Chapter 31

Alcohol Withdrawal

Diagnosis and Management

Alcohol withdrawal syndrome (AWS) is a relatively common problem in the intensive care unit (ICU). However, the intensivist faces numerous challenges in accurately recognizing and appropriately treating this syndrome. First, the critically ill patient may not communicate to allow an accurate assessment of risk for AWS. In addition, because manifestations of AWS are nonspecific, the syndrome may be difficult to distinguish or may be obscured by concurrent medical conditions. Finally, the primary class of medications used to prevent or treat AWS, benzodiazepines, commonly cause or exacerbate delirium resulting from other medical conditions. Thus, one must maintain a high index of suspicion to recognize the patient at high risk for AWS and to accurately diagnose patients who develop the syndrome. This chapter provides an evidenced-based approach to the management of ICU patients who are at risk for, or who develop, AWS.

Alcohol Dependency and Alcohol Withdrawal Syndrome

Alcohol withdrawal syndrome (AWS) is defined by criteria listed in Box 31.1. Although overall mortality and morbidity due to AWS have steadily decreased with the advent of improved treatment and monitoring strategies, utilization of these strategies remains inconsistent. For instance, a considerable proportion (15% to 20%) of patients admitted to the hospital are alcohol dependent (as high as 39% in the ICU), yet studies show that only about half of these patients are initially identified as such by their physicians. Although this may in part be due to inaccurate self-reporting of true alcohol consumption, these data likely reflect lack of implementation of validated screening techniques for alcohol dependence. In addition, the decision process to give pharmacologic prophylaxis and the choice of which medication to use is not consistent or standardized. Although this is not widely appreciated, many patients who are alcohol dependent will not undergo alcohol withdrawal during hospitalization. In fact, only 5% to 7% of this patient population progress into AWS.

BOX 31.1 Criteria for Diagnosis of Alcohol Withdrawal Syndrome (AWS)

Patient manifests at least two of the following signs or symptoms that occur within hours to a few days following cessation of heavy and prolonged alcohol consumption and that cannot be attributed to another medical disorder:

1. Autonomic hyperactivity (e.g., sweating or heart rate > 100 beats per minute)

2. Tremors

3. Insomnia

4. Transient visual, tactile, or auditory hallucinations or illusions

5. Nausea or vomiting

6. Psychomotor agitation

7. Anxiety

8. Grand mal seizures

From Bayard M, McIntyre J, Hill KR, Woodside J Jr: Alcohol withdrawal syndrome. Am Fam Physician 69:1443-1450, 2004.

Once a patient at high-risk for alcohol withdrawal has been identified, the patient should be monitored closely for the development of signs and symptoms of AWS. The most widely studied and used scoring tool is the Revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar) (Box 31.E2). This 10-question assessment tool combines both patient responses to questions related to orientation, nervousness, and hallucinations and observations made by medical personnel to complete the score. In addition to being a tool to monitor the emergence of AWS, because the CIWA-Ar score tracks the severity of the withdrawal (see Box 31.E2), it is also used to guide the titration of medicines used to treat AWS. Although the CIWA-Ar quantifies the clinical manifestations of AWS, these are not specific to alcohol withdrawal. As such, other states of withdrawal and other medical conditions associated with an increase in catecholamines may mimic or coexist with AWS and cause a false-positive increase in the CIWA-Ar score (e.g., delirium, meningitis, drug ingestions, liver failure). Therefore, before initiating medical treatment for AWS, based on an elevated CIWA-Ar score, it is essential to assess the patient first to rule out other potential causes.

Importantly, one should not use the CIWA-Ar in a noncommunicative patient (e.g., one who is delirious or intubated). Regrettably, there is no standard assessment tool for monitoring such patients; however, in these cases it is reasonable to use a validated ICU sedation agitation scale to quantify the severity of agitation (e.g., the Richmond Agitation-Sedation Scale [RASS] [see Table 5.2, Chapter 5]). Similar to the CIWA-Ar, an increased RASS score is not specific for alcohol withdrawal; however, it is useful to guide therapeutic management. For example, clinicians can target treatment with benzodiazepines to a RASS goal of −2 to +1 to have objective drug administration goals.

Indications for Transfer to the ICU

Once one diagnoses AWS (Box 31.1), one must consider whether the patient has indications for ICU level of care (see Box 31.2). Patients who don’t meet the criteria in Box 31.2 for admission to the ICU should be able to be managed on a general medical floor—provided that the floor unit’s nursing staff has been trained to perform CIWA-Ar scoring in conjunction with a protocolized or physician-driven titration of appropriately dosed benzodiazepines.

BOX 31.2 Indication for Transfer to Intensive Care Unit (ICU) of Patients Diagnosed with Alcohol Withdrawal Syndrome (AWS)

1. If at any point during treatment patients cannot protect their airway, they should be intubated and transferred to the ICU for further management.

2. Patients with moderate alcohol withdrawal, defined as a CIWA-Ar ^∗ score of 9 to 15, who are deemed high risk for complications, including:

a. the frail, older adult

b. those with comorbidities including

i. hemodynamic instability

ii. pulmonary disease

iii. pancreatitis

iv. gastrointestinal bleeding

c. those with an alcohol level > 100 mg/dL

d. those who are unable to communicate (e.g., delirium) such that the CIWA-Ar cannot be used to guide treatment.

3. Patients with severe alcohol withdrawal syndrome, defined as the requirement for:

a. > 6 mg of lorazepam (or equivalent) in the first hour, or

b. ≥ 12 mg of lorazepam (or equivalent) in the first 6 hours, or

c. CIWA-Ar that remains > 15 for > 1 hour with appropriate benzodiazepine treatment

^∗CIWA-Ar, Clinical Institute Withdrawal Assessment for Alcohol (see Box 31.E2)

Indication 3 is from Hack JB, Hoffman RS, Nelson LS: Resistant alcohol withdrawal: does an unexpectedly large sedative requirement identify these patients early? J Med Toxicol 2:55-60, 2006.

BOX 31.E1 CAGE Questionnaire to Screen for Alcohol Use Disorder

	CAGE Questions^∗
1	Have you ever felt you needed to Cut down on your drinking?
2	Have people Annoyed you by criticizing your drinking?
3	Have you ever felt Guilty about drinking?
4	Have you ever felt you needed a drink in the morning (Eye-opener) to steady your nerves or get rid of a hangover?

^∗Two or more positive answers is considered as a positive screen.

From Liskow B, Campbell J, Nickel EJ, Powell BJ: Validity of the CAGE questionnaire in screening for alcohol dependence in a walk-in (triage) clinic. J Stud Alcohol 56:277-281, 1995.

BOX 31.E2 Clinical Institute Withdrawal Assessment for Alcohol: CIWA-Ar ^∗

Date/Time

Rater’s Initials/Signature

1 Nausea and Vomiting—“Do you feel sick to your stomach? Have you vomited?”

Observation