Alcohol Withdrawal Management

1. Dr SumitChandak
Asst. Prof, Department of Psychiatry
SKNMC & GH
Management of Alcohol Withdrawal

2. Objectives:
 Identifying an at risk patient.
 Assessment for severity of withdrawal in at risk
patient.
 Complication’s of alcohol withdrawal and their
assessment.
 Management of alcohol withdrawal and its
complications.

3. Identify at risk individuals:-
 Need to identify at risk individuals:-
Low detection rates
High rates of Mx/Sx complications when undetected

4. Identifying an at risk patient :
Elicit: History of alcohol/ substance use in all patients.
Ask → Pattern of use
Duration of use
Quantity of use
Time since last drink
May not be possible when → acutely intoxicated
acute trauma
Then ask :– friends
family members
Look for:- Smell of alcohol in the breath
Features of withdrawal
– Tremors
–
Tachycardia
-↑BP
Obtain blood alcohol level- if possible

5. To identify potential problem drinkers:
Use screening tool: CAGE questionnaire.
 C: Have you ever felt you should cut down on your
drinking?
 A: Have people annoyed you by criticizing your
drinking ?
 G: Have you ever felt bad or guilty about your
drinking ?
 E: Have you ever had a drink first thing in the morning
to steady your nerves or get rid of a hangover (eye
opener)?

6. Assessment in at risk patient:
Primarily for:
 factors predisposing to complications
 severity of withdrawal

7. Assessment for predisposing
factors:
Metabolic disturbances: Hypoglycemia
Lactic acidosis
Ketoacidosis
↓Na, Ca2+,Mg²
↓ed /↑ ed K.
↑ed Triglycerides
Cardiac problems : most common
Serious post op problems sec to:
↑ Risk of CAD
↑ed cardiovascular stress sec to
withdrawal
G.I. problems: PUD
Hepatitis
Hematological monitoring:
As alcohol suppresses bone marrow
Presence of neurological factors

8. For severity of withdrawal :
 Clinical monitoring – intensively for first few days.
 For s/s of alcohol withdrawal
 Sx population : can use scales like CIWA-AI

9. CIWA-Ar Clinical Institute withdrawal
assessment of Alcohol scale , revised
 Observation on 10 parameters.
Nausea and
vomiting
Tactile
disturbances
Tremor
Auditory
disturbance
Paroxysmal
sweats.
Visual
disturbances
Anxiety

10. CIWA-Ar Clinical Institute
withdrawal assessment of Alcohol
scale , revised
 Scores max possible: 67
 Interpretation 6-7 mild withdrawal
8-14 : moderate withdrawal
>15: severe withdrawal

11. Complication of withdrawal state:
Delirium: can occur anytime within 7days
Seizures: usually around 3 day of last drink
Other : Wernickes encephalopathy
Psychosis
Depression

12. Delirium
Definition: The hallmark symptom of delirium is an
impairment of consciousness, usually
accompanied by global impairments of cognitive
functions; generally associated with emotional
labiality, hallucinations or illusions, and
inappropriate, impulsive, irrational, or violent
behavior.
 Generally considered to be an acute reversible
disorder but can become irreversible.

13. Delirium
 Diagnostic criteria:
A] Disturbance of consciousness (i.e. reduced clarity
of awareness of the environment) with reduced
ability to focus, sustain, or shift attention.
B] A change in cognition (such as memory deficit ,
disorientation, language disturbance) or the
development of a perceptual disturbance that is not
better accounted for by a preexisting, established,
or evolving dementia
.

14. Delirium:
 Diagnostic criteria:
C] The disturbance develops over a short period of time
(usually hours to days) and tends to fluctuate during
the course of the day.
D] There is evidence from the history, physical
examination, or laboratory findings of either (1) or (2):
1] The symptoms in Criteria A and B developed during
substance intoxication.
2] Medication use is etiologically related to the
disturbance.

15. Delirium
Assessment:
 Points to remember: fluctuating orientation
Sequence of disorientation: T->PL->PE
Sequence of re-orientation: PE->PL->T
 ASK for TIME: time/day/date/month/year
PLACE: where are you/On what floor
PERSON: Check for recognition of
relatives/confabulation
 Cross check data with relative/attendant

16. Management of alcohol withdrawal /
risk patient:
 In at risk patient promote abstinence for at least 4
weeks of an elective pre-op procedure as it
decreases morbidity from 74% -31%
 Modalities of Intervention:
1]Pharmacotherapy : Substitute
Adjuvant
2] Counseling

17. Pharmacotherapy:
Substituent : Act on GABA receptors & mimic the
action of
alcohol:
Lorazepam :po│im│iv
Librium : po only
 Dosing depends on : severity of withdrawal
presence of hepatic
dysfunction
altered neurological
states
 1st 24 hours: fixed dosing schedule
flexible dosing schedule

18. Pharmacotherapy
 Fixed dosing :Depending on the Quantity, Quality
of alcohol and the time of last drink consumed.
For Ex:
Librium (10/25): 1-1-2
0-1-2
0-0-2
Lopez (2) : 2-2-2
1-1-2
 Caution: Monitor Respiratory Rate

19. Pharmacotherapy:
 Flexible dosing admission monitor for—s/s of
withdrawal :
IF PRESENT: IF ABSENT:
If present
↓
Give Librium (10) 2 stat
↓
Monitor 2 hourly
↓
If increased F/O withdrawal
↓
If decreased
↓
Continued monitoring 2
hourly
If absent
↓
Monitor 4 hourly
↓
If present

20. Pharmacotherapy
 Dose obtained at end of 24hours is the total dose
required by that individual
 Continue on the same dose for 48 hours.
 Then taper by 20% every day every day, till
eliminated.

21. Pharmacotherapy:
Adjuvant :For symptomatic control:
1] Propranolol
2]CBZ
For metabolic parameters :
 Plenty of oral fluids
 Injection Thiamine/MVBC before any I.V. fluids
especially containing sugar
 Tb Thiamine 75/100mg bid

22. M/M of Delirium :
 Rule out other causes
 Lab: Se Electrolytes, BSL, LFT, RFT
SOS: EEG
 M/M:
 Pharmacotherapy as above
 Restrain the patient
 Keep the lights on at night
 Frequently talk to & reorient the patients
 Correct electrolyte imbalance and underlying
hepatic d/o if any
 When protracted - ECT

23. THANK YOU

24. DO’S FOR DELIRIUM:
 Employ environmental interventions to reduce
factors that may
exacerbate delirium.
These interventions include
• changing the lighting to cue day and night,
• reducing monotony and overstimulation and
understimulation,
• correcting visual and auditory impairments (e.g.,
retrieve glasses,
hearing aids), and
• rendering the patient’s environment less alien by
having familiar
people and objects present (e.g., family photographs).

25. DO’S FOR DELIRIUM
 Reorient the patient to person, place, time, and
circumstances.
 Reorientation should be provided by all who
come into contact with the patient.
 Provide reassurance to patients that the deficits
they are experiencing are common but usually
temporary and reversible.

26. DONT’S FOR DELIRIUM
 Unnecessarily restrain the patient
 Avoid Anticholinergics drugs like Phenergan in
delirium especially alcohol withdrawal