prepared by j. mabbutt & c. maynard namo september 2008 7: managing alcohol withdrawal
TRANSCRIPT
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Prepared by J. Mabbutt & C. MaynardNaMO
September 2008
7: Managing Alcohol Withdrawal
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1. During the session nurses & midwives will learn how to identify, assess & manage a patient in alcohol withdrawal
2. By the end of the session nurses & midwives will have an understanding or use of the AWS/CIWAR-Ar withdrawal scales
3. At the end the session, nurses & midwives will have a basic understanding & knowledge to safely & effectively identify, monitor & manage alcohol withdrawal
7: Managing withdrawalObjectives
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Effective management of withdrawal in its early stages can reduce or prevent progression to complicated withdrawal
Complicated withdrawal may be life-threatening due to:
Accidental injury, dehydration, electrolyte imbalance, seizures, delirium tremens, or the negative impact on other concurrent disorders, including acute infection, renal disease or diabetes
7: Managing withdrawal
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Severe alcohol withdrawal is potentially life threatening
The most important thing is to anticipate when it may occur & to suspect it when an unexplained acute organic brain syndrome is detected
Before continuing to assess alcohol withdrawal, the following information focuses on a form of brain injury called the Wenicke’s-Korsakoff syndrome
7: Indications and guidelines: Assessing withdrawal
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This is a form of brain injury resulting from thiamine deficiency, which complicates alcohol dependence
If not treated early it can lead to permanent brain damage & memory loss – young alcohol-dependent people are at risk
Signs & symptoms of Wernicke’s encephalopathy, which is usually the first stage of the syndrome, are:
Ophthalmoplegia (reduced eye movements or nystagmus)
Ataxia & confusion
7: Indications and guidelines: Complications of misuse – Wernicke-Korsakoff syndrome (1)
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This condition is reversible if recognised and treated with parenteral vitamin B1
Parenteral thiamine should be administered before any form of glucose
Glucose in the presence of thiamine deficiency risks precipitating Wernicke’s encephalopathy
7: Indications and guidelines: Complications of misuse – Wernicke-Korsakoff syndrome (2)
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Onset of alcohol withdrawal is usually 6-24 hours after the last drink
Consumption of benzodiazepines or other sedatives may delay the onset of withdrawal
In some severely dependent drinkers, simply reducing the level of consumption may precipitate withdrawal, even if they have consumed alcohol recently
7: Indications and guidelines: Assessing withdrawal – Onset & duration of alcohol withdrawal (1)
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Usually withdrawal is brief & resolves after 2-3 days without treatment; occasionally, withdrawal may continue for up to 10 days
Withdrawal can occur when the blood alcohol level is decreasing, even if the patient is still intoxicated
7: Indications and guidelines: Assessing withdrawal – Onset & duration of alcohol withdrawal (2)
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Figure 9.1: Progress of alcohol withdrawal syndrome
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Severity of alcohol withdrawal ranges from mild to severe
The following questions, known as the Index for Suspicion of Alcohol Withdrawal, will help you determine whether the patient is likely to move into alcohol withdrawal:
A regular intake of 80 grams (8 drinks-Males) or 60 grams (6 drinks-Females) of alcohol or more per day?
Taken even smaller amounts of alcohol in conjunction with other CNS depressants?
Previous episodes of alcohol withdrawal?
7: Indications and guidelines: Assessing withdrawal – Index for Suspicion of Alcohol withdrawal (1)
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Current admission for an alcohol-related reason?
Physical appearance indicate chronic alcohol use:
– parotid swelling (swelling in the gland under the ear)
– cushingoid face (full/moon looking face)
– facial telangiectasia (red spots/blood vessels)
– eyes reddened or signs of liver disease
– ascites, jaundice, limb muscle wasting
7: Indications and guidelines: Assessing withdrawal – Index for Suspicion of Alcohol withdrawal (2)
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Pathology results show raised serum GGT
Raised mean cell volume (MCV)
Displaying symptoms such as
– anxiety,
– agitation,
– tremor,
– sweatiness or early morning retching, which might be due to an alcohol withdrawal syndrome?
7: Indications and guidelines: Assessing withdrawal – Index for Suspicion of Alcohol withdrawal (3)
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Alcohol withdrawal is a syndrome of central nervous system hyperactivity characterised by symptoms that range from mild to severe
The symptoms and signs of alcohol withdrawal may be grouped into three major classes: See Table 9.4
7: Indications and guidelines: Signs & symptoms of alcohol withdrawal (1)
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Autonomic overactivity Gastrointestinal Cognitive & perceptual changes
Sweating Anorexia Anxiety
Tachycardia Nausea Vivid dreams
Hypertension Vomiting Illusions
Insomnia Dyspepsia Hallucinations
Tremor Delirium
Fever
Table 9.4: Main signs & symptoms of alcohol withdrawal
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Seizures occur in about 5% of patients withdrawing from alcohol
They occur early (usually 7-24 hours after the last drink), are grand mal in type (i.e. generalised, not focal) & usually (though not always) occur as a single episode
Delirium tremens (“the DTs”) is rare & is a diagnosis by exclusion
It is the most severe form of alcohol withdrawal syndrome, & a medical emergency
7: Indications and guidelines: Signs & symptoms of alcohol withdrawal (2)
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DT’s usually develops 2-5 days after stopping or significantly reducing alcohol consumption
The usual course is 3 days, but can be up to 14 days
Its clinical features are:Its clinical features are:
Confusion & disorientation
Extreme agitation or restlessness – the patient often requires restraining
7: Indications and guidelines: Signs & symptoms of alcohol withdrawal (3)
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Gross tremor
Autonomic instability (e.g. fluctuations in BP & pulse), disturbance of fluid balance & electrolytes, hyperthermia
Paranoid ideation, typically of delusional intensity
Distractibility & accentuated response to external stimuli
Hallucinations affecting any of the senses, but typically visual (highly coloured, animal form)
7: Indications and guidelines: Signs & symptoms of alcohol withdrawal (4)
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The most systematic & useful way to measure the severity of withdrawal is to use a withdrawal scale
These provide a baseline against which changes in withdrawal severity may be measured over time
Research shows that the use of scales minimises both under-dosing & overdosing with benzodiazepines for alcohol withdrawal syndromes
7: Indications and guidelines:Alcohol withdrawal scales (1)
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There has been considerable debate about the application of withdrawal scales
Two different scales, the Alcohol Withdrawal Scale (AWS) and the Clinical Institute Withdrawal Assessment for Alcohol (revised) (CIWA-Ar) are both are recommended for use (see Appendices 2 and 3)
Being familiar with the alcohol withdrawal scale used in your local area is a priority
7: Indications and guidelines:Alcohol withdrawal scales (2)
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Note that withdrawal scales do not diagnose withdrawal, but are merely guides to the severity of an already diagnosed withdrawal syndrome
The nurse or midwife should re-evaluate the patient to ensure that it is alcohol withdrawal & not another condition that is being measured, particularly if the patient does not respond well to treatment
7: Indications and guidelines:Alcohol withdrawal scales (3)
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The CIWA-Ar (see Appendix 2) is a 10-item scale that can be administered as part of supportive care
Several studies have shown that the CIWA-Ar scale is a valid, reliable & sensitive instrument for assessing the clinical course of simple alcohol withdrawal
7: Alcohol withdrawal scales Clinical Institute Withdrawal Assessment for Alcohol Revised Version (CIWA-Ar) (1)
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Video options show either of the following from the CIWA-Ar CD ROM
E5 Using the CIWA-Ar alcohol withdrawal scale (withdrawal symptoms are demonstrated) (10.37 min)
E8 – A Case study
7: Alcohol withdrawal scales Clinical Institute Withdrawal Assessment for Alcohol Revised Version (CIWA-Ar) – Videos
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This scale allows a quantitative rating (from 0 to 7 with a maximum This scale allows a quantitative rating (from 0 to 7 with a maximum possible score of 67) of the following components of withdrawal:possible score of 67) of the following components of withdrawal:
Nausea & vomiting
Tremor
Paroxysmal sweats
Anxiety
7: Alcohol withdrawal scales Clinical Institute Withdrawal Assessment for Alcohol Revised Version (CIWA-Ar) (2)
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Agitation
Tactile disturbances
Auditory disturbances
Visual disturbances
Headache and fullness in head
Orientation & clouding of sensoria
7: Alcohol withdrawal scales Clinical Institute Withdrawal Assessment for Alcohol Revised Version (CIWA-Ar) (3)
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Using the CIWA-Ar in presentation to the emergency department:
Monitor the patient hourly for at least 4 hours using the CIWA-Ar
Contact the medical officer or drug & alcohol nurse practitioner for assessment and monitor hourly if:
– the alcohol score increases by at least 5 points over this 4-hour period, or
– the CIWA-Ar total score reaches 10
7: Alcohol withdrawal scales Clinical Institute Withdrawal Assessment for Alcohol Revised Version (CIWA-Ar) (4)
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Using the CIWA-Ar for hospitalised patients:
Monitor the patient 4-hourly, using the CIWA-AR, for at least 3 days
If the total score reaches 10, monitor hourly & notify the medical officer or drug & alcohol nurse practitioner
7: Alcohol withdrawal scales Clinical Institute Withdrawal Assessment for Alcohol Revised Version (CIWA-Ar) (5)
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Alcohol Withdrawal Scale (AWS)
The AWS (see Appendix 3) is a widely used scale in NSW
If a patient’s history or presentation suggests possible withdrawal, the patient’s condition must be monitored & documented
7: Alcohol withdrawal scales Alcohol withdrawal scale (AWS) (1)
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The AWS (see Appendix 3) is a widely used scale in NSW and is a 7 item scale that allows a quantitative rating (from 0 to 4) of the following components:
Perspiration
Tremor
Anxiety
Agitation
Axilla temperature
Hallucinations
Orientation
7: Alcohol withdrawal scales Alcohol withdrawal scale (AWS) (2)
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Using the AWS in presentation to the emergency department:
Monitor the patient hourly for at least 4 hours using the AWS
Contact the medical officer or drug & alcohol nurse practitioner for assessment & monitor hourly if:
– the alcohol score increases by at least 5 points over this 4-hour period, or
– the AWS total score reaches 5
7: Alcohol withdrawal scales Alcohol withdrawal scale (AWS) (3)
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Using the AWS for hospitalised patients:
Monitor the patient 4-hourly, using the AWS, for at least 3 days
If the total score reaches 5, monitor hourly & notify the medical officer or drug & alcohol nurse practitioner
Depending on the resources of the local area, these may need review
7: Alcohol withdrawal scales Alcohol withdrawal scale (AWS) (4)
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From NSW Drug & Alcohol Withdrawal Clinical Practice Guidelines NSW Health 2007
The most commonly prescribed pharmacological treatment for alcohol withdrawal is diazepam because of its cross-tolerance with alcohol & anti-convulsant properties
Two types of regimes for specialist residential or inpatient setting
Diazepam loading regime
Symptom-triggered sedation
7: Indications and guidelines:Pharmacological Treatment (1)
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Diazepam loading regime
On the development of withdrawal symptoms initiate diazepam loading
20mg initially, increasing to 80mg over 4-6 hours
Or until pt is sedated
Medial review required if dose exceeds 80mg & more diazepam can be ordered depending on withdrawal condition
7: Indications and guidelines:Pharmacological Treatment (2)
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Symptom-triggered sedation
Mild withdrawal CIWA-AR <10 & AWS <4
Supportive care, observations 4 hourly
If sedation necessary; 5-10mg oral diazepam every 6-8 hours for first 48 hrs
7: Indications and guidelines:Pharmacological Treatment (3)
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Symptom-triggered sedation
Moderate withdrawal CIWA-AR 10-20 & AWS <5-14
Medical officer to assess
If alcohol withdrawal confirmed: hourly observations; give 10-20 oral diazepam immediately; repeat 10mg hourly or 10-20mg 2hrly until the pt achieves good symptom control (up to a total dose of 80mg)
Repeat medical review after 80mg of diazepam and if pt is not settling, consider olanzepine (zyprexia) 5-10mg
7: Indications and guidelines:Pharmacological Treatment (4)
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Symptom-triggered sedation
Severe withdrawal CIWA-AR 20+ & AWS 14+
Urgent management. Give a loading dose
Review more frequently until score falls
A rising score indicates a need for more aggressive management
7: Indications and guidelines:Pharmacological Treatment (5)
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Contraindications to diazepam include:
– respiratory failure,
– significant liver impairment,
– possible head injury or cerebrovascular accident – in these situations, specialist consultation is essential
From NSW Drug and Alcohol Withdrawal Clinical Practice Guidelines NSW Health 2007 http://www.health.nsw.gov.au/policies/gl/2008/GL2008_011.html
7: Indications and guidelines:Pharmacological Treatment (6)