CASE PRESENTATION ON ALCOHOL WITHDRAWAL DELIRIUM

Submitted by:

G.H.R.R.MANOJ,611171602006,IV PHARM.D

PATIENT PROFILE FORM

Name: ch.veerababu DOA:24/01/14 Ward: psychiatric Age:28 years IP no:59579 Weight : 55kgs Gender :male Occupation:coolie

Reasons for admission:

severe manifestation of alcohol withdrawal, which occurs 5 days following the last drink these symptoms are observed Hallucinations, shortness of breath, delusions, irrelevant talk, sleeplessness.

Past medical history: history of habitual alcohol use or

alcoholism that has existed for more than 6 years.

Past Medication history: not significant

Family History:

Pastly his father also chronic alcoholic, his father died with life threatening seizures and using tranquilizer drugs of the barbiturate or benzodiazepines strong addiction to them.

DIAGNOSIS:

ALCOHOL WITHDRAWAL DELIRIUM

what is alcohol withdrawal delirium(awd) and causes of AWD?

Alcohol Withdrawal Delirium:Alcohol withdrawal delirium (AWD) is the most serious form of alcohol withdrawal. It causes sudden and severe problems in brain and nervous system. Approximately five percent of hospital patients being treated for alcohol withdrawal also experience AWD. AWD is also known as delirium tremens or DTs. It is a medical emergency

Delirium tremens (also referred to as The DTs, "the horrors", "the bottle ache", "quart mania", "ork orks", "gallon distemper", "barrel fever", or "the shakes") is an acute episode of delirium that is usually caused by withdrawal from alcohol

Causes of Alcohol Withdrawal Delirium: AWD only affects people with a history of heavy alcohol use. Heavy drinkers may develop this condition if they:suddenly stop drinking ,reduce their alcohol use too quickly,don’t eat enough when reducing alcohol use, head injury, another cause of delirium tremens is abrupt cessation of tranquilizer drugs of the barbiturate or benzodiazepine classes in a patient with a relatively strong addiction to them

Delirium:

It is a neuropsychiatric syndrome also called acute confusional state or acute brain failure that is common among the medically ill and often is misdiagnosed as a psychiatric illness which can result in delay of appropriate medical intervention. There is significantly mortality associated with delirium so identifying it is crucial

Pharmaceutical care plan:

1.Subjective evidence:

severe manifestation of alcohol withdrawal, which occurs 5 days following the last drink these symptoms are observed Hallucinations, shortness of breath, delusions, irrelevant talk, sleeplessness.

2.Objective evidence:

doctor will perform a physical exam to see if have AWD symptoms. Based on scales CIWA- Ar scale (The Clinical Institute Withdrawal Assessment for

alcohol scale) is used widely as a means to gauge the severity of alcohol withdrawal).

doctor suggests Some tests that may be needed for a diagnosis include: take a breath analyzer reading –indicates where patient is in the withdrawal

process. Using a nonalcoholic skin preparation, draw blood for measurement of ethanol

concentration, toxicology screen for other drugs of abuse. blood tests to measure magnesium and phosphate

3.Assessment:

based on subjective and objective evidence of physical examination and patient social history the diagnosis was made as “Alcohol Withdrawal Delirium”

Goals to be achieved

To Save the patient life. To Relieve the signs and symptoms. if hospital stay is needed. The health care team will regularly

check To Avoid or reduce the use of alcohol. Get prompt medical

treatment for symptoms of alcohol withdrawal. To Prevent further possible complications like Injury from falls during seizures Injury to self or others caused by mental state

(confusion/delirium) Irregular heartbeat, may be life threatening alcoholic liver disease alcoholic neuropathy (nerve damage caused by alcohol use) alcoholic cardiomyopathy (weak heart muscle due to alcohol use) Wernicke-Korsakoff syndrome (brain damage from a lack of vitamin

B1)

TREATMENT OPTIONS:

Benzodiazepines diazepam or lorazepam,

chlordiazepoxide (Librium) or oxazepam (Serax) temazepam (Restoril) or midazolam (Versed) Antipsychotic medications haloperidol, butyrophenone Other drugs Baclofen, Chlormethiazole,diphenyramine

maleate,sioneuronforte, Trihexyphenidyl,vitamins

Day 1:

B.P :140/90 mm Hg

Heart rate:82/min

On first day patient is not sleeping well, irrelevant talk,

night mares etc.

Advised to antipsychotic drugs . special precaution to be

taken for tab.librium i.e. 2tabs till patient sleep later 4th

hourly ,skip a dose if patient is a sleep

Day 2:

Normal body temperature and blood pressure.

Slept well Relevant talk Hearing disturbances occurring in the

patient. On the second day doctor suggest a

precaution for tab.librium i.e. 2tabs 6th hourly ,skip a dose if patient is a sleep.

DRUG CHART :

DRUGS Dose Route

FREQ

DAY-1

DAY-2

DAY-3 DAY-4

Tab.librium 25mg oral 0D D D D D

Inj.sioneuronforte

1amp I.M B.D D D D D

Tab.Haloperipol

5mg oral O.D D D D D

Tab.Tryhexyphenidyl

2mg oral B.D D D D D

Inj.haloperidol

1amp

+ I.m SOS D D ------ -------

Inj.diphenyramine maleate

1amp

Day 3:

Slept well Talk Relevantly Blood pressure is normal Advised to stop injection haloperidol +

inj,diphenyramine maleate

Day 4:

Slept well Patient is drowsy Pulse rate: 80 beats/min Talk relevantly Doctor advised to discharge for the

patient in better relevant talk ,no psychotic features

GOALS ACHIEVED:

Reduction of sleeping disturbances and patient is sleeping well after taking the medication.

Patient Talking Relevantly by 2nd day. Patient feels better on 3rd day.

MONITORING PARAMETERS:

Monitor thorough examination for signs of autonomic hyperreactivity i.e, tachycardia,diaphoresis,elevated body temperature,dilated but reactive pupils.

Be aware that people tend to underestimate drinking habits. Observe behavior for

talkativeness,restlessness,agitation,preoccupation. monitoring of electrolytes and vital signs every 30 minutes. Place the patient in a private room for close observation. To assess respiratory,hepatic, and cardiovascular status of patient ---

pneumonia, liver disease, and cardiac failure are complications. To observe for hypoglycemia and treat appropriately.hypoglycemia may

accompany alcoholic withdrawal because alcohol depletes liver glycogen stores and impairs gluconeogenesis—many patients also suffer from malnutrition.

To monitor electrocardiogram (ECG) to check heart function To monitor electroencephalogram (EEG) to record the electrical

activity in brain

Problems Identified:

If problem drinking is identified early, it may mean that complications, including severe alcohol withdrawal and delirium tremens, are avoided.

In this patient electrolyte balance should not maintain.

Drug interactions:

The interaction of alcohol with the CYP-450 enzyme system can be complex and depends upon the duration of alcohol consumption. (34) Short-term consumption leads to a competitive inhibition of the CYP2E1 enzyme, whereas chronic use leads to its induction. CYP2E1 induction leads to an increased clearance of drugs such as warfarin, diazepam, rifamycin, meprobamate, pentobarbital, propranolol, and alcohol itself, with the effect upon liver metabolism lasting for days to weeks after the discontinuation of alcohol.

the CYP2E1 enzyme system converts otherwise safe substances into highly toxic metabolites. These include industrial solvents, cocaine, some anesthetic agents (e.g., enflurane, methoxyflurane), isoniazid, phenylbutazone, and acetaminophen. Through the induction of this alternate pathway of drug metabolism, ordinarily innocuous doses of these agents may become hepatotoxic.

The combination of benzodiazepines and alcohol can amplify the adverse psychological effects of each other causing enhanced depressive effects on mood and increase suicidal actions and are generally contraindicated except for alcohol withdrawal

PATIENT COUNSELLING:

ABOUT DISEASE: Cognitive behavioral therapy and

motivational enhancement therapy (which are sometimes combined with pharmacologic therapy) have been used successfully to prevent relapse.

Alcohol cessation programs and support groups, such as Alcoholics Anonymous, should be recommended.

Computer-based screening and counseling programs may be useful when clinicians do not have time to perform screening and face-to-face intervention

ABOUT DRUGS:

Antipsychotics - Phenothiazines and butyrophenones lower the seizure threshold. They should be used with extreme caution in the withdrawing alcoholic. These agents may also interfere with heat dissipation and, perhaps most importantly, do not exhibit cross-tolerance with alcohol thus their efficacy is suspect. Antiepileptic: There is some interest in the use of anti-epileptics for the treatment of acute alcohol withdrawal. In initial studies carbamazepine, an anticonvulsant agent widely used in Europe for alcohol withdrawal syndrome, was shown to decrease the severity of withdrawal symptoms comparable to the benzodiazepines in terms of adverse events, and was equally as effective as lorazepam in decreasing the symptoms of alcohol withdrawal. (21-23 ciwa-ar) However, a subsequent systemic review of a heterogeneous group of trials was unable to draw definite conclusions based on the variable study designs employed and the low overall mortality rates observed. (24) Hence, there is not a large enough body of evidence to suggest using carbamazepine in acute alcohol withdrawal.

The vitamins of most importance in alcohol withdrawal are thiamine and folic acid. To help to prevent Wernicke syndrome alcoholics should be administered a multivitamin preparation with sufficient quantities of thiamine and folic acid.