that it may be important to treat everyone who is suffering from alcohol withdrawal

In a classic study that has shaped our understanding of alcohol withdrawal for many years, Isbell et al. (1955) found that alcohol-related seizures occur only after stopping heavy drinking. In a recent study that looked primarily at seizures, Ng et al. (1988) challenged Isbell's concept and reported that the risk of first seizure is related to current alcohol use rather than to withdrawal.

Symptoms of Alcohol Withdrawal Syndrome

Symptoms of Alcohol Withdrawal Syndrome

Mild to moderate psychological symptoms:

Feeling of jumpiness or nervousness

Feeling of shakiness

Anxiety

Irritability or easily excited

Emotional volatility, rapid emotional changes

Depression

Fatigue

Difficulty with thinking clearly

Bad dreams

Symptoms of Alcohol Withdrawal Syndrome

Mild to moderate physical symptoms:

Headache - general, pulsating

Sweating, especially the palms of the hands or the face

Nausea and Vomiting

Loss of appetite

Insomnia, sleeping difficulty

Paleness

Rapid heart rate (palpitations)

Eyes, pupils different size (enlarged, dilated pupils)

Skin, clammy

Abnormal movements

Tremor of the hands

Involuntary, abnormal movements of the eyelids

Symptoms of Alcohol Withdrawal Syndrome

Severe symptoms:

A state of confusion and hallucinations (visual) -- known as delirium tremens

Agitation

Fever

Convulsions

"Black outs" -- when the person forgets what happened during the drinking episode

TreatmentBenzodiazepines

 are effective for the management of symptoms as well as the prevention of seizures. Benzodiazepines can be life saving, particularly if delirium tremens appears during alcohol withdrawal should only be used short term in alcoholics who aren't already dependent on benzodiazepines as benzodiazepines share cross tolerance with ethanol and there is a risk of replacing the addiction with a benzodiazepine dependence or worse still adding an additional addiction.

Benzodiazepines such as ;

Diazepam or Lorazepam, are the most commonly used drug for the treatment of alcohol withdrawal and are generally safe and effective in suppressing alcohol withdrawal signs and most commonly used in alcohol detoxification. The combination of benzodiazepines and alcohol can amplify the adverse psychological effects of each other causing enhanced depressive effects on mood and increase suicidal actions and are generally contraindicated except for alcohol withdrawal.

TreatmentAntipsychotics

Antipsychotic agents, such as haloperidol, are sometimes used for alcohol withdrawal as an add-on to first-line measures such as benzodiazepines to control agitation or psychosis.Antipsychotics may potentially worsen alcohol withdrawal effects (or other CNS depressant withdrawal states) as they lower the seizure threshold and can worsen withdrawal effects. Clozapine,olanzapine or low potency phenothiazines (e.g. chlorpromazine) are particularly risky; if used, extreme caution is required. There is also concern for this class of drugs prolonging the QT interval, sometimes leading to fatal heart dysrhythmias.

TreatmentAnticonvulsants

Some evidence indicates that topiramate carbamazepine and other anticonvulsants are effective in the treatment of alcohol withdrawal however, research is limited.  A Cochrane review similarly reported that the evidence to support the role of anticonvulsants over benzodiazepines in the treatment of alcohol withdrawal is not statistically significant and noted significant weaknesses in the studies available and recommended further research. The Cochrane Review did note however, that paraldehyde combined with chloral hydrate showed superiority over chlordiazepoxide with regard to incidence of life threatening side effects and also noted that carbamazapine may have advantages for certain symptoms.[36] The advantages of carbamazapine demonstrated in one trial are less rebound withdrawal symptoms and appears to have a higher success rate for abstinence from alcohol post detoxification compared to benzodiazepines.

TreatmentBaclofen and Barbiturates

Baclofen has been shown to be as effective as diazepam in uncomplicated alcohol withdrawal syndrome.

Barbiturates are superior to diazepam in the treatment of severe alcohol withdrawal syndromes such as delirium tremens but equally effective in milder cases of alcohol withdrawal.

TreatmentClomethiazole

Clomethiazole (Heminevrin) is a non-benzodiazepine sedative-hypnotic with anticonvulsant effects which is active on the barbiturate site of the GABA-A receptor. Clomethiazole also inhibits the enzyme alcohol dehydrogenase, which is responsible for breaking down alcohol in the body. This slows the rate of elimination of alcohol from the body, which helps to relieve the sudden effects of alcohol withdrawal in alcoholics.

TreatmentClonidine, trszodone and Caffeine

Clonidine has demonstrated superior clinical effects in the suppression of alcohol withdrawal symptoms in a head to head comparison study with the benzodiazepine drug chlordiazepoxide.

Trazodone has demonstrated efficacy in the treatment of the alcohol withdrawal syndrome. It may have particular use in withdrawal symptoms, especially insomnia, persisting beyond the acute withdrawal phase.

Caffeine has been shown to upregulate GABA receptors although high doses can cause caffeine poisoning and nervous system damage.

TreatmentEthanol

Alcohol (ethanol) itself at low doses, but only when given intravenously by medical personnel, has been found to be superior to chlordiazepoxide in the detoxification of alcohol dependent patients. Low dose ethanol as a means of weaning alcoholics from alcohol was found to produce less profound sleep disturbances during withdrawal. Low dose ethanol has been found to reduce treatment time, improve the failure rate from 20% down to 7% and increase retention in treatment centers with an increased rate of alcoholics attending substance misuse clinics after detoxification.

TreatmentFlumazenil and Magnesium

Flumazenil, which has shown some promise in the management of the benzodiazepine withdrawal syndrome has also demonstrated benefit in a research study in reducing anxiety withdrawal related symptomatology during alcohol withdrawal.

Magnesium appears to be effective in the treatment of alcohol withdrawal related cardiac arrhythmias. It is ineffective in controlling other symptoms of alcohol withdrawal.

TreatmentNitrous Oxide

Nitrous oxide has been shown to be an effective and safe treatment for alcohol withdrawal.  Over 20,000 cases of the alcoholic withdrawal state have been successfully treated with psychotropic analgesic nitrous oxide (PAN) in South Africa and Finland. In 1992 it was officially approved for the treatment of addictive withdrawal states by the medical authorities in South Africa. Consequently, patients receiving it can claim a refund from their medical insurance. The gas therapy reduces the use of highly addictive sedative medications (like benzopdiazepines and barbiturates) by over 90%. The technique thus reduces the danger of secondary addiction to benzodiazepines, which can be a real problem amongst alcoholics who have been treated with these agents.

TreatmentVitamins

The prophylactic administration of thiamine intravenously is recommended before starting any carbohydrate containing fluids or food. Alcoholics are often deficient in various nutrients which can cause severe complications during alcohol withdrawal such as the development of Wernicke syndrome. The vitamins of most importance in alcohol withdrawal are thiamine and folic acid. To help to prevent Wernicke syndrome alcoholics should be administered a multivitamin preparation with sufficient quantities of thiamine and folic acid. Vitamins should always be administered before any glucose is administered otherwise Wernicke syndrome can be precipitated.

TreatmentNMDA antagonists, calcium antagonists, and glucocorticoid antagonists

Prevention of brain damage

Failure to manage the alcohol withdrawal syndrome appropriately can lead to permanent brain damage or death. It has been proposed that brain damage due to alcohol withdrawal may be prevented by the administration of NMDA antagonists, calcium antagonists, and glucocorticoid antagonists. The NMDA antagonist acamprosate reduces excessive glutamate rebound thereby suppressing excitotoxicity and potential withdrawal related neurotoxicity. A cheaper, non prescription substance would be dextromethorphan, which is metabolized into dextrothrophan, which has calcium channel and NMDA blocking effects. Any NMDA antagonist is likely to be of benefit in alcohol withdrawal, due to the upregulated nature of ligand gated calcium channels due to the downregulated GABAA Cl- channel.

Treatment

Substances impairing recovery

Continued use of benzodiazepines may impair recovery from psychomotor and cognitive impairments from alcohol. Cigarette smoking may slow down or interfere with recovery of brain pathways in recovering alcoholics.

Nursing Care for the PatientWithdrawing from Alcohol

Nursing Care for the PatientWithdrawing from Alcohol Management Goals for Alcohol Withdrawal

•Prevent the progression of symptoms

•Provide for the patient’s safety and comfort

•Motivate the patient to engage in long term treatment

In-patient Screening

Who should be screened?

• All patients should be screened for alcohol abuse upon

Admission

• Statistics show that up to 40% of patients admitted to the

hospital may have some alcohol dependency

Screening: The Interview

As part of the admission assessment and history

• Do you consume 3 or more drinks a week?

• Date of the last alcoholic drink consumed?

Screening: Physical Exam

System Affected Effects

CNS Impaired memory, Coordination, Sleep

disturbances, Neuropathy, Hallucinations

Cardiovascular Cardiomyopathy, Dysrhythmias, Hypertension

Hemo Thrombocytopenia, Anemia

Gastrointestinal Esophageal inflammation, Varices,

Pancreatitis, Cirrhosis, Nausea and Vomiting

Muskoskeletal Malnutrition, Weakness, Tremors

(Alcohol tremulousness)

Screening: Lab Tests

LFTs: Liver Function Tests

• AST: aspartate aminotransferase

• ALT: alanine aminotransferase

• AST/ALT ratio

•ALP: alkaline phosphatase

(“There are various reasons why liver enzymes could be elevated”)

• Serum Albumin Concentration

• Gamma Glutamyltranspeptidase (GGT)

• Total Bilirubin

• PT/INR

• CBC

• CMP

• Ethyl Glucuronide

Nursing Interventions

• Safety

• Fall risk

• Restraints

• Hourly rounding

• Aspiration precautions

• Nausea/Vomiting

• Suction

• Nasogastric tube

• Cardiac Monitoring

• Dysrhythmias

• Vital Signs

Nutrition

• Vitamin B1 (Thiamine)

• Wernicke’s Encephalopy

• Korsakoff’s Psychosis

• Electrolytes

• Frequent meals and snacks

• Fluids

• Intake and Output

Consultsand Patient Education

• Nutrition therapy

• Psychiatry

• Case Management

• Social Work

• Assess for barriers

• Outpatient Resources

• AA

• Substance Abuse Treatment Centers

Patient Education

• Cessation of alcohol use

• Nutrition

• Resources

 

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BSN 4B

GROUP 2B

Ampac, Hannah

Cantoja, Carlito

Delgado, Janine

Enilo, JOy

Romero, Eunilie

Tabarno, Catherine Anne

Tablada, Lenie

Tarapas, Bai Sahara

Tudtud, Jane