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									7: Managing
Alcohol Withdrawal

           Prepared by J. Mabbutt & C. Maynard
                                         NaMO
                                 September 2008
     7: Managing withdrawal
     Objectives
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 withdrawal
   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: Indications and guidelines:
    Assessing withdrawal
   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:
    Complications of misuse –
    Wernicke-Korsakoff syndrome (1)
   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 (2)
   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:
    Assessing withdrawal – Onset &
    duration of alcohol withdrawal (1)
   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 (2)
   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
Figure 9.1: Progress of alcohol withdrawal syndrome
    7: Indications and guidelines:
    Assessing withdrawal – Index for
    Suspicion of Alcohol withdrawal (1)
   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 (2)
   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 (3)
   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: Signs
    & symptoms of alcohol withdrawal (1)
   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
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
    7: Indications and guidelines: Signs
    & symptoms of alcohol withdrawal (2)
   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 (3)
   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:

   Confusion & disorientation

   Extreme agitation or restlessness – the patient often requires restraining
    7: Indications and guidelines: Signs
    & symptoms of alcohol withdrawal (4)
   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:
    Alcohol withdrawal scales (1)
   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 (2)
   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 (3)
   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: Alcohol withdrawal scales
    Clinical Institute Withdrawal Assessment
    for Alcohol Revised Version (CIWA-Ar) (1)
   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) –
    Videos
   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) (2)
   This scale allows a quantitative rating (from 0 to 7 with a maximum
    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) (3)
   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) (4)
    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) (5)
    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
    Alcohol withdrawal scale (AWS) (1)
    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) (2)
   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) (3)
    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) (4)
    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: Indications and guidelines:
    Pharmacological Treatment (1)
    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 (2)
    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 (3)
    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 (4)
    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 (5)
    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 (6)
   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

								
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