Document Type : Original Article
Authors
University of Rochester Medical Center
Abstract
Background: Little evidence supports intravenous ethanol (IVE) as an alternative alcohol withdrawal syndrome (AWS) prophylactic agent. This study characterized the use of IVE in alcohol dependent patients and described clinically relevant efficacy and safety outcomes.
Methods: Retrospective descriptive study of IVE use between January 1st, 2011 and September 15th, 2018 was carried out in this study. Patient characteristics, infusion parameters, and outcomes were recorded. Results: In this study, 69 patients received IVE; 24 (34.8%) received IVE for AWS treatment. Percent infusion time outside goal Sedation-Agitation Scale (SAS) and Clinical Institute Withdrawal Assessment (CIWA) ranges were 4.8% (IQR 0 – 17.4) and 3.8% (IQR 0 – 9.8), respectively. Forty-two (60.9%) patients received a benzodiazepine with a median daily requirement of 0.72 mg (IQR 0 – 3.12) of lorazepam equivalent. Mechanical ventilation was associated with increased benzodiazepine dose (p = 0.002) and a higher percentage of time spent outside goal SAS (p < 0.001) range. Treatment patients required higher daily doses of IVE (p = 0.05) and spent more time outside of goal CIWA range (p < 0.001). Higher initial infusion rate was associated with intubation during infusion.
Conclusion: Patients spent a majority of infusion time within goal SAS and CIWA ranges and required low doses of benzodiazepines. Mechanical ventilation and indication were associated with significant differences in patient outcomes and are likely to be confounders for any future investigation utilizing benzodiazepine requirements or sedation or withdrawal scales as endpoints. Further study is required to elucidate the potential benefits and risks of IVE.
Keywords
- Ambrosi L, Borden MT, Phelan GC, Blea M, Nasraway SA. Current practices of ethanol administration in the prevention and treatment of alcohol withdrawal syndrome: A survey of US academic medical centers. J Sub Abuse & Alcoholism 2016;5:1051.
- Gashlin LZ, Groth CM, Weigand TJ, Ashley ED. Comparison of alcohol withdrawal outcomes in patients treated with benzodiazepines alone versus adjunctive phenobarbital: a retrospective cohort study. Asia Pacific J Med Toxicol 2015;4:31-36.
- Dewan G, Chowdhury FR. Alcohol use and alcohol use disorders in Bangladesh. Asia Pacific J Med Toxicol 2015;4(2):83-90.
- Hodges B, Mazur JE. Intravenous ethanol for the treatment of alcohol withdrawal syndrome in critically ill patients. Pharmacother 2004;24:1578-85.
- Fullwood JE, Mostaghimi Z, Granger CB, Washam JB, Bride W, Zhao Y, et al. Alcohol withdrawal prevention: a randomized evaluation of lorazepam and ethanol (AWARE) pilot study. Am J Crit Care 2013;22:398-409.
- Mirijello A, D’Angelo C, Ferrulli A, Vassalo G, Antonelli M, Caputo F, et al. Identification and management of alcohol withdrawal syndrome. Drugs 2015;75:353-65.
- Jesse S, Brathen G, Ferrara M, Keindl M, Ben-Menachem E, Tanasescu R, et al. Alcohol withdrawal syndrome: mechanisms, manifestations, and management. Acta Neurol Scand 2017;135(1):4-16.
- O’Connor AB. Should ethanol be removed from hospital formularies? Am J Med 2007;120: 651-652.
- Lindsay D, Freeman K, Jarvis M, Lincoln P, Williams J, Nelson LS, et al. Executive summary of the American Society of Addiction Medicine (ASAM) clinical practice guideline on alcohol withdrawal management. J Addiction Med 2020;14:376-92.
- Mayo-Smith MF, Beecher LH, Fischer TL, Gorelick DA, Guillaume JL, Hill A, et al. Management of alcohol withdrawal delirium: An evidence based practice guideline. Arch Intern Med 2004;164(13):1405-12.
- Weinberg JA, Magnotti LJ, Fischer PE, Edwards NM, Schroeppel T, Fabian TC, et al. Comparison of intravenous ethanol versus diazepam for alcohol withdrawal prophylaxis in the trauma ICU: results of a randomized trial. J Trauma 2008;64:99-104.
- Hansbrough JF, Zapata-Sirvent RL, Carroll WJ, Johnson R, Saunders CE, Barton CA. Administration of intravenous alcohol for prevention of withdrawal in alcoholic burn patients. Am J Surg 1984;148:266-9.
- Wilkens L, Ruschulte H, Rückoldt H, Schroder D, Piepenbrock S, Leuwer M. Calculation of ethanol elimination rate is not sufficient to provide ethanol substitution therapy in the postoperative course of alcohol-dependent patients. Intensive Care Med 1998;24:459-63.
- Dissanaike S, Halldorsson A, Frezza EE, Griswold J. An ethanol protocol to prevent alcohol withdrawal syndrome. J Am Coll Surg 2006;203:186-91.
- Eggers V, Tio J, Neumann T, Pragst F, Muller C, Schmidt LG, et al. Blood alcohol concentration for monitoring ethanol treatment to prevent alcohol withdrawal in the intensive care unit. Intensive Care Med 2002;28:1475-82.
- Dillard W, Welch T, Abdul-Hamed S, Kesey J, Dissanaike S. Ethanol infusion for alcohol withdrawal prophylaxis does not cause intoxication. SWRCCC 2016;4:11-18.
- Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict 1989;84:1353-7.
- Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med 1999;27:1325-1329.
- Sachdeva A, Chandra M, Deshpande SN. A comparative study of fixed tapering dose regimen versus symptom-triggered regimen or lorazepam for alcohol detoxification. Alcohol and Alcoholism 2014;49:287-291.
- Duby JJ, Berry AJ, Ghayyem P, Wilson MD, Cocanour CS. Alcohol withdrawal syndrome in critically ill Patients: Protocolized vs non-protocolized management. J Trauma Acute Care Surg 2014;77:938-943.
- Daeppen JB, Gache P, Landry U, Sekera E, Schweizer V, Gloor S, et al. Symptom-triggered vs fixed-schedule of benzodiazepine for alcohol withdrawal. Arch Intern Med 2002;162:1117-1121.
- Spies CD, Dubisz N, Funk W, Blum S, Muller C, Rommelspacher H, et al. Prophylaxis of alcohol withdrawal syndrome in alcohol-dependent patients admitted to the intensive care unit after tumour resection. Br J Anaesth 1995;75:734-9.
)