The Assessment and Management Practices of Acute Alcohol Withdrawal: Results of a Nationwide Survey of Critical Care Pharmacists.

Background

Alcohol withdrawal occurs commonly but diagnosis and therapies have not been described.

Objective

To characterize practices regarding the assessment and treatment of acute severe alcohol withdrawal and describe perceived barriers to therapies.

Methods

A random sample of 500 US-based critical care pharmacists received the pretested, electronically distributed questionnaire.

Results

94 (20%) of 471 eligible recipients responded with diverse representation. Manifestations of alcohol withdrawal that were commonly rated as severe were seizures (91.3%), not oriented to person/place/date (84.1%), delusions (73.8%), diastolic blood pressure >110 mmHg (51.7%), inconsolable agitation (50.7%), and tachycardia (50.7%). Scoring tools were considered highly effective for assessing severity by 43 respondents (45.8%). Management protocols existed in 86 (90.5%) institutions. Sixty-eight (72.3%) respondents indicated protocols were used often/routinely for initial management but only 23 (24.5%) for adjunctive therapies (p<0.0001). Agents employed for initial and adjunctive management were benzodiazepines (92.6% and 61.7%, respectively, p<0.0001), clonidine (29.8% and 34%, respectively), haloperidol (26.6% and 33%, respectively), and barbiturates (20.2% and 24.5%, respectively). Adjunctive agents were most commonly added to reduce dosages of benzodiazepines (antipsychotics, barbiturates, alpha-2 agonists), prevent respiratory depression (alpha-2 agonists), prevent or treat autonomic symptoms (alpha-2 agonists), and prevent or treat agitation/delusions (antipsychotics, barbiturates, alpha-2 agonists). Agents with common barriers to use were dexmedetomidine (bradycardia, hypotension, cost), propofol (hypotension, tracheal intubation required), and ketamine (lack of supportive data).

Conclusion

Assessment and management strategies of acute severe alcohol withdrawal vary considerably. Benzodiazepines are the mainstay of treatment. Other agents are commonly used to prevent complications from benzodiazepines or treat agitation/delusions.