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.

3.

By the end of the session nurses & midwives will have an understanding or use of the AWS/CIWAR-Ar withdrawal scales At the end the session, nurses & midwives will have a basic understanding & knowledge to safely & effectively identify, monitor & manage alcohol withdrawal

7: Managing withdrawal

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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

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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

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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

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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

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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

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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

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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?

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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

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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?

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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

Sweating Tachycardia Hypertension Insomnia Tremor Fever

Gastrointestinal

Anorexia Nausea Vomiting Dyspepsia

Table 9.4: Main signs & symptoms of alcohol withdrawal Cognitive & perceptual changes

Anxiety Vivid dreams Illusions Hallucinations Delirium

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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

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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)

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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