Alcohol withdrawal: Inpatient management
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Management
Start aggressive Benodiazepine therapy at CIWA score of 8. Consider ICU admission with score >20
Benzodiazepines
- Diazepam (Valium) 5-10mg IV (depending on severity)
- May repeat q5-10min for severe withdrawal (double dose until desired effect achieved)
- Lorazepam (Ativan) 1-4mg IV (depending on severity)
- May repeat q15-20min for severe withdrawal (titrated to effect)
- Rarely causes hepatitis, as opposed to diazepam which may cause a cholestatic hepatitis[1]
Special Situations
- The propylene glycol diluent in lorazepam, phenobarbital and diazepam, may induce a hyperosmolar anion gap metabolic acidosis if given as a drip in high doses ≥ 48hrs.[2] Consider alternatives such as propofol or dexmedetomidine if patients need long term sedation for Delirum tremens
Alpha-2 agonists (Dexmedetomidine)
- Decrease severity of sxs, but only supplemental to GABA-ergic first-lines
- Dexmedetomidine drip, start 0.2 mcg/kg/min, likely needing no more than 0.7 mcg/kg/min
Barbituates (Phenobarbital)
- Used when refractory to benzodiazepines
- Phenobarbital 130-260 mg IV q 15-20 minutes
Ketamine
- May have some use in refractory cases
- Blocks the NMDA receptor which is excited an unregulated. [3]
Nutritional supplementation
- Banana bag
- Thiamine 100mg IV
- Folate 1mg IV (cheaper PO)
- MVI 1 tab IV (cheaper PO)
- Magnesium sulfate 2mg IV
- Normal saline as needed for hydration
See Also
- Beer Potomania Syndrome
- Alcohol (ETOH) Intoxication
- Alcoholic ketoacidosis
- Alcohol withdrawal
- Alcohol withdrawal: Inpatient management
- Alcohol withdrawal: Outpatient management
- Alcohol withdrawal seizures
- Altered mental status
- Delerium tremens
- EBQ:Outpatient use of benzodiazepines for the treatment of acute alcohol withdrawal
- Sedative/Hypnotic
- Wernicke-Korsakoff Syndrome
External Links
References
- ↑ National Institute of Diabetes and Digestive and Kidney Diseases. Lorazepam Drug Record. http://livertox.nih.gov/Lorazepam.htm
- ↑ Arroliga AC, Shehab N, McCarthy K, Gonzales JP. Relationship of continuous infusion lorazepam to serum propylene glycol concentration in critically ill adults*. Critical Care Medicine. 2004;32(8):1709–1714. doi:10.1097/01.CCM.0000134831.40466.39.
- ↑ Wong, A et al. Evaluation of adjunctive ketamine to benzodiazepines for management of alcohol withdrawal syndrome. Ann Pharmacother. 2015 Jan;49(1):14-9. PMID: 25325907