Heavner – Alcohol withdrawal management in the ICU

Mojdeh S. Heavner, PharmD, BCPS, BCCCP, Assistant Professor, Critical Care, Department of Pharmacy Practice and Science at the U of Maryland School of Pharmacy and Jason J. Heavner, M.D., Chair, Department of Critical Care Medicine, University of Maryland Baltimore Washington Medical Center, present the weekly multi-departmental critical care fellows’ lecture on “Advances in Protocol-Driven Management of Alcohol Withdrawal Syndrome in the ICU.”

Lecture Summary (by Dr. Jason Nam)

Alcohol use disorders (AUD) include:

  • excessive alcohol intake
  • alcohol abuse
  • alcohol dependence

Alcohol use disorders (AUD) are associated with:

  • 49% increased risk for mechanical ventilation
  • Chronic alcohol intake leads to immune dysregulation
  • Pneumonia is most common cause of sepsis in AUD patients
  • Delirium tremens develops in 24-33% of AWS patients

Timeline of alcohol withdrawal

Protocols in the ICU

  • Advantages – reduce harmful variations in care, maximize efficiency, improve outcomes
  • Disadvantages – minimize clinical judgment, encourage complacency, and stifle learning
  • CIWA-Ar
    • Symptom-triggered scoring.
    • Validated in outpatient detox unit.
    • Not studied in post-operative, medically complex, or ICU patients.

The Yale New Haven Experience

  • Presenters’ experience of developing a novel ICU protocol at Yale New Haven.
  • The protocol utilizes an objective administered scoring system (Modified MINDS). Dosing regimens derived from pharmacokinetic profile of each drug.
  • Reiterates need for accurate diagnosis. Suggests adjuvant therapies specially to treat autonomic hyperactivity. Requires physician re-evaluation at critical times.
  • Outcomes of YAWP:
    • Significant reduction in ICU intubation and pneumonia.
    • Significant use of adjuvants like clonidine.
    • Annual cost-savings of $3.5M for the health system.
  • Overall, YAWP implementation associated with significant improvements.

Conclusions

  • Patient with AWS in the ICU can experience serious complications.
  • Small, single center studies evaluating the use of ICU-specific AWS protocols, but more work is needed to establish a standard of care for ICU management.
  • YAWP implementation has been associated with decreased odds of MICU intubation as well as significant cost savings for patients with AWS.

References

Uploaded by Sami Safadi, MD

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