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Alcohol Withdrawal. Author: Charlene Roberson, MEd, RN, BC, Director of Leadership Services, ASNA.

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Alcohol Withdrawal Author: Charlene Roberson, MEd, RN, BC, Director of Leadership Services, ASNA. Goal: Improved care for hospitalized patients in alcohol withdrawal. Target Audience: Nurses, nursing students,
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Alcohol Withdrawal Author: Charlene Roberson, MEd, RN, BC, Director of Leadership Services, ASNA. Goal: Improved care for hospitalized patients in alcohol withdrawal. Target Audience: Nurses, nursing students, health care providers, or consumers interested in the political process. At the conclusion of this activity the learner should be able to: 1. Implement a plan of care to ensure patient safety in alcohol withdrawal. 2. Review commonly administered medications for alcohol withdrawal. Disclosures: The Author and Planning Committee declare no conflicts of interest. Contact Hours: 2.5 contact hours (60 minutes equal 1.0 contact hour) or 3.0 contact hours (50 minutes equal 1 contact hour) Activity is valid May 1, May 1, Accreditation: Alabama State Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission of Accreditation. Alabama Board of Nursing (Exp. 30 March 2017) Cost: $20 ASNA members $25 Non members If we mail this program to you, postage and processing fee is $3. Directions: Complete the written material as directed and the answer/evaluation form and send to: Contact Information: Alabama State Nurses Association 360 N. Hull Street Montgomery, Al Fax: or scanned documents to A Continuing Education Certificate of Completion will be sent to you upon successful completion of both the evaluation and posttest. You must score at least 80% on the posttest for successful completion. Should you fail the posttest you will be offered the opportunity to retake the posttest for an additional $5.00 fee. Allow at least three (3) weeks after receipt of the certificate of completion for course to be placed on your official Alabama Board of Nursing transcript. Alcohol Withdrawal Introduction - Before discussing withdrawal issues it is essential to review the status of Ethanol (alcohol) use/abuse in the US. The task to quantify exact numbers is difficult as all reference sources differ somewhat. But somewhere between 5 10% of the American population has chronic alcoholism. Approximately 1.2 million hospital admissions are for problems related to alcohol, and of this number each year, there are approximately 500,000 separate episodes requiring some type of pharmacologic treatment. This is not 500,000 different individuals as the same person may require treatment more than once during any given year. The important fact is that so many individuals have alcohol issues, with or without their awareness, and often require treatment for non alcohol related problems (motor vehicle accidents, elective surgery, etc.). Once hospitalized they experience withdrawal symptoms. Therefore, it is essential for nurses to be cognizant of potential alcohol issues. Often younger men will also have comorbid issues with polysubstance abuse and/or mental health issues. Unhealthy alcohol use is a very general concept describing any pattern of alcohol consumption which increases risk to self or others in general or for developing physical problems. This is any time a person consumes alcohol in excess of the accepted health-related guidelines. The National Institute on Alcohol Abuse and Alcoholism provides the following guidelines: more than one drink daily, more than seven drinks weekly, or exceeding more than three drinks/day for women in general or for men over 65. For men under 65 alcohol consumption should not exceed more than two drinks daily, more than 14 drinks weekly, or more than 4 drinks on any single day. A standard drink is 14 Gm of alcohol (12 oz can of beer or 5 oz of 5% table wine, or 1.5 oz 40% {standard} liquor). If a person occasionally exceeds these limits it is unlikely to proceed to alcohol-related concerns. The problems are long term excessive consumption of alcohol. Frequency/Morbidity/Mortality In the past the death rate from alcohol withdrawal (AW) was anywhere to 20-35%. Not all individuals sought help for AW so numbers are not exact. Most important, in the past 30 years this number has steadily declined due to early and intensive care. In the United States only about 5% of individuals with alcohol withdrawal now progress to DT. However, the mortality rate of untreated DT remains near 35%; whereas, if treated the death rate is about 5%. Many alcoholics in withdrawal have other medical or traumatic conditions not related to the withdrawal process. The mortality rate from less severe alcohol withdrawal (any person not in DT) is very low and almost always related to the other medical or traumatic conditions. Pathophysiology - Withdrawal symptoms occur when the use of a substance capable of causing tolerance is reduced or discontinued. Tolerance is defined when the long-term use of an agent produces an adaptation so that a larger and larger amount of the substance is needed to achieve the desired effect. Factors that affect tolerance include the substance itself as well as frequency and duration of use. The body adapts to the substance presence either at the metabolic or cellular level. Some people have more pronounced withdrawal symptoms than others despite consuming the same amount of alcohol - probably related to genetics. Generally, withdrawal symptoms are fairly rare in the general population as most individuals drink episodically and never develop tolerance. Alcohol depresses the central nervous system overall. It simultaneously increases inhibitory functions and reduces excitatory tone or functions. A heavy drinker needs a constant present of alcohol to maintain homeostasis. The mechanism is that alcohol binds at the postsynaptic GABA receptors which are major inhibitory neurons/neurotransmitters in the brain. A result of activating these receptors is a release of chloride, which leads to hyperpolarization the cell. This leads to a decreased firing rate of neurons resulting in sedation. Prolonged use of alcohol decreases these receptor functions and thus causes tolerance and not sedation. As this develops, the person remains alert at alcohol concentrations that would produce lethargy or even coma in others. Glutamate is an excitatory neurotransmitter. It binds with N-methyl-D-asparate (NMDA) and produces neuronal excitement as a result of calcium influx. Alcohol inhibits this neuronal excitement. An alcoholic adapts to an increased sensitivity to glutamate to maintain homeostasis. When someone, who is a heavy drinker reduces the amount of alcohol either suddenly entirely or cuts back the body's neurotransmitters are stimulated or rebound causing withdrawal symptoms such as fever, hypertension, tachycardia, hyperventilation, seizures, DT, and hallucinations. This action forces the brain to compensate by increasing the synthesis of excitatory neurotransmitters, but alcohol has inhibited these. This results in an increase in neuroexcitability, which in turn contributes to withdrawal seizures. The result is alcohol craving and explains why opioid antagonists, i.e. benzodiazepines are used to prevent this craving. Benzodiazepines stimulate GABA receptors which in turn decreases neurotransmitter activity and sedation. Thus the person achieves more of a homeostatic state without alcohol. Symptoms - Symptoms of AW are usually absent in the first hours after admission. Often the person has been admitted for other reasons, such as trauma. If they are in the advanced stages of withdrawal such as seizures or full-blown DT they should be admitted to the Intensive Care Unit for careful follow-up of the hemodynamic profile. Persons having active withdrawal symptoms from alcohol should not be moved because of the risk of seizures. In uncomplicated cases of withdrawal where the vital signs are normal and they respond to sedation they may be treated as an outpatient. Sex and Age Men are more often seen with chronic alcoholism and withdrawal symptoms. It is rare to encounter an individual under 20 years of age with alcohol withdrawal symptoms as a period of time is needed to develop tolerance. Withdrawal symptoms are only noted after the individual tolerant to alcohol is deprived of the agent. DT is a rarely noted in individual under 30 years of age. The Withdrawal Clinical Profile The history will reflect daily abuse for at least 3 months or an individual who has consumed large quantities for at least a week prior (binge drinking) to the withdrawal symptoms. The symptoms appear 6 12 hours after the last drink and will subside with the ingestion of alcohol. The hangover is often an early and mild form of alcohol withdrawal; this explains why ingesting additional alcohol often relieves the hangover. Individuals who have developed significant tolerance have 4 separate phases of withdrawal as follows: Stage I Mild symptoms - usually occur within 6 hours of last drink - insomnia, mild anxiety, anorexia, GI Upset, headache, diaphoresis, palpitations, and trembling. These symptoms will resolve within hours or progress to Stage II. If no progression is noted they can may treated with ambulatory management. Not all patients have all of these symptoms and the ones experienced are usually consistent in each reoccurring episode of withdrawal. Stage II Occurs hours after last drink and consists of an excessive adrenergic effects (i.e.), low-grade fever, hyperventilation, tachycardia, systolic hypertension, intense anxiety, diaphoresis, tremor, hallucinosis, and insomnia. Alcoholic hallucinosis occurs in up to 25% of all patients with a history of excessive alcohol intake. Misperceptions and misinterpretations of real stimuli in the environment characterize these sensory experiences. Most often the hallucinosis consists of bugs, snakes, or rodents. The person remains aware of person, place, and time. Auditory sounds are heard less often and if experienced it is persecutory and usually the voice of someone they know. This is not to be confused with hallucinations. This condition does not always proceed to DT. Stage III This occurs at hours (peak occurrence 24 hours) after the last drink. Up to one-third of individuals in severe withdrawal may have these seizures which are sometimes called rum fits. It consists of a brief, generalized tonic-clonic seizure, which is not preceded by an aura. They often are in a cluster of 1 3 separate seizures with a brief postictal period. Localized or partial seizures are sometimes noted. These seizures usually terminate spontaneously and are easily controlled with the administration of a benzodiazepine. Status epilepticus occurs in up to 3% of cases of alcohol withdrawal. When present the person should be evaluated for other conditions such as a head injury as alcoholics are prone to head injuries due to life style while drinking. Somewhere between 30% 50% of all individuals with seizures proceeds to DT. Stage IV This is DT and it occurs hours after the last drink. Often it occurs immediately following a seizure. Note: only about 5% of all patients in alcohol withdrawal progress to DT. It is more common in patients who have a long history of alcohol abuse and who have a prior history of significant withdrawal symptoms. This may be triggered by head injury, infections or debilitating illnesses. All of the before mentioned symptoms occur but they do not improve in fact they become more pronounced. This condition when untreated will last from 2 7 days. In addition the person often develops additional physical complications such as cardiac failure or pneumonia. Alcohol Withdrawal Clinical Profile Feeling jumpy, nervous, shaky, restless, or increased activity Excitement Anxiety Irritability and easily excited and/or belligerent, uncooperative behavior Labile emotions Depression Fatigue Inability to concentrate or think clearly Rapid mood shifts Palpitations Headache Diaphoresis (especially palmer and around the face) Nausea and vomiting Anorexia Insomnia Confusion and/or disorientation Hallucinosis (usually visual but may be auditor) Hypersensitivity to light, sound, and touch Delirium (severe, acute loss of mental function) Decreases mental status including lethargic, somnolent, deep sleep for more than a day Seizures and/or tremors Treatment 1.) Screening, brief intervention, and referral to treatment (SBIRT) This is the quality indicator identified by the Joint Commission on Accreditation for Health Care Organizations (JCAHO) for hospitalized care for an alcoholic. A patient will be stabilized and then discharged and referred to outpatient treatment. 2.) Medication management involves providing a substitute medication that has crosstolerance to the chronically ingested substance. The selected medication will react at either specific receptor sites such as methadone in opiate withdrawal or reduce specific symptoms such as barbiturates in alcohol withdrawal. Non hospitalized patients in withdrawal will self medicate with either alcohol as their drug of choice or other sources such as rubbing alcohol, mouth wash, or cough medicines to reduce the unpleasant symptoms. Detox regimes titrate cross-tolerant medications. The amount and frequency is directly related to the severity of the person s symptoms. The goal is to gradually wean the person off the tolerant substance using ever decreasing dosages spaced further and further apart. Overall these individuals will require more medication than non alcoholics. Often nurses who are new to substance abuse treatment or treatment of persons in withdrawal may be uncomfortable with the amount of medication given to a individual in withdrawal. The employer should provide in service training in medication protocols. The most common drugs are as follows: Benzodiazepines (drugs of choice for withdrawal) Chlordiazepoxide (Librium) is inexpensive and has a relatively long half-life. It has long been established as the gold standard for alcohol withdrawal symptoms. The drug decreases all levels of the CNS and probably increases GABA activity. The usual dose is 25mg to 100 mg IV/IM every 2 hours until AW is controlled. In an emergency may give up to 50 mg to 100 mg IV every 5 to 15 minutes until sedated. The total dose in a 24 hours period should not exceed 300 mg. The person should be tapered gradually. Use the drug cautiously in patients with low albumin levels, narrow angle glaucoma, hypotension, or hepatic failure. Diazepam (Valium) is usually the first drug of choice in treating withdrawal symptoms because of the rapid onset of action and prolonged duration of effect. The drug depresses all levels of the CNS and probably increases GABA activity. The dosage should be individualized and carefully monitored as it can lead to progressive apnea and hypotension. The usual dosage is 5 10 mg IV every 2 15 minutes. The dosage may be increased up to 20 mg IV and given frequently up to several hours or until the person is lightly sedated. Large doses may need to be given, to achieve the desired results. Use with caution in patients with hepatic disease, low albumin levels, or with other CNS depressants. Oxazepam (Serax) is usually used to treat Level I alcohol withdrawal. The mg dose is given orally. Most often it is seen in an outpatient setting. Contraindication includes narrow angle glaucoma, history of substance abuse, and severe uncontrolled pain. Lorazepam (Ativan) takes about 20 minutes to achieve the peek effect. One side effect is the lowering of blood pressure. The blood pressure should be monitored very frequently. The usual dose is 1-2 mg IV bolus every 2-5 minutes until the desired effect is achieved (patient is sedated). Be especially diligent for oversedation or respiratory depression occurring about minutes after the last dose as the drug peaks slowly. This is the drug of choice if the person has profound liver involvement. It is a very effective drug for withdrawal symptoms when the person is able to take oral medications. Midazolam (Versed) has a very brief half-life. Persons receiving this need a constant infusion to maintain sedation. The drug is expensive and no more effective that other benzodiazepines. The drug is used when other cross-tolerant drugs are not available or when an intravenous access is readily available. The usual dose is 2 mg bolus dose followed by a titrated intravenous solution. It is contraindicated with narrow angle glaucoma and hypotension. Barbiturates (drug of choice if person does not respond to benzodiazepines) Phenobarbital (Luminal) effectively reduces the symptoms of withdrawal. It use is limited due to hypotension and respiratory depression. Persons on this drug may need mechanical ventilation. The usual dose is 3 5 mg/kg of body weight IV or IM. It may be repeated every minutes until the person is sedated, hypotension occurs or 15mg/kg have been administered. Contraindications are hypotension and known sensitivity. Pentobarbital (Nembutal) is a short acting drug that may be given IV at the rate of 100mg IV over 1-2 minutes every 5 15 minutes until the person is sedated. The main contraindication is liver failure. Cardiovascular Agents (these drugs are used in conjunction with other medications and never used as monotherapy) Clonidine (Catapres) decreases blood pressure and pulse rate (less predictable). Very useful in opiate withdrawal as it diminishes excessive lacrimation, diarrhea, and tachycardia. The usual dose is mg orally every 8 hours. Monitor cardiovascular status while on the drug and abrupt discontinuation may cause rebound hypertension. Rarely used in alcohol withdrawal. Propranolol (Inderal) decreases blood pressure, heart rate, and tremor. It has no effect on alcohol cravings nor does it reduce the severity or incidence of seizures or delirium. The usual dose is 1 mg IV initially and should not exceed 0.1 mg/kg of body weight in 24 hours. The drug should gradually be discontinued as an abrupt cessation may lead to an increase in hprerthyroid symptoms including a thyroid storm. In addition the drug may decrease signs of hypoglycemia. Magnesium sulfate is given for magnesium replacement. The symptoms of low magnesium level resemble acute alcohol withdrawal, i.e. seizures, tachycardia, tremors, and hypereflexia. The administration of magnesium in individuals with low magnesium levels usually reduces the amount of sedation needed. In addition the administration prevents seizures with individuals with low magnesium levels. The usual dose is 1 gram every 6 hours for four doses. It is recommended not to exceed more than 1 2 grams per hour. Vitamins Vitamin (Vitamin B-1) is an essential cofactor of many metabolic processes. Most alcoholics have a low level of Thiamin. Thiamin deficiencies are noted by the presence of Beriberi or Wernicke-Korsakoff (thiamin dementia). Giving IV glucose can precipitate the Wernicke encephalopathy. This may be prevented by administering Thiamin either before (preferably) or at the same time as glucose. The IV dose depends on the patient profile and may be anywhere from 50 mg 500 mg. Care should be taken not to administer the Thiamin too rapidly as the patient may develop heart failure due to cardiac stress. Resolution of acute symptoms of Wernicke-Korsakoff may be noted quickly with the administration of Thiamin. Phytonadione (Vitamin K- 1, Aqua-Mephyton) should only be used in patients with hypoprothrombinemia. A deficiency in Vitamin K-1 is a frequently noted in individuals with chronic alcoholism and cirrhosis. The usual dose is 5 25 mg PO, IV, or IM depending on the patient s profile. Antidotes Alcohol is administered in very rare cases to individuals who do not become sedated with the usual cross-tolerant medications. The administration of Alcohol is considered a last resort. The recommended dosage is a 10% solution given at a rate of ml/hour. The dosage should be tapered as soon as possible and discontinued within hours. Use extreme caution if the patient has also ingested other depressants. It should be noted that IV administration may cause thrombophlebitis and an oral administration may cause severe gastritis. Propofol (Dipri
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